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Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding

ACOG COMMITTEE OPINION SUMMARY, Number 785

doi: 10.1097/AOG.0000000000003412
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ABSTRACT: Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman's physical, social, emotional, or material quality of life. If obstetrician–gynecologists suspect that a patient has a bleeding disorder, they should work in coordination with a hematologist for laboratory evaluation and medical management. Evaluation of adolescent girls who present with heavy menstrual bleeding should include assessment for anemia from blood loss, including serum ferritin, the presence of an endocrine disorder leading to anovulation, and evaluation for the presence of a bleeding disorder. Physical examination of the patient who presents with acute heavy menstrual bleeding should include assessment of hemodynamic stability, including orthostatic blood pressure and pulse measurements. The first-line approach to acute bleeding in the adolescent is medical management; surgery should be reserved for those who do not respond to medical therapy. Use of antifibrinolytics such as tranexamic acid or aminocaproic acid in oral and intravenous form may be used to stop bleeding. Nonmedical procedures should be considered when there is a lack of response to medical therapy, if the patient is clinically unstable despite initial measures, or when severe heavy bleeding warrants further investigation, such as an examination under anesthesia. After correction of acute heavy menstrual bleeding, maintenance hormonal therapy can include combined hormonal contraceptives, oral and injectable progestins, and levonorgestrel-releasing intrauterine devices. Obstetrician–gynecologists can provide important guidance to premenarchal and postmenarchal girls and their families about issues related to menses and should counsel all adolescent patients with a bleeding disorder about safe medication use and future surgical considerations.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on acog.org or by calling the ACOG Resource Center.

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Recommendations and Conclusions

The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions regarding bleeding disorders in adolescents:

  • Heavy menstrual bleeding at menarche and in adolescence may be an important sentinel for an underlying bleeding disorder.
  • If obstetrician–gynecologists suspect that a patient has a bleeding disorder, they should work in coordination with a hematologist for laboratory evaluation and medical management.
  • When obtaining a medical history, it is important to identify risk factors for bleeding disorders as well as medical conditions that would alter management.
  • Physical examination of the patient who presents with acute heavy menstrual bleeding should include assessment of hemodynamic stability, including orthostatic blood pressure and pulse measurements.
  • In adolescent girls with heavy menstrual bleeding, speculum examination typically is not required.
  • Evaluation of adolescent girls who present with heavy menstrual bleeding should include assessment for anemia from blood loss, including serum ferritin, the presence of an endocrine disorder leading to anovulation, and evaluation for the presence of a bleeding disorder.
  • Routine ultrasonography should not be obtained solely for the workup of heavy menstrual bleeding in adolescents; however, it can be considered for patients who do not respond to initial management.
  • The first-line approach to acute bleeding in the adolescent is medical management; surgery should be reserved for those who do not respond to medical therapy.
  • Adolescents who are hemodynamically unstable or actively bleeding heavily should be hospitalized for management.
  • In the absence of contraindications to estrogen, hormonal therapy for acute heavy menstrual bleeding can consist of intravenous conjugated estrogen every 4–6 hours; alternatively, monophasic combined oral contraceptive pills (OCPs) (in 30–50 microgram ethinyl estradiol formulation) can be used every 6–8 hours until cessation of bleeding.
  • Use of antifibrinolytics such as tranexamic acid or aminocaproic acid in oral and intravenous form may be used to stop bleeding.
  • After correction of acute heavy menstrual bleeding, maintenance hormonal therapy can include combined hormonal contraceptives, oral and injectable progestins, and levonorgestrel-releasing intrauterine devices (LNG-IUDs).
  • Iron replacement therapy should be provided for all reproductive-aged women with anemia due to bleeding.
  • Nonmedical procedures should be considered when there is a lack of response to medical therapy, if the patient is clinically unstable despite initial measures, or when severe heavy bleeding warrants further investigation, such as an examination under anesthesia.
  • Obstetrician–gynecologists can provide important guidance to premenarchal and postmenarchal girls and their families about issues related to menses and should counsel all adolescent patients with a bleeding disorder about safe medication use and future surgical considerations.
  • Adolescents in whom a bleeding disorder has been diagnosed should be reminded that products that prevent platelet adhesion, such as aspirin or nonsteroidal antiinflammatory drugs, should be used only with the recommendation of a hematologist.
  • In adolescents with known bleeding disorders, preoperative surgical evaluation, choice of hemostatic agents for control of intraoperative blood loss, and need for blood products should be determined in conjunction with a hematologist and an anesthesiologist.

Number 785

For a comprehensive overview of these recommendations, the full-text version of this Committee Opinion is available athttp://dx.doi.org/10.1097/AOG.0000000000003411.

Scan this QR code with your smartphone to view the full-text version of this Committee Opinion.

Committee on Adolescent Health Care

This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care in collaboration with committee members Oluyemisi Adeyemi-Fowode, MD and Judith Simms-Cendan, MD.

Full-text document published online on August 22, 2019.

Copyright 2019 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

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Official Citation

Screening and management of bleeding disorders in adolescents with heavy menstrual bleeding. ACOG Committee Opinion No. 785. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134:e71–83.

© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.