Original Study| Volume 31, ISSUE 5, P451-458, October 2018

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Treatment Modalities in Adolescents Who Present with Heavy Menstrual Bleeding

Published:March 07, 2018DOI:


      Study Objective

      On this study we sought to determine the relationship of bleeding disorders to iron deficiency anemia. Additionally, this study was undertaken to examine all current treatment modalities used in a menorrhagia clinic with respect to heavy menstrual bleeding management to identify the most effective options for menstrual management in the setting of an underlying bleeding disorder.

      Design, Setting, Participants, Interventions, and Main Outcome Measures

      We performed a retrospective chart review of adolescents younger than 21 years with heavy menstrual bleeding attending a multidisciplinary hematology-adolescent gynecology clinic. Information including demographic characteristics, bleeding diathesis, hematologic parameters, treatment, and the diagnosis was extracted from each chart. Subjects were grouped into 2 categories on the basis of the diagnosis of a bleeding disorder. Hemoglobin level, iron deficiency anemia, and need for transfusion were compared between a bleeding disorder and no bleeding disorder group. Subjects were grouped into categories depending on hormonal modality and treatment success of the groups were compared.


      Seventy-three subjects were tested for a bleeding disorder. Of the subjects who completed testing, 34 (46%) were diagnosed with a bleeding disorder. Thirty-nine subjects (54%) had heavy menstrual bleeding because of other causes. There was no significant difference in hemoglobin between those with and without a bleeding disorder. Iron deficiency anemia was significantly higher in subjects without a bleeding disorder. In a comparison of hormone therapy success, the levonorgestrel intrauterine device (89%, 8 out of 9 subjects) had the highest rate of menstrual suppression followed by norethindrone acetate 5-10 mg/d (83%, 5 out of 6 subjects), and the transdermal patch (80%, 4 out of 5 subjects). All subjects using tranexamic acid as well as hormonal therapy had 100% achievement of menstrual suppression.


      A high frequency of bleeding disorders was found in those tested. Subjects with a bleeding disorder were less likely to present with severe anemia requiring blood transfusion and less likely to have iron deficiency anemia. Although combined oral contraceptives were commonly used clinically for menstrual suppression, they were not found to be the most effective option.

      Key Words

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        • Barr F.
        • Brabin L.
        • Agbaje S.
        • et al.
        Reducing iron deficiency anemia due to heavy menstrual blood loss in Nigerian rural adolescents.
        Public Health Nutr. 1998; 1: 249
        • Friberg B.
        • Ornö A.K.
        • Lindgren A.
        • et al.
        Bleeding disorders among young women: a population-based prevalence study.
        Acta Obstet Gynecol Scand. 2006; 85: 200
        • Chi C.
        • Pollard D.
        • Tuddenham E.G.
        • et al.
        Menorrhagia in adolescents with inherited bleeding disorders.
        J Pediatr Adolesc Gynecol. 2010; 23: 215
        • James A.H.
        Women and bleeding disorders.
        Hemophilia. 2010; 16: 160
        • James A.H.
        More than menorrhagia: a review of the obstetric and gynecological manifestations of bleeding disorders.
        Hemophilia. 2005; 11: 295
        • Neunert C.
        • Lim W.
        • Crowther M.
        • et al.
        The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia.
        Blood. 2011; 117: 4190
        • Sokkary N.
        • Dietrich J.E.
        Management of heavy menstrual bleeding in adolescents.
        Curr Opin Obstet Gynecol. 2012; 24: 275
        • James A.H.
        • Kouides P.A.
        • Abdul-Kadir R.
        • et al.
        Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel.
        Am J Obstet Gynecol. 2009; 201: 12.e1
        • James A.H.
        Obstetric management of adolescents with bleeding disorders.
        J Pediatr Adolesc Gynecol. 2010; 23: S31
        • Haamid F.
        Heavy menstrual bleeding in adolescents.
        J Pediatr Adolesc Gynecol. 2017; 30: 335
        • WHO/UNICEF/UNU
        Iron deficiency anaemia assessment, prevention, and control: a guide for programme managers.
        World Health Organization, Geneva2001 (Available:, Accessed December 1, 2018)
        • American College of Obstetricians and Gynecologists
        ACOG committee opinion no. 557: management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women.
        Obstet Gynecol. 2013; 121: 891
        • From the Centers for Disease Control and Prevention
        Iron deficiency–United States, 1999-2000.
        JAMA. 2002; 288: 2114
        • Halterman J.S.
        • Kaczorowski J.M.
        • Aligne C.A.
        • et al.
        Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States.
        Pediatrics. 2001; 107: 1381
        • Bruner A.B.
        • Joffe A.
        • Duggan A.K.
        • et al.
        Randomised study of cognitive effects of iron supplementation in non-anemic iron-deficient adolescent girls.
        Lancet. 1996; 348: 992
        • Cooke A.G.
        • McCavit T.L.
        • Buchanan G.R.
        • et al.
        Iron deficiency anemia in adolescents who present with heavy menstrual bleeding.
        J Pediatr Adolesc Gynecol. 2017; 30: 247
        • Flood V.H.
        • Gill J.C.
        • Morateck P.A.
        • et al.
        Common VWF exon 28 polymorphisms in African Americans affecting the VWF activity assay by ristocetin cofactor.
        Blood. 2010; 116: 280
        • Mikhail S.
        • Varadarajan R.
        • Kouides P.
        The prevalence of disorders of hemostasis in adolescents with menorrhagia referred to a hemophilia treatment center.
        Hemophilia. 2007; 13: 627
        • Claessens E.
        • Cowell C.
        Dysfunctional uterine bleeding in the adolescent.
        Pediatr Clin North Am. 1981; 28: 369
        • Kirtava A.
        • Crudder S.
        • Dilley A.
        • et al.
        Trends in clinical management of women with von Willebrand disease: a survey of 75 women enrolled in hemophilia treatment centers in the United States.
        Hemophilia. 2004; 10: 158
        • Wang W.
        • Bourgeois T.
        • Klima J.
        • et al.
        Iron deficiency and fatigue in adolescent females with heavy menstrual bleeding.
        Hemophilia. 2013; 19: 225
        • Kadir R.A.
        • Sabin C.A.
        • Pollard D.
        • et al.
        Quality of life during menstruation in patients with inherited bleeding disorders.
        Hemophilia. 1998; 4: 836
        • Barr R.D.
        • Sek J.
        • Horsman J.
        • et al.
        Health status and health-related quality of life associated with von Willebrand disease.
        Am J Hematol. 2003; 73: 108
        • Shanker M.
        • Chi C.
        • Kadir R.A.
        Review of quality of life: menorrhagia in women with or without inherited bleeding disorders.
        Hemophilia. 2008; 14: 15
        • Higham J.M.
        • O’Brien P.M.
        • Shaw R.W.
        Assessment of menstrual blood loss using a pictorial chart.
        Br J Obstet Gynaecol. 1990; 97: 734
        • Philipp C.S.
        • Faiz A.
        • Dowling N.F.
        • et al.
        Development of a screening tool for identifying women with menorrhagia for hemostatic evaluation.
        Am J Obstet Gynecol. 2008; 198: 163
        • Sanchez J.
        • Andrabi S.
        • Bercaw J.L.
        • et al.
        Quantifying the PBAC in a pediatric and adolescent gynecology population.
        Pediatr Hematol Oncol. 2012; 29: 479
        • Janssen C.A.
        • Scholten P.C.
        • Heintz A.P.
        A simple visual assessment technique to discriminate between menorrhagia and normal menstrual blood loss.
        Obstet Gynecol. 1995; 85: 977
        • Reid P.C.
        • Coker A.
        • Coltart R.
        Assessment of menstrual blood loss using a pictorial chart: a validation study.
        BJOG. 2000; 107: 320
        • Committee on Adolescent Health Care
        Committee on Gynecologic Practice: Committee Opinion No.580: von Willebrand disease in women.
        Obstet Gynecol. 2013; 122: 1368
        • Johnson S.
        • Lang A.
        • Sturm M.
        • et al.
        Iron deficiency without anemia: a common yet under-recognized diagnosis in young women with heavy menstrual bleeding.
        J Pediatr Adolesc Gynecol. 2016; 29: 628
        • American College of Obstetricians and Gynecologists
        ACOG Practice Bulletin No. 95: anemia in pregnancy.
        Obstet Gynecol. 2008; 112: 201
        • Short M.W.
        • Domagalski J.E.
        Iron deficiency anemia: evaluation and management.
        Am Fam Physician. 2013; 87: 98
        • Siu A.L.
        Screening for iron deficiency anemia in young children: USPSTF recommendation statement.
        Pediatrics. 2015; 136: 746
        • McDonagh M.S.
        • Blazina I.
        • Dana T.
        • et al.
        Screening and routine supplementation for iron deficiency anemia: a systematic review.
        Pediatrics. 2015; 135: 723
      1. Recommendations to prevent and control iron deficiency in the United States Centers for Disease Control and Prevention.
        MMWR Recomm Rep. 1998; 47: 1
        • Huguelet P.S.
        • Buyers E.M.
        • Lange-Liss J.H.
        • et al.
        Treatment of acute abnormal uterine bleeding in adolescents: what are providers doing in various specialties.
        J Pediatr Adolesc Gynecol. 2016; 29: 286
        • Dowlut-McElroy T.
        • Williams K.B.
        • Carpenter S.L.
        • et al.
        Menstrual patterns and treatment of heavy menstrual bleeding in adolescents with bleeding disorders.
        J Pediatr Adolesc Gynecol. 2015; 28: 499
        • Wilkinson J.P.
        • Kadir R.A.
        Management of abnormal uterine bleeding in adolescents.
        J Pediatr Adolesc Gynecol. 2010; 23: S22
        • Mikhail S.
        • Kouides P.
        Von Willebrand disease in the pediatric and adolescent population.
        J Pediatr Adolesc Gynecol. 2010; 23: S3
        • Abrams L.S.
        • Skee D.
        • Natarajan J.
        • et al.
        Pharmacokinetic overview of Ortho Evra/Evra.
        Fertil Steril. 2002; 77: S3
        • CDC
        Centers for Disease Control and Prevention: Contraceptive use.
        (Available) (Accessed November 2017)
        • Kadir R.A.
        • Chi C.
        Levonorgestrel intrauterine system: bleeding disorders and anticoagulation therapy.
        Contraception. 2007; 755: S123
        • Schaedel Z.E.
        • Dolan G.
        • Powell M.C.
        The use of the levonorgestrel-releasing intrauterine system in the management of menorrhagia in women with hemostatic disorders.
        Am J Obstet Gynecol. 2005; 193: 1361