See also
Adolescent gynaecology - lower abdominal pain
Dysmenorrhoea
Engaging and assessing the adolescent
Sexual health history taking in the adolescent
Contraception
Key points
- The most common cause of heavy menstrual bleeding (HMB) in adolescents is anovulatory cycles
- Pregnancy-related bleeding and bleeding disorders are important differentials to consider
- Non-hormonal and hormonal treatments can be used in combination
- Mild bleeding with a normal haemoglobin can be managed with non-hormonal treatments and observation
Background
- In normal menstrual blood loss, pads or tampons are changed at ≥3-hour intervals, seldom overnight and there are fewer than 21 pads/tampons per cycle
- Excessive menstrual flow is defined as any of the following
- >7 days duration or >80 mL per cycle
- bleeding necessitating changing a super pad/tampon more than every 2 hours
- causing symptomatic anaemia
- causing lifestyle disturbance
- Anovulatory uterine bleeding is excessive noncyclic uterine bleeding related to immaturity of the hypothalamic-pituitary-ovarian axis (in the absence of structural uterine lesions or systemic disease)
- Menstrual cycles are often irregular and anovulatory in the first few years after menarche. The time to establish regular ovulatory cycles increases with increasing age of menarche
Causes
- Pregnancy: miscarriage, ectopic pregnancy, gestational trophoblastic disease
- Endocrine: anovulatory cycles (most common cause in adolescence), thyroid dysfunction, polycystic ovarian syndrome (PCOS)
- Haematological: von Willebrand Disease, platelet function disorder, thrombocytopenia, other bleeding disorder
- Medication: hormonal contraception, anticoagulants
- Other: trauma, infection, malignancy, structural causes (uncommon in adolescence), gastrointestinal bleeding
Assessment
History
- Menstrual history (menarche, last menstrual period, frequency, duration, flow, pain, flooding, large clots (>2 cm in diameter), and frequency of pad/tampon changes)
-
Symptoms of anaemia
- dizziness, shortness of breath, fatigue
- Symptoms of bleeding disorders
- epistaxis, bleeding gums, easy bruising
- Sexual history and adolescent assessment (HEADSS screen)
- Past medical history including coagulopathy, platelet function disorders, recurrent haemorrhagic cysts
- Impact on daily life eg missing school, sports, social activities
- Factors which may influence treatment choice
- Presence of concomitant menstrual symptoms (Dysmenorrhoea, mid cycle pain, luteal phase symptoms such as nausea, breast tenderness, bloating)
- Desire for contraception
Examination
- Vital signs: hypotension, tachycardia
- Skin: pallor, petechiae, bruising
- Abdominal examination: tenderness or pelvic mass
- Vaginal examination is rarely indicated in an adolescent. It should be discussed with a senior clinician, and if needed should only be performed once
Assessment of severity
| Mild |
Slightly or moderately increased menstrual flow with normal haemoglobin |
| Moderate |
Moderately prolonged or frequent menses (every 1–3 weeks), with moderate to heavy flow and reduced haemoglobin (≥100 g/L) |
| Severe |
Heavy bleeding with haemoglobin <100 g/L and/or haemodynamic instability |
Management
Investigations
Consider
- FBE
- Ferritin
- Coagulation screen
- TSH
- Urine or blood ßhCG (with consent)
- Blood group and antibody screen if severe bleeding
If a bleeding disorder is suspected, consider platelet function assay (PFA) 100 and von Willebrand screen. These tests should not be done during acute bleeding or with recent NSAID use
Pelvic ultrasound is rarely required. Consider if there are atypical features or a palpable mass
Treatment
- Treatment is targeted to the underlying cause. For anovulatory bleeding, the objective is to stabilise the endometrium (oestrogen for initial haemostasis and progestins for extended endometrial stability)
- Consider iron supplementation
- Consider a menstrual calendar or app eg Clue®, Flo®
Acute management
| Severity |
Treatment |
| Mild |
If no desire for contraception, provide reassurance and observation
Consider non-hormonal management such as regular NSAIDs and tranexamic acid during menses |
| Moderate |
Tranexamic acid during menses
Hormonal therapy:
- Oral progesterone-only hormone therapy
or
- Combination oestrogen-progesterone oral contraceptive pills
|
| Severe |
Consider other causes such as pregnancy or bleeding disorder
IV access
Resuscitation
Tranexamic acid
Hormonal therapy eg high dose norethisterone
Iron infusion as required or packed red blood cells (PRBC) if haemodynamic instability despite fluid resuscitation. See blood product prescription
Specialist review (gynaecology) and consider inpatient observation |
Non-hormonal medications
- Tranexamic acid 15-25 mg/kg (maximum 1 g) 2-3 times a day for days of heavy bleeding can decrease flow by 25-50%
- NSAIDs (eg mefenamic acid 500 mg tds, naproxen 500 mg bd) can decrease flow if taken regularly during menstruation. NSAIDs can be used in conjunction with tranexamic acid
Hormonal medications
- Progestins (eg norethisterone 5 mg, medroxyprogesterone acetate 10 mg) generates a secretory endometrium and are good for anovulation due to the lack of progesterone
- Use in active bleeding
- Norethisterone 5-10 mg can be taken 3 times daily for 10 days then weaned slowly (eg by 5 mg/week)
- Alternatively, medroxyprogesterone acetate 10-20 mg tds for 10 days then cease or continue with 10 mg daily prophylactic treatment (see below)
- Notes:
- if progesterone-only treatment is stopped abruptly this will precipitate bleeding
- seek specialist advice for higher doses or patients not responding to initial treatment
- Prophylactic treatment
- Norethisterone 5-10 mg or medroxyprogesterone acetate 10 mg daily taken continuously
- Depot medroxyprogesterone-acetate 150 mg IM every 12 weeks
- Mirena (levonorgestrel intrauterine device) 5-8 yearly
- Combined oestrogen and progestin oral contraceptive pill can decrease flow by 50% and is effective for anovulation or irregular menses. Often started with a low dose oestrogen and moderate progestin (eg ethinylestradiol 30 microg + levonorgestrel 150 microg). See Contraindications
- Use in active bleeding
- One pill every eight hours until bleeding stops (usually within 48 hours), then
- One pill every 12 hours for 3 days, then
- One pill daily continuously until outpatient review with GP or gynaecology
- Prophylactic treatment
Follow up
GP or paediatrician in 2 weeks to ensure resolution of active bleeding
After commencement of maintenance therapy, follow up in 3-4 months (usually equating to 3-4 periods) to assess efficacy of management
Consider consultation with gynaecology team when
- Features of severe bleeding
- Haemodynamically unstable
- Symptomatic anaemia
- Haemoglobin <100 g/L
- Not responding to empiric treatment with tranexamic acid and/or hormonal treatment
Consider transfer when
Advice regarding escalation of care beyond the local centre capabilities or unable to control bleeding
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services
Consider discharge when
Stable, and a review is scheduled
- within a month for mild bleeding
- within 48 hours for ongoing heavy bleeding
Parent information
Heavy periods (Raising Children Network)
Heavy Menstrual Bleeding (Royal Australian & New Zealand college of Obstetricians and Gynaecology)
Patient Information Oral contraceptives - skipping periods (Royal Children's Hospital Melbourne)
Last updated June 2025