What Evaluation Should Be Considered for Heavy Menstrual Bleeding?

Patient Presentation
A 15-year-old female came to clinic for her health supervision visit. During the visit she said that although her periods were regular she had heavy bleeding that was interfering with running and swimming. She said that she would soak a pad and tampon every hour during the first 1-2 days then for the next 1-2 days she would soak a pad and tampon every 2-3 hours. On days 5-6 she would soak a pad or tampon every 6 hours. She said she had some cramping on day 1 of her periods but ibuprofen usually took care of the pain. Her menses lasted 5-6 days and occurred every 28-29 days almost since menarche at almost 12 years of age. She denied sexual activity or any bleeding problems. She said that sometimes she was more tired but attributed it to increased sports activities and staying up late to finish homework. Her exercise program included working out with her teammates during and just before the competitive seasons. She ran and swam for fun otherwise. She denied any eating disorders. The past medical history was non-contributory. The family history was negative for bleeding disorders, cancer or gynecological problems. The review of systems was negative including changes in hair or skin, heat or cold intolerance, epistaxis, easy bruising or bleeding.

The pertinent physical exam showed a well-developed female with a weight at the 10-25%, height at the 75% with a BMI of 16.4. These were consistent with previous measurements and she was appropriately gaining weight. HEENT was negative including normal hair texture, thyroid and teeth. She was Tanner V for breast and pubic hair and her external genital examination showed no clitoromegaly and normal introitus. The diagnosis of heavy menstrual bleeding was made. The physician explained that the most likely reason was still anovulatory cycles, however other possibilities existed such as hypothyroidism or a bleeding problem. She also explained that usually this was treated with hormonal therapy, most often with contraceptive pills, but that there were other options such as an intrauterine device or vaginal contraceptive ring. After more discussion the teen and her mother decided that they wanted to discuss the issue with a gynecologist and do the appropriate evaluation at one time with the gynecologist. A referral was made. The physician did suggest that the teen eat an iron-rich diet or take a general multivitamin with iron in it. She also recommended that the girl use ibuprofen throughout her periods to possibly help decrease the bleeding.

Heavy menstrual bleeding is a common problem. The rates depend on the population and underlying cause, but can occur 30% of adolescent females who go to a gynecologist. Average menstrual blood loss is 30-40 ml. Hypermenorrhea or menorrhagia are regular menstrual cycles that last too long (>7 days) or are too heavy (> 80 ml blood loss). Metrorrhagia is irregular menstrual bleeding. Menometrorrhagia is abnormally heavy bleeding that occurs with an irregular timing. Dysfunctional uterine bleeding is a more generic term describing prolonged, excessive or frequent, unpatterned uterine bleeding that is not related to an anatomical uterine abnormality or systemic cause.

Adolescents can have a very difficult time accurately describing their menses but abnormal bleeding is considered pathologic if “…menstrual loss requiring pad or tampon changes every 1-2 h, with anything longer resulting in ‘flooding’ or ‘accidents’….” Problems associated with heavy menstrual bleeding include anemia, fatigue, missed school and difficulties participating in social and sporting activities. For young women with various disabilities it may offer the additional challenge of difficulty with managing menstrual hygiene.

Causes of heavy menstrual bleeding include:

  • Anovulation – most common cause and is normal in the first 2-3 years after menarche due to the immature hypothalamic-pituitary-ovarian axis
  • Pregnancy and pregnancy related complications
  • Genitourinary infections especially chlamydia and gonorrhea
  • Bleeding disorders
    • von Willebrands disease
    • Thrombcytopenia
  • Drugs
    • Contraceptives including intrauterine devices
    • Anticoagulants
    • Androgens
    • Antipsychotics
  • Endocrine
    • Hypothyroid
    • Hyperthyroid
    • Hyperprolactinemia
    • Adrenal disease
    • Ovarian problems such as polycystic ovary syndrome (PCOS) or ovarian failure
  • Systemic disease
    • Diabetes
    • Renal disease
    • Systemic lupus erythematosus
  • Trauma
  • Tumors of the GU tract- uncommon but can occur

Treatment depends on the acuity and severity. Some patients need to be hospitalized and aggressively managed. In addition iron rich foods are recommended for all adolescents but especially those with heavy menstrual bleeding. Non-steroidal anti-inflammatory medications (600-1200 mg/day) have been shown to improve the bleeding too. For patients with chronic heavy menstrual bleeding hormonal treatment is usually prescribed. Combined contraceptives in the form of pills, patches or contraceptive ring are used. Progesterone only treatment is also a potential option in the form of progestin only pills, levonorgestrel intrauterine devices and implants.

For other information see What is the Treatment for Dysfunctional Uterine Bleeding? and
What Are Indications for IUD Use in Teens?.

Learning Point
The initial evaluation for menorrhagia depends on the history and physical examination but often includes:

  • Pregnancy test
  • Sexually transmitted infection screening for chlamydia and gonorrhea
  • Complete blood count
  • Prothrombin time (PT)
  • Partial thromboplastin time (PTT)
  • Fibrinogen
  • von Willebrand Factor panel
  • Thyroid stimulating hormone
  • Prolactin

Some clinicians will do iron studies during the initial evaluation. Also additional bleeding disorder studies may be ordered if a disorder is suspected such as ristocetin cofactor activity and Factor VIII. If PCOS is initially suspected then testosterone and dehydroepiandrosterone sulfate should also be considered. Pelvic ultrasound is also an initial consideration depending on the circumstances.

Questions for Further Discussion
1. At what age is normal menarche?
2. At what age should an evaluation for late menarche begin?
3. What are treatment options for menstrual cramps?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Menstruation

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Gray SH, Emans SJ. Abnormal vaginal bleeding in adolescents. Pediatr Rev. 2007 May;28(5):175-82.

Grover S. Bleeding disorders and heavy menses in adolescents. Curr Opin Obstet Gynecol. 2007 Oct;19(5):415-9.

Sokkary N, Dietrich JE. Management of heavy menstrual bleeding in adolescents. Curr Opin Obstet Gynecol. 2012 Oct;24(5):275-80.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital