How should I evaluate and manage a 10‑year‑old girl with an 8‑day heavy menstrual bleed (menorrhagia)?

Evaluation and Management of Heavy Menstrual Bleeding in a 10-Year-Old

This 10-year-old requires immediate laboratory screening for bleeding disorders—particularly von Willebrand disease and platelet function defects—because up to 20% of adolescents with heavy menstrual bleeding have an underlying coagulopathy, and first-line medical therapy with NSAIDs should be initiated while awaiting results. 1, 2

Immediate Clinical Assessment

Obtain a detailed bleeding history beyond menstruation: specifically ask about epistaxis requiring medical attention, gingival bleeding with tooth brushing, easy bruising (>2 cm without known trauma), prolonged bleeding from minor cuts, and any family history of bleeding disorders. 1, 3 These associated bleeding symptoms significantly increase the likelihood of an underlying coagulopathy and are statistically more frequent in patients with bleeding disorders. 4

Quantify the bleeding objectively: document whether she saturates more than 5 pads/tampons per day, requires pad changes at night, passes clots larger than a quarter, or has bleeding lasting beyond 7 days. 1, 3 A Pictorial Bleeding Assessment Chart (PBAC) score provides objective quantification of blood loss. 1

Essential Laboratory Evaluation

Order the following tests immediately:

• Complete blood count with platelet count to assess for anemia and thrombocytopenia 1, 5
• Ferritin level (iron deficiency is extremely common and requires treatment even if hemoglobin is normal) 3
• PT/INR and aPTT to screen for coagulation factor deficiencies 1
• Von Willebrand factor antigen, ristocetin cofactor activity, and factor VIII level (von Willebrand disease is the most common inherited bleeding disorder in this population) 1, 2
• Consider platelet function studies if family history or other bleeding symptoms are present 1

The prevalence of bleeding disorders in adolescents with heavy menstrual bleeding ranges from 13-22%, with von Willebrand disease and platelet function defects being most common. 2, 5, 4 Thrombocytopenia (platelet count <150,000/μL) occurs in approximately 13% of cases, most commonly from immune thrombocytopenic purpura. 5

First-Line Medical Management

Start mefenamic acid 500 mg three times daily for 5-7 days during menstruation as first-line therapy. 1, 6 NSAIDs reduce menstrual blood loss by 20-60% acutely and are the recommended initial medical management before any invasive intervention. 1, 6

Tranexamic acid is an excellent alternative non-hormonal option that reduces menstrual blood loss by up to 50% and is particularly useful if NSAIDs are contraindicated or ineffective. 1 However, it is contraindicated if thrombocytopenia or a prothrombotic disorder is identified. 6

When to Escalate Therapy

If bleeding persists after 3-6 months of NSAID therapy or if the patient finds the bleeding unacceptable, add hormonal therapy: combined oral contraceptives containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate are recommended. 1, 6 These should be reserved for cases where first-line medical management fails, as hormonal therapies are not typically first-line in this age group. 1

For acute severe bleeding requiring immediate control: high-dose estrogen therapy (conjugated equine estrogen 25 mg IV every 4-6 hours) may be necessary, and transfusion should be considered if hemoglobin is <7 g/dL or the patient is hemodynamically unstable. 1

Critical Decision Points for Hematology Referral

Refer to pediatric hematology if:

• Laboratory testing suggests a bleeding disorder (prolonged aPTT, low von Willebrand factor, thrombocytopenia, or abnormal platelet function) 1, 3
• Severe anemia (hemoglobin <7 g/dL) is present 5
• Bleeding fails to respond to conventional first-line therapies 1, 3
• History of other significant bleeding symptoms (epistaxis, gingival bleeding, easy bruising) is present 4

Common Pitfalls to Avoid

Do not assume this is simply "anovulatory bleeding" without excluding pathology. While immature hypothalamic-pituitary-ovarian axis is common in early adolescence, bleeding disorders often present with menorrhagia at menarche and must be systematically excluded. 1, 2

Do not delay iron supplementation. Approximately 50% of adolescents with heavy menstrual bleeding have anemia, and 10% may have life-threatening anemia (hemoglobin <5 g/dL). 5 Iron deficiency requires treatment even in patients who receive packed red cell transfusions. 3

Do not prescribe combined oral contraceptives as first-line therapy in this age group. NSAIDs or tranexamic acid should be tried first, with hormonal therapies reserved for refractory cases. 1

Reassure the patient and family that unscheduled bleeding is common during the first 3-6 months of any hormonal therapy and is generally not harmful, but re-evaluate for underlying gynecological problems if bleeding persists beyond this initial period. 6