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Clinical Practice Guidelines

Adolescent gynaecology - Heavy menstrual bleeding

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  • See also

    Adolescent Gynaecology - Lower Abdominal Pain
    Adolescent – Engaging and Assessing

    Key Points

    1. The most common cause of Heavy Menstrual Bleeding (HMB) in adolescents is anovulatory cycles
    2. Mild bleeding with a normal haemoglobin can be managed with reassurance, non-hormonal treatments and observation
    3. Pregnancy related bleeding and bleeding disorders are important differentials to consider
    4. Hormonal therapy aims to stabilise the endometrium

    Background

    • Normal menstrual blood loss: pads/tampon changes at ≥3 hour intervals, seldom overnight and fewer than 21 pads/tampons per cycle
    • Excessive menstrual flow is defined as any of the following:
      • >7 days duration or >80 mL 
      • necessitating changing a super pad/tampon more than every 2 hours
      • causing symptomatic anaemia
      • causing lifestyle disturbance
    • 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
    • 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)

    Causes

    • Pregnancy: miscarriage, ectopic pregnancy, gestational trophoblastic disease
    • Endocrine: anovulatory, 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

    Red flags in red

    History

    • Menstrual history (menarche, last menstrual period, frequency, duration, flow, pain, flooding, large clots (>2cm in diameter), and frequency of pad/tampon changes)
    • Impact on daily life: missing school, sports, social activities
    • Sexual history and contraception
    • Symptoms of
      • Anaemia: dizziness, shortness of breath, fatigue
      • Bleeding disorders: epistaxis, bleeding gums, easy bruising
    • Past medical history including: coagulopathy, platelet function disorders, recurrent haemorrhagic cysts, chronic medical conditions
    • Adolescent assessment (HEADSS screen)

    Examination

    • Vital signs: hypotension, tachycardia
    • Skin:  pallor, petechiae, bruising
    • Abdominal examination: tenderness or pelvic mass
    • Secondary signs of PCOS: acne, excess facial or body hair, weight gain

    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

    • FBE
    • Blood group and antibody screen for severe bleeding
    • Ferritin
    • Coagulation screen
    • TSH
    • Urine or blood ßhCG (with consent)
    • Consider pelvic ultrasound if bleeding accompanied by pain or palpable mass

    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

    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)

    Severity

    Treatment

    Mild

    Mild bleeding with a normal haemoglobin and 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

    • Combination estrogen-progesterone oral contraceptive pills ***

    or

    • Oral progesterone-only hormone therapy

    Severe

    IV Access
    Fluid bolus & Resuscitation
    Tranexamic acid

    Hormonal Therapy

    • High dose norethisterone

    Iron infusion as required or PRBC if haemodynamic instability despite fluid resuscitation

    Specialist review (Gynaecology) and consider inpatient observation

    *** Contraindications include (consider progesterone only): uncontrolled hypertension, cardiovascular disease, migraine with focal neurological signs, thrombosis risk

    All patients may benefit from iron supplements
    Consider a menstrual calendar or app (for example Clue, Flo)

    Non-hormonal

    • Tranexamic acid taken day 1–5 of menses can decrease flow by 25–50%. The usual dose in adolescents is 1 gram TDS (Dosing by weight 15–25 mg/kg 2–3 times a day, maximum 1 gram). Antifibrinolytics do not regulate the menstrual cycle, but reduce bleeding by inhibiting clot-dissolving enzymes in the endometrium
    • All NSAIDs (eg Mefenamic acid 500 mg TDS, Naproxen 500 mg BD) can decrease flow if taken regularly during menstruation.  These can be used in conjunction with tranexamic acid.  NSAIDs reduce the effects of prostaglandins, which are elevated in those with excessive menstrual bleeding, and may aid dysmenorrhoea symptoms

    Hormonal

    • Progestins (eg norethisterone 5 mg, medroxy-progesterone acetate 10 mg) generates a secretory endometrium and are good for anovulation (infrequent periods) due to the lack of progesterone

    Active bleeding acute treatment:

      • Norethisterone 5–10 mg can be taken 3 times daily for 10 days then weaned slowly (eg by 5 mg/week)
      • Alternatively, medroxy-progesterone acetate 10–20 mg 3 times per day for 10 days then weaned
      • 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)
    • Combined estrogen and progestin oral contraceptive pill: can decrease flow by 50% and is effective for anovulation or irregular menses.  Often started with a low dose estrogen and moderate progestin (eg ethinylestradiol 30 microg + levonorgestrel 150 microg) 

      • Active bleeding acute treatment

      • One pill every eight hours until the 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

    Contraindications include (consider progesterone only): smoking, uncontrolled hypertension, cardiovascular disease, migraine with focal neurological signs, thrombosis risk

    Consultation with local paediatric team when

    Consider admission for hemodynamically unstable patients with a low haemoglobin concentration or who have symptomatic anaemia

    Consider transfer when

    Advice regarding escalation of care if 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

    Patients can be discharged when stable and a review is scheduled:

    • within a month for mild bleeding
    • within 48 hours for ongoing mild to moderate bleeding (with confirmatory haemoglobin)

    If there are concerning or symptoms persist refer to paediatrician or local gynaecologist

    Parent information

    Heavy Periods (Royal Women’s Hospital - Vic)
    Heavy Periods (Women’s & Newborn Health – NSW)
    Heavy Menstrual Bleeding (Royal Australian & New Zealand college of Obstetricians and Gynaecology)
    Patient Information Oral contraceptives – skipping periods (Royal Children’s Hospital - Vic)

     

    Last Updated August 2020

  • Reference List

    1. Apter D 1997, Development of the Hypothalamic-Pituitary-ovarian Axis. Ann New York Acadmey Sci ;Jun 17(816):9–21.
    2. Apter D, Vihko R, 1983, Early menarche, a risk factor for breast cancer, indicates early onset of ovulatory cycles, J Clin Endocrinol Metab. 57(1):82–6.
    3. Bennett AR, Gray SH 2014, What to do when she's bleeding through : the recognition, evaluation, and management of abnormal uterine bleeding in adolescents, Curr Opin Pediatr;26:413–9.
    4. Bryant-smith A et al 2018, Antifibrinolytics for heavy menstrual bleeding ( Review ) Cochrane Database Syst Rev.
    5. De Silva N, 2019, Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis [Internet], Uptodate, Available from: https://www.uptodate.com/contents/abnormal-uterine-bleeding-in-adolescents-evaluation-and-approach-to-diagnosis
    6. De Silva N 2019, Abnormal uterine bleeding in adolescents: Management [Internet]. UpToDate. Available from: https://www.uptodate.com/contents/abnormal-uterine-bleeding-in-adolescents-management
    7. Howell J, Flowers D 2016, Prepubertal Vaginal Bleeding: Etiology, Diagnostic Approach, and Management, Obstet Gynecol; 71(4):231–42.
    8. Kaunitz A 2019, Approach to abnormal uterine bleeding in nonpregnant reproductive-age women [Internet], UpToDate,  Available from: https://www.uptodate.com/contents/approach-to-abnormal-uterine-bleeding-in-nonpregnant-reproductive-age-women
    9. Rodriguez B, Lethaby A, Farquhar C 2019, Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding, Cochrane Database Syst Rev;31535715.
    10. Sriprasert I et al 2017, Heavy menstrual bleeding diagnosis and medical management, Contracept Reprod Med, 2(20):1–8.