Adolescent gynaecology - Heavy menstrual bleeding


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Adolescent Gynaecology - Lower Abdominal Pain

    Definition

    1. excessive menstrual flow in its duration (>7 days) or its volume (equates to needing to change a super pad/tampon more frequently than every two hours)
    2. Bleeding causing symptomatic anaemia or lifestyle disturbance

    Background

    Menstrual cycles are often irregular in the first years after menarche.
    Most cases of cases of heavy menstrual bleeding in adolescents can be caused by anovulatory cycles, which is related to immaturity of the hypothalamic-pituitary-ovarian axis. Other causes include pregnancy, infection, the use of hormonal contraceptives, stress (psychogenic or exercise induced), under- and over-weight or weight changes, and bleeding disorders.
    Less common causes of heavy menstrual bleeding in adolescents include systemic illness and endocrine disorders. Structural lesions that cause heavy menstrual bleeding in adolescents are incredibely rare (cervical polyps and uterine leiomyomas such as fibroids).

    Assessment

    History:

    1. Menstrual history (menarche, last menstrual period, frequency, duration, flow, pain)
    2. Bruising
    3. Galactorrhea
    4. Lethargy, headache

    Examination:

    1. Pallor
    2. Evaluation for signs of androgen excess: hirsutism; acne;
    3. Examination of the skin for acanthosis nigricans or signs of abnormal bleeding (eg, petechiae and/or bruising)
    4. Palpation of the abdomen for uterine or ovarian mass

    Investigations:

    1. FBE & Ferritin
    2. Coagulation screen
    3. ßhCG
    4. Measurement of serum TSH to exclude thyroid abnormalities
    5. Consider pelvic ultrasonography if accompanied by pain or palpable mass (to exclude structural causes, such as fibroids, polyps, and/or ovarian tumors)

    Management

    • Single or combination of non-hormonal and hormonal treatment (for example NSAIDS & Tranexamic acid & Progesterone) can be used depending on severity

    Non-hormonal forms of treatment

    • If anaemic or recurrent/severe bleeding: Iron supplements
    • First line to decrease flow:
      • NSAIDS (Naproxen, Mefenamin acid, Ibuprofen) - unless contraindicated. Can decrease flow up to 30% if taken regularly during the first 48 hours of menstruation
      • Tranexamic acid (1 gram, every 6 hours) can decrease flow 50%, does not reduce the duration of menses or regulate the menstrual cycle, needs to be taken for 3-5 days following cessation of bleeding

    Hormonal forms of treatment

    • Progesterone (e.g. Norethisterone 5mg, Medroxy-progesterone acetate 10mg). Good with anovulation (infrequent periods) due to the lack of progesterone
      • Acute treatment: 5-10 mg x 21 days (N.B. Will bleed when ceased!)
      • Prophylactic treatment: 7-10 days/month
    • Combined oral contraceptive pill : can decrease flow by 50%. Good with anovulation/irregular menses: often commence with Ethinylestradiol 30mcg/Levonorgestrel 150mcg, and transition to continuous use after the first month’s withdrawal bleed.

    Discharge criteria & follow up

    Organize follow up with GP within a month. If concerned or persistent symptoms refer to Paediatrician or local Gynaecologist.

    When to admit/consult local paediatric team

    Admission for hemodynamically unstable adolescents with a low hemoglobin concentration, or who have symptomatic anemia.

    When to consider transfer to tertiary centre

    If unable to control bleeding

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Parent information sheet 

    Information Specific to RCH – contact the oncall gynaecology fellow/consultant via switch for advice and/or admission.