Management of Heavy Menstrual Bleeding in Pediatric Patients

Educational Objectives

The goal of this program is to improve management of heavy menstrual bleeding (HMB) in pediatric patients. After hearing and assimilating this program, the clinician will be better able to:

1. List components of the PALM mnemonic used in HMB.
2. Identify the most common causes of HMB in the first few years after menarche.
3. Use the hemoglobin test in diagnosis of HMB in pediatric patients.

Summary

Physiology of menstruation: the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recognize menstruation as the fifth vital sign; the average age for menarche is now ≈12.5 yr of age, typically occurring within 2 to 3 yr of breast budding; menarche occurs by age 15 yr in 98% of adolescent girls; a normal menstrual cycle ranges from 21 to 45 days and so cycles occurring between 3 to 6 wk apart are generally considered normal; menstrual cycles are counted from the first day of one period to the first day of the next; however, many adolescents remember the last day rather than the first, which may require further questioning; the average cycle length is 32 days, with periods lasting between 2 and 7 days; blood loss ranges from 20 to 80 mL, although this is not easily measured in a clinical setting

Concerning symptoms: menarche should occur by age 15 or ≤3 yr of breast budding; if there are signs of hirsutism (eg, chin, mustache, chest hair) in a 14-yr-old who has not yet menstruated, this is also concerning; if an adolescent athlete or someone with an eating disorder has not menstruated by age 14 yr, this warrants further evaluation

Terminologies: the terminology of menstruation has evolved; previously used terms (eg, menorrhagia, metrorrhagia) have been replaced; heavy menstrual bleeding (HMB) now refers to excessive bleeding based on the patient’s perception of what is abnormal for them; if a teenager reports using more pads per day than usual or bleeding for longer than before, this may indicate HMB; intermenstrual bleeding, formerly called metrorrhagia, refers to bleeding between periods; dysfunctional uterine bleeding is now termed abnormal uterine bleeding (AUB), which is characterized by irregular volume, frequency, or duration of bleeding that persists for at ≥6 mo

Etiology of HMB: the causes of HMB are categorized under PALM and COEIN; PALM represents structural causes, including polyps, adenomyosis, leiomyomas (fibroids), and malignancy, which are more commonly associated with older women; COEIN encompasses nonstructural causes, eg, coagulopathies, ovulatory disorders like polycystic ovary syndrome (PCOS), endometrial dysfunction, iatrogenic factors, and not classified

Etiology of AUB: in adolescents, the most common cause is an immature hypothalamic-pituitary-ovarian axis during the first 2 to 3 yr postmenarche; other causes include pregnancy complications, pelvic infections (vaginitis, cervicitis, or pelvic inflammatory disease), hormonal contraception inconsistencies, thyroid disorders, PCOS, hyperandrogenemia, and hyperprolactinemia; other causes may include bleeding disorders, vaginal trauma, malignancies (rare), cervical or uterine polyps, ovarian cysts or tumors, endometriosis, retained foreign bodies, systemic diseases (eg, diabetes, lupus, renal disease), and medication effects (eg, anticoagulants, psychiatric medications, contraceptives)

Assessment: to determine the cause, clinicians assess cycle regularity; regular cycles with menstrual cramps suggest normal ovulatory bleeding; regular heavy cycles warrant evaluation for bleeding disorders; irregular cycles without heavy bleeding indicate anovulation or endocrine dysfunction (eg, PCOS, thyroid disease); intermenstrual bleeding suggests infections or hormonal contraceptive-related breakthrough bleeding

History: a comprehensive history is essential; clinicians should inquire about menarche timing, cycle frequency, duration, and pad/tampon usage, including overnight protection and doubling up; patients experiencing “flooding” (sudden gushing of blood) or passing clots should specify clot size; questions regarding school absences, dizziness, syncope, prolonged epistaxis, easy bruising, or other medical conditions can help identify potential bleeding disorders; a confidential sexual history should also be obtained

Bleeding disorders: should be suspected if menarche is excessively heavy (lasting >10 days or requiring hourly pad changes), if cycles occur every 2 wk, if anemia is severe, if emergency room visits are needed for transfusions, or if blood clots >2 cm; approximately 33% of adolescents with HMB have a bleeding disorder, though the true prevalence is unknown; additional signs include persistent nosebleeds, gingival bleeding lasting >10 min, excessive bleeding from minor cuts, prolonged bleeding after dental procedures, and postpartum hemorrhage

Physical examination: should assess for orthostatic changes, tachycardia, pallor, hirsutism, severe acne, male-pattern balding, unexplained bruising, petechiae, hematomas, thyroid enlargement, abdominal masses, and genital trauma; a speculum examination is necessary only if the patient is sexually active and consents

Investigations: include a complete blood count, ferritin, pregnancy test, sexually transmitted infection screening, and androgen excess markers (free and total testosterone, dehydroepiandrosterone, androstenedione, 17-hydroxyprogesterone); if a bleeding disorder is suspected, obtain prothrombin time (PT), partial thromboplastin time (PTT), von Willebrand factor, factor VIII activity, ristocetin cofactor, and von Willebrand multimers; additional testing for factors VIII, IX, XI, and XIII may be needed based on PT/PTT results; platelet aggregation studies should be referred to hematology specialists; bleeding times are outdated and no longer recommended; patients with anemia (hemoglobin <10 g/dL) should not undergo von Willebrand testing immediately, as results may be skewed; testing should be deferred until the patient is stabilized on 30 to 35 μg estrogen for ≥3 mo; stress, inflammation, and high estrogen levels can also interfere with von Willebrand results

Imaging: pelvic ultrasonography is warranted if structural abnormalities or ovarian cysts are suspected; transvaginal ultrasonography should be performed only on sexually active patients because of the invasive nature of the probe; magnetic resonance imaging may be considered for equivocal ultrasonography findings, although structural abnormalities are rare in adolescents

Management: hormonal therapy is the primary treatment, aiming to stabilize the endometrium with estrogen for hemostasis and progestin for endometrial thinning; >90% of anovulatory bleeding cases respond to hormonal therapy, with surgical intervention rarely needed; language is crucial, ie, “hormonal medication” is preferable to “birth control” to minimize resistance; patients hesitant about hormonal therapy may benefit from educational resources before making a decision; outpatient management is appropriate for hemodynamically stable patients with hemoglobin >8 g/dL and no syncopal episodes; continuous hormonal therapy (skipping placebo pills) for 6 to 12 mo is recommended

Dosing: initial dosing includes one pill 3 times daily for a week, then tapering to twice daily for 7 to 14 days before maintaining a daily dose; a 30 to 35 μg estrogen pill is preferred over 20 μg to minimize breakthrough bleeding; levonorgestrel and norethindrone are common options; a newer formulation, estradiol valerate with dienogest (Natazia), is US Food and Drug Administration approved for HMB; for patients with contraindications to estrogen, eg, migraine with aura, progestin-only therapy (medroxyprogesterone acetate or norethindrone) is used continuously; if bleeding persists, a tapering regimen of medroxyprogesterone (20 mg 3 times daily for 7 days, then twice daily for a week, then once daily) or norethindrone (10 mg 3 times daily for 7 days, then tapering) is effective; medroxyprogesterone acetate (Depo-Provera) can also be given more frequently than every 12 wk until bleeding is controlled

Hospitalization: is required for patients with a hemoglobin <7 mg/dL, syncope, or significant orthostatic changes; intravenous estrogen (conjugated estrogen 25 mg every 4-6 hr for 24 hr) may be used for rapid stabilization, alongside hematology consultation for potential intravenous iron therapy; the levonorgestrel intrauterine device (Mirena) is the most effective long-term treatment, and nulliparous adolescents can safely receive it; hematology may prescribe tranexamic acid or aminocaproic acid for HMB because of bleeding disorders

Readings

Borzutzky C, Jaffray J. Diagnosis and management of heavy menstrual bleeding and bleeding disorders in adolescents. JAMA Pediatr. 2020;174(2):186-94. doi:10.1001/jamapediatrics.2019.5040; Carlson LJ, Shaw ND. Development of ovulatory menstrual cycles in adolescent girls. J Pediatr Adolesc Gynecol. 2019;32(3):249-53. doi:10.1016/j.jpag.2019.02.119; Elmaoğulları S, Aycan Z. Abnormal uterine bleeding in adolescents. J Clin Res Pediatr Endocrinol. 2018;10(3):191-97. doi:10.4274/jcrpe.0014; Hall EM, Ravelo AE, Aronoff SC, et al. Systematic review and meta-analysis of the etiology of heavy menstrual bleeding in 2,770 adolescent females. BMC Womens Health. 2024;24(1):136. doi:10.1186/s12905-024-02921-7; Itriyeva K. The normal menstrual cycle. Curr Probl Pediatr Adolesc Health Care. 2022;52(5):101183. doi:10.1016/j.cppeds.2022.101183; Mansour D, Hofmann A, Gemzell-Danielsson K. A review of clinical guidelines on the management of iron deficiency and iron-deficiency anemia in women with heavy menstrual bleeding. Adv Ther. 2021;38(1):201-25. doi:10.1007/s12325-020-01564-y; Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding: ACOG COMMITTEE OPINION, Number 785. Obstet Gynecol. 2019;134(3):e71-e83. doi:10.1097/AOG.0000000000003411; Wouk N, Helton M. Abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2019;99(7):435-43.

Disclosures

For this program, members of the faculty and the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Tanaka was recorded at Pediatrics in the Islands: Clinical Pearls 2024, held on October 28, 2024, in Waikoloa, HI, and presented by Children’s Hospital Los Angeles Medical Group. For information about upcoming CME activities from this presenter, please visit https://www.chla.org/chla-medical-group/cme-conferences. Audio Digest thanks the speakers and Children’s Hospital Los Angeles Medical Group for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

PD711601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.