18 - Menstrual Concerns in the Adoelscent

We walk through a clear roadmap for evaluating heavy menstrual bleeding in teens, from what counts as normal to when labs and treatment should start. A case of a 15-year-old with 10-day periods and nosebleeds anchors a practical workup and evidence-based care plan.

• Normal adolescent cycle ranges and red flags for heavy bleeding
• Definitions that guide when to test and treat
• Key causes in teens: anovulation and coagulopathy
• Focused history and exam without routine pelvic exams
• Labs that matter: pregnancy, ferritin, thyroid, coagulation, von Willebrand
• When imaging helps and when it delays care
• Iron repletion strategies and when to use IV iron
• Hormonal vs nonhormonal therapy, adherence, and expectations
• Acute management thresholds, IV estrogen, and layering therapy
• Long-term options including levonorgestrel IUD and progestins

What is PAG?
Pediatric and Adolescent Gynecology is a subspecialty of OBGYN (2 year fellowship) focusing on reproductive healthcare for children and young adults. It fills the overlap between general gynecologists and pediatricians. It is a multi-disciplinary field involving work with pediatric endocrinology, dermatology, hematology, surgery, ect. Go to NASPAG.org for more PAG educational resources.

Want to test your knowledge?
PAG WebEd cases are a great way to review our podcast content. 

Transcript

Case: Teen With Heavy Periods

SPEAKER_00 0:24

A 15-year-old underwent menarchy three months ago. Her periods have been heavy, lasting 10 days. She soaks through a maxi pad every one to two hours for the first six days and passes large plots the size of a half dollar. She's tired, pale, and has frequent nosebleeds that lasts 12 minutes. Hi everyone, and welcome to Pagover Pastries, a 20 to 30 minute review podcast regarding all things pediatric and adolescent gynecology. I'm Dr. Camille Imbo, a now graduated pediatric and adolescent gynecologist at Spark Gynecology in St. Petersburg, Florida. And today I have with me I'm Dr.

SPEAKER_01 1:00

Trisha Hugelet. I am a pediatric and adolescent gynecologist at Children's Hospital, Colorado in Denver.

SPEAKER_00 1:05

Thank you so much for joining us today. Today we'll be talking about common menstrual concerns in the adolescent. We have two references. One is our trusted NASPAC book, Essentials of Pediatric and Adolescent Gynecology. This is chapter nine by Nancy Sakari and Oyu Messi Areyemi Fuore. And we also have a JPEG article, Heavy Menstrual Bleeding in Adolescence by Drs. Hamid, Saz, and Dietrich. So as always, what is your favorite pastry?

SPEAKER_01 1:35

Definitely a blueberry muffin that has all the like sugar crumbles on top. Alright, let's get started.

SPEAKER_00 1:46

So let's talk about abnormal uterine bleeding and menstrual bleeding because it's a very common complaint in teens. So before we talk about abnormal, do you want to do a quick review of what's normal in those first few years after menarchy?

SPEAKER_01 1:59

Patients commonly are, you know, saying, well, they don't know what's abnormal if they don't know what's normal. And in adolescence, it can be anywhere from every 21 to upwards of every 45 days, is considered normal. Typically, mencies should be lasting in duration less than seven days, and on average, changing maybe three to six pads or tampons in a day. Clots are normal, but usually have a very small size, certainly less than a one-inch diameter or what we refer to as a quarter. Although frequently cycles are going to be anovulatory in the first couple of years, by the third year after menarchy, about 60 to 80% of cycles should be between 21 to 35 days.

Defining Abnormal Uterine Bleeding

SPEAKER_00 2:37

Yeah, I often will tell people it can be up to six years before it's in that 90 to 100% of teens. So I'll say by the time you graduate high school. Exactly. There's actually a study that showed that out of 848 girls, 41.3% reported irregular mences and 17.2% had cell kills longer than six days. So just like we said, in that 12 to 14 age group, it's extremely common to be irregular compared to the slightly older teens, but doesn't mean that they should just ignore if they have irregular or abnormal periods because it's important that we differentiate a normal irregular versus completely abnormal. So what is the official definition of abnormal uterine bleeding?

SPEAKER_01 3:22

Basically, bleeding from the uterus, it's abnormal in volume, which we consider greater than 80cc or more of blood loss to be abnormally heavy, which is really hard to estimate for a patient, which is exactly why we ask, you know, are you soaking tampons or pads every one to two hours? Are you passing quarter size clots? Are you having regular flooding accents? Because that's getting at that abnormal heavy volume. If they are having bleeding more frequently than every 21 days or less frequently than every 45 days, if they're bleeding consistently eight or more days in a row, unrelated to pregnancy, that's definitely abnormal.

SPEAKER_00 3:58

As simple as this is, this is one of the most important things I learned through my fellowship because I feel that with adult Obi Chulan, we're really just asking when was your last menstrual period? Is it normal? Is it not? And something else, as we talk about like more than six pads a day, is also are they changing just out of discomfort? So it's like, are those pads actually full if they're having more than six a day? Or on the other end, if they're like, oh yeah, I'm soaking through a pad, but then they say they only change once or twice a day. And it's like, oh, okay, you're just not changing enough, and that's why you're soaking. So there's a lot of that importance of really dissecting all the answers we get from our teens.

SPEAKER_01 4:33

That's such a great point. And then I think the other thing that we all know is ultimately, which is part of why the definition has changed, is it impacting your quality of life, right? So are you missing school? Are you missing activities? Are you missing sleepovers? Well, if you are, that's actually abnormal, and we need to do something about it. But certainly all these other objective questions really get at, are we really worried about this bleeding?

Causes: PALM-COEIN For Teens

SPEAKER_00 4:55

The most common things that teens will present with are all the way from no bleeding at all, amenorrhea, heavy menstrual bleeding, shortened menstrual bleeding, or intermenstrual bleeding. So, how do we classify abnormal uterine bleeding in non-pregnant women? What's kind of our categorical breakdown?

SPEAKER_01 5:13

Sure. So we still, you know, commonly use a Palm Cohen acronym for breaking down abnormal uterine bleeding, and that standing for P for polyps, A adenomyosis, L liomyosis, M for malignancies, C coopathy, O ovulatory, E endometrial, Iatrogenic, and then finally N none of the above. In the adolescent, we're really drilling down to usually just a couple of etiologies, ovulatory and coagulopathy.

SPEAKER_00 5:46

Right. Yeah. And in the ovulatory, because that has to do with puberty, immaturity of the HBO axis, which I feel like 80 to 90% of the time, that's the reason why. Or of course, never forgetting that just because they're teenagers, pregnancy and breastfeeding is still one. And from a pathological perspective, though, what other are common reasons for abnormal bleeding in teens?

SPEAKER_01 6:10

Getting at that, you know, ovulatory and ovulatory etiologies, of course, polycystic ovary syndrome, PCOS, is one of the most common etiologies. Of course, then you can certainly have your less common hyperandrogenic disorder, so androgen-producing tumors, adult onset, congenital adrenal hyperplasia. If you're looking more at hypothalamic dysfunction, baby from disordered eating, anorexia, bulimia, or as we're seeing more and more AFID these days, that can definitely really impact and cause menstrual irregularity. Certainly, of course, hyperprolactinemia, whether it's from a prolactinoma or medication-induced, certainly thyroid disease, it's a great masquerad. It presents in many different ways, including menstrual dysfunction. And then, of course, unfortunately, sometimes we're actually dealing with premature ovarian insufficiency. And so thinking about that. And then finally, iatrogenic, maybe chemotherapy, radiation. We have all had those patients where you have a whole conversation with them and they're like, I'm taking hormonal therapy. So, of course, iatrogenic hormonal bleeding that sometimes they forget to lead with that. They end with that in the conversation. Always important to remember that one too.

History And Physical Priorities

SPEAKER_00 7:18

Yeah, I've at some point switched my kind of line of questioning by starting with, have you been treated for this by someone else or worked up? Because that will speed through things already. If they're like, oh yeah, I started on birth control, I didn't like it, and I stopped it a week ago or something like that. On that line of thinking, other things that we'd ask. So we've already drilled down the questions we asked related to their periods, but their menstrual history as far as when they started, especially if they're coming in with an abnormality like irregularity or anything like that, we want to get a good understanding of how long that's been going on for. Is it since their period started, or is that a sudden change? That helps then go off into those diagnoses you mentioned. Because is there an event that was a catalyst to this change? Other things of exactly as you mentioned, the impact on their quality of life. I think that's so incredibly important and a conversation to have with parents as well, because sometimes we're like, I had horrible periods and I'm fine, so it should be fine for her. And I say, just like you said, if she's not happy, we can do something about it. So there's no reason for her to suffer, even if it wouldn't be suffering for another patient. And then also not forgetting, just like we shouldn't forget about pregnancy, but that bleeding can not necessarily be uterine, so sexual activity, abuse, trauma, because it can be from the vulva, vagina, or cervix as well, which kind of leads into if you're doing a physical exam, when what would you be looking for?

SPEAKER_01 8:49

One of the first things I'll do even before I start the physical exam is actually look at their growth chart. You know, what's their BMI? Are they, you know, have a really high BMI and we're thinking maybe PCOS? Did they fall off the weight curve? And we're actually thinking about disordered eatings. With that, then of course, vital signs, making sure they're hemodynamically stable. Then a good skin exam, again, thinking about the hyperandrogenic patient and looking for things like acne, hairsuit features, akanthosis. If we're thinking about, you know, signs of anemia or and or a bleeding disorder, you know, how pale are they? Are there big, large bruises, especially in uncharacteristic locations, batechite, you know, other echymoses? Um, a good thyroid exam is always important. Again, thinking about thyroid dysfunction. And with an abdominal exam, just generally, you know, is there any signs of a potentially pelvic abdominal mass? It's actually what's causing the bleeding, or even like hepatosplenomegaly and some sort of sequestration that's resulting in the bleeding. And then always good to know where they are in their pubertal maturation and so their sexual maturity rating, at least potentially a breast exam, depending on the patient's comfort and how important you think that is to the clinical picture. You know, is it not clear where they're at in their puberty progression? And then really reserving the pelvic exam for the patient where it's really indicated patients do not need a pelvic exam in order to assess their bleeding. And the majority is not related to, you know, sexual activity, sexual trauma.

Labs That Actually Change Care

SPEAKER_00 10:12

Right. That's a big difference from adult patients where pretty much doing a pelvic exam for just about all complaints that they present with versus in teens, we want to be as least invasive as possible. And so many of the things that you mentioned, we can get before we're even actually officially doing the physical exam, right? The MA comes in with the vital signs. And then as we're talking with them, sometimes I'll look at their skin color versus their parents. It's like, oh, is she usually more pale than you? Lab-wise, we, as I mentioned, we want to do a pregnancy test. And then in the office as well, back in fellowship, we had a hemoglobin, a point of cure. Is that something that you do as well?

SPEAKER_01 10:52

So that's a great question. We actually usually will just send patients to the lab for the reason being is that it's not just the hemoglobin that we want, but more importantly the ferritin. And I think that's something that, especially in the adult world, that often gets forgotten. We know that there are such high rates of iron deficiency in adolescents, with the number one reason being from heavy menstrual bleeding, the number two being poor iron in their diet and iron absorption, but the just rates are so high. And there have actually been some really nice studies that show upwards of 50% of teens would have missed their iron deficiency based on the CBC alone, even when you looked at the um red cell indices, because those are, you know, the last things to change and the ferritin is the first thing to drop. So really remembering that iron stores are so important. But certainly if you're in a in a setting where you're concerned about a girl's bleeding and you don't have that easy lab access, then it's always a great test to do.

Imaging: When And Why

SPEAKER_00 11:46

Especially because sometimes people will get a CBC in their anemic and then just start treating iron. And, you know, while there's a huge percentage that it's iron deficiency anemia, there are other causes as well. And sometimes it's way down the road that it's like, huh, their anemia is still not responding. Other things we can add is TSH for the thyroid, as we've mentioned, testing for bleeding disorders, especially von Willebrand disease, is extremely common. STIs, testosterone, DHAS, 17 OHP, those, if you're leaning towards thinking there's any signs of hyperandrogenism, and then prolactin as well can affect periods. What about imaging? How often are you doing imaging on these patients?

SPEAKER_01 12:29

I'm sure you know moms come in and they're like, oh, are we not getting a pulp pulpic ultrasound? What about the ultrasound? What about the cyst? And the reality is, is we know that the incidence of structural etiologies to causing heavy menstrual bleeding in the adolescent are rare. So we really don't need to lead with that test. Now, certainly, if the patients aren't responding to therapy, then absolutely you want to get an ultrasound. Look at the endometrial stripe. You know, is it thick? Is it thin? Maybe there is some ovarian cyst or mass, although that's a much more unlikely. Um, so really that pelvic imaging is sort of second-tier testing. Definitely. I mean, if you think about the statistics, upwards of 30% of patients with heavy menstrual bleeding at teens have a bleeding disorder. So I'm definitely thinking about, you know, a bleeding disorder workup well before imaging. And I think that surprises a lot of parents because right, again, that whole palm cohen index, we know that for teens, it's down to two coagulopathy and ovulatory dysfunction, whereas for adult women it's much larger. And that's then really where the pelvic imaging can be helpful, but not usually in the teen.

Treatment Framework And Goals

SPEAKER_00 13:28

And it can delay care sometimes. I'll have patients come into the emergency room and I don't get the phone call until hours later because they were waiting for the pelvic ultrasound. And then I'm like, she didn't even need the ultrasound in the first place. Okay, so then let's talk about treatment. Although, of course, it depends on what it is, but generally speaking, what are the types of treatments that you're going over with patients and their families?

Hormonal And Nonhormonal Options

SPEAKER_01 13:52

So, as you said, obviously ultimately trying to go for treat the underlying etiology, if there's high thyroid dysfunction, what have you, obviously addressing that, or if there's medication, you know, causing the bleeding, potentially adjusting that. But in general, um, we know that hormonal therapy is sort of first line and really the mainstay of therapy. But, you know, a lot of patients and families come potentially with worries about hormonal therapy or just sort of preconceived notions. So I always start by reading the room and, you know, really talking about being a shared decision and saying, look, there's hormonal therapies and there's non-hormonal therapies like antifibrinolytics. And then of course there's iron, which everybody should have on top of whatever you choose. And so then we'll just kind of so that I think just starting the conversation with, look, both options are on the table, but let me explain to you now, you know, that trenoximic acid is not going to do anything for ovulatory dysfunction and regulating the cycle or stopping the bleeding. It's really designed, you know, just to reduce volume of blood loss. Whereas hormonal therapy has the benefit of doing all of those things, regulating the cycle, shortening the cycle, lightening the volume of bleeding, addressing the cramping. And when you talk about quality of life for so many of these girls, and there's been good literature on this, they'll say, no, no, no, no. I know I'm having heavy bleeding, but it's the cramping along with it that's keeping me from school that's really impacting my life. And you're not hearing me because we're talking about bleeding, and they're thinking you're not hearing them about the pain.

SPEAKER_00 15:16

It takes kind of talking through the options and then tailoring the treatment to the patient, simplifying it to patients, especially when it's younger patients, and saying your hormones are a roller coaster right now. There's your body's still figuring it out. So by giving you the hormones, I'm telling your body what the output should be and what it should look like. And also reminding them it doesn't necessarily have to be a lifelong thing. As we've said, you know, 60% of patients, 60 to 80% normalize after three years, but up to 90% after six years. So that helps calm patients down sometimes too, because sometimes people think it's going to be a lifelong treatment.

SPEAKER_01 15:52

And then I'm also, you know, it's a combination of how severe is the bleeding, how severe is the anemia, or not. Is it just quality of life versus I'm really worried about this patient? And then what are their goals? Because certainly for somebody who's really severely anemic, iron deficient, you know, they really probably need menstrual suppression for a little while. You know, then something like northendrone acetate is going to be really high on my recommendation list, and I'm going to explain why, versus somebody else who, you know, and the lead magester, of course, IUD, um, versus a patient that we're just really trying to regulate the cycle. We've got some time, we don't need complete menstrual suppression, maybe they don't like the idea of having a suppressed period, then you know, something combination, estrogen, progesterone, I think is a much more reasonable option. So yeah, it's trying to meet the patient where they're at, but also depending upon how sick or not sick they are.

Estrogen Contraindications And Progestins

SPEAKER_00 16:40

That leads right into our next topic of you know, going into a little bit more about hormonal treatments. So, first we have the combined versions of estrogen and progestin, and you know, the lovely aspect of a lot of patients when they think birth control, they only think about the pills. So it's really nice to cover all of the different options that there are. And I separate it from the perspective of how often you want to do something. So, do you want to remember pills every day, patches every week, shots every three months, or something more long-term, like the IUD, emphasizing that whatever treatment they choose, if they forget to take the medications or are all over the place with it, they can actually make things worse for themselves. So it's extremely important that they pick something that they're gonna be steady with.

SPEAKER_01 17:26

For sure. How many of our patients have come to you as a you know, second opinion or what have you and said, Oh, those birth control pills, they don't work? Like, well, let's talk about that, right? Was it that they didn't work or was it a compliance issue and it's just not the right option for them?

SPEAKER_00 17:39

Now, what about our patients who can't have estrogen? What options do they have?

SPEAKER_01 17:44

You know, it's a careful conversation with patients to understand why. And then the beauty is we do have progestin-only options that are very effective. I think the most important there is reassurance to the patients and families that these are also very effective. It's gonna be a different bleeding pattern, right? And so if somebody's like, wait, what? I, you know, I'm not gonna have a period or I'm gonna have a less frequent period, just you know, making sure they understand so they don't feel that there's something wrong there. I think then usually, you know, especially if patients that are coming and complaining of heavy bleeding and cramping, they're more than happy to take a break from their cycle, right? It's just all about education and and sort of expectation setting.

Admission Thresholds And Acute Care

SPEAKER_00 18:21

And one of the ones you mentioned that I absolutely love is northangeline acetate, partially because it's not technically birth control, even though it works the exact same way. For some reason, that resonates for a lot of families and patients, and they love that. And I especially love it for our much younger patients where sexual activity is not part of the concern, our special needs patients where they want menstrual suppression, which we'll talk about in another podcast, but it's really great. And because it's something where if one pill, five milligrams a day, isn't quite perfect, we can increase up to 15 milligrams a day because I know there's that frustration oftentimes where if one doesn't work after three months, we're switching to a completely different type of birth control. So with at least north ingeline acetate, we have some time and wiggle room with it. It's a great point. So we've talked about how we treat these patients outpatient, but at what point in time do you determine, oh, they should be admitted?

Transition To Outpatient Regimens

SPEAKER_01 19:21

In general, certainly patients that have active bleeding with a hemoglobin less than eight, they may not have room to drop. I mean, you've got bleeding that you still need to get under control, and they're really at a range where they, you know, need a blood transfusion. So those can be some common thresholds used. Certainly if they're hemodynamically unstable, hypotensive tachycardic, needing volume resuscitation, they, you know, should not be managed in the outpatient setting at that point. And again, in addition to volume resuscitation, which I sometimes see, you know, we quickly jump to the blood transfusion, but remembering still volume resuscitation, that there's a lot of volume in menstrual blood loss, not just packed red blood cells. So doing both and then getting hormonal treatment, it is absolutely the mainstay. IV estrogen, and we know is very effective. It's effective within just a couple of doses. Doing whether an a high dose taper, there is good evidence that whether it's a combined oral contraceptive pill taper or progestin-only taper, both all are really very effective at achieving amenorrhea within a few days. Of course, not. So not all medicines are available and there are certain side effects. You know, we all have our biases. I personally don't use the combined oral contraceptive pill taper as much because of the nausea that we can see, but we do know they work. And then not forgetting about how important the antiferminalytics are. So much good literature in the obstetric literature, in the surgery literature, and in the menstrual management literature, that it's very effective and safe, even in combination with estrogen when you have somebody acutely bleeding.

Returning To The Case: Likely VWD

SPEAKER_00 20:53

And something else that you mentioned, which is definitely important, of transfusion if they're severely anemic, but that it's not just about those packed red blood cells. FFP is something that comes into play if we're having to transfuse more than four units, some say six units. So now we've stabilized our patient. They're not bleeding anymore. We've gotten their hemoglobin back to normal. So they've been on the, let's say, IV estrogen since that's the most common in iron and they got their TXA. What are we transitioning them to? What's the plan to send them home?

SPEAKER_01 21:28

We are usually doing, you know, progestin therapy. Northindrone acetate is definitely one of our best friends because we know it's so good at achieving menstrual stabilization. But certainly oral contraceptive pills are an option as well, as well as trenoxymic acid. Once they follow up and they're back in the ambulatory setting, then having a real conversation with them about the efficacy of the leaving registeral IUD, we know it is hands down the most effective at reducing menstrual blood volume, like how much blood loss you can really reduce, as well as a very, very, very high patient satisfaction. We all know that, you know, in the setting of heavy bleeding and that initial withdrawal bleeding, there's a higher risk for IUD expulsion than there is as well in patients with known bleeding disorder. So until we've fettered that out, that's not something I'm generally using in that acute setting and sending them home, but it's absolutely a conversation we're starting to have and what I hope to transition a lot of my patients to.

Key Takeaways And Resources

SPEAKER_00 22:23

And a big thing with these transition as well is layering them. So being very careful that we don't want to stop the estrogen, wait hours, right? It's a Q6. So wait eight, 10 hours before we start the next thing because if they start bleeding again, we may have to start all over. So I always very specifically write in my notes if they're you know admitted to the hospitalist theme, is give the last dose of estrogen and then immediately start whatever they pick to go with. And of course, this depends on what's available in the hospital, if they want patches, if they want a shot of the depo provera. And then in the office, as you talked about, then we can kind of break it down a little bit more, but just explaining to them, I don't I just don't want you to bleed for another month or two. Let your body recuperate.

SPEAKER_01 23:09

It's such a good point. I'm so glad you brought that one up because we talk about that all the time too. And that, yeah, what's how quickly can we get the oral therapy going on top of the IV estrogen? Um, because that's going to be the maintenance, and the the worst thing we could do is induce a hormonal withdrawal bleed.

SPEAKER_00 23:23

Absolutely. So going back to our case, we had a 15-year-old who presented with heavy menstrual bleeding that lasts 10 days, starting three months after her menarchy. She soaks through a maxi pad every one to two hours for the first six days and passes large clots the size of a half dollar. She's tired, pale, has frequent noseblees that last 12 minutes. So, based on everything that we talked about, what are we thinking is most likely going on and what is our workup for her?

SPEAKER_01 23:52

We've hopefully convinced everybody enough that she definitely should have a bleeding disorder evaluation. This is a significant amount of bleeding, and the odds are very high that she could have one. So after doing a thorough history and your physical exam, testing should include a pregnancy test, thyroid function, clotting factor time, so PTPTT, a ferritin, of course, because many of these girls are iron deficient, and then a von Willebrand panel. So labs, you could also consider looking for, you know, hypothalamic immaturity, include ganatotropins and an estradiol. Usually, a lot of times those are reserved when patients having less frequent bleeding, periods of amenorrhea. So something to consider, but not necessarily always necessary, you know, in this acute setting. But then ultimately, in this patient, she did have a von Willebrand panel consistent with type one von Willebrand's disease and with both low antigen and activity, and therefore warrants the options for both hormonal and non-hormonal therapy long term.

SPEAKER_00 24:49

Right. Especially the von Willebrand patients, sometimes they need two forms of hormones at the same time because they will just bleed through anything. And something else to consider is during this acute bleed, let's say she was someone who was severely anemic in the hospital, sometimes the von Willebrand may not be as accurate. And especially if they started transfusing or started estrogen before they got that lab for von Willebrand, it again may not be accurate. So that's something to not immediately throw away as normal just because it you how it came back before, if the rest of the workup was normal and it still seems very likely that she has a coagulopathy to test for it again. Usually we say a couple of months in after their acute bleeding has subsided.

SPEAKER_01 25:36

That's an excellent point as well. Absolutely. I think the literature is supportive that. We know, and it's an acute phase reactant, right? Exactly. Yeah, I think the two take homes for me that I see the most are one, the iron deficiency, not only screening for it, but treating them and giving them the option for IV iron, because so many girls are so severely iron deficient and it can just take months of oral repletion that they may not be able to tolerate to get them feeling better and improve their quality of life. And then two, again, remembering the just the high prevalence of bleeding disorders, because for the vast majority of patients that I diagnose, um, and I diagnose them daily and weekly, their families have no idea. And so you're finally really starting to change like how their families and how the women in their and their families get care. And it's so it's important.

SPEAKER_00 26:24

Well, thank you so much for your time with us, Trisha, today. For more information, visit the Pagover Pastries page on the NASPEG website. This will include transcript of all the podcasts, links to the references, and any tables that we mentioned. If you have any questions for our speaker today or any feedback, email Pagoverpastries at gmail.com. But otherwise, thank you for listening to Pagover Pastries, and I'll see you next time.