DOI: 10.1111/tog.

12924 2024;26:84–94
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Heavy menstrual bleeding in adolescence: who to

investigate and how to manage it
MBChB(hons) MRCOG, *
a b b
S L Walter S Channing MBBS MA(Cantab) MRCOG PGCertMedEd, N S Crouch MD MRCOG
a
Speciality Registrar in Obstetrics and Gynaecology, Severn Deanery, UK
b
Consultant Gynaecologist with a special interest in Paediatric & Adolescent Gynaecology, University Hospitals Bristol and Weston NHS
Foundation Trust, St Michaels Hospital, Southwell Street, Bristol BS2 8EG, UK
*Correspondence: S L Walter. Email: [email protected]

Accepted on 15 March 2024.

Key content Learning objectives

 Adolescent heavy menstrual bleeding (HMB) is commonly related  To understand how to clinically evaluate adolescent HMB.
to hypothalamic pituitary ovarian axis immaturity, which  To understand when and how to investigate adolescent HMB.
improves with age. This article outlines when and how to  To understand the different medical treatment options for HMB,
investigate for underlying pathological their efficacy, risks and alternatives.
causes.  To understand the management of acute adolescent HMB.
 Medical treatment for adolescent HMB consists predominantly
Ethical issues
of hormonal contraceptives. Preparation choice depends upon  Duties of confidentiality must be balanced against
patient preference, comorbidities and co-existing
safeguarding concerns.
conditions.
 Acute adolescent HMB is rare; a suggested framework for assessing Keywords: adolescent gynaecology / heavy menstrual bleeding /
and managing such cases is provided within this article. hormonal contraception / intrauterine devices

Please cite this paper as: Walter S L, Channing S, Crouch N S. Heavy menstrual bleeding in adolescence: who to investigate and how to manage it. The
Obstetrician & Gynaecologist 2024;26:84–94. https://doi.org/10.1111/tog.12924

psychosocial consequences with higher rates of fatigue,

Background
decreased verbal learning and memory, depression and
There are 1.2 billion adolescents in the world, comprising school absenteeism reported.7-10
16% of the population. Menstrual health is becoming
increasingly recognised as a major health issue for women
Adolescent menstrual cycles
and girls. In 2022, the World Health Organization issued a
statement on menstrual health, highlighting its impact on The mean age of menarche in the UK is 12–13 years old.7
education, non-discrimination and gender equality.1 The UK Over the past century there has been a notable decline in age
Government cited menstrual health as a priority area within of menarche, which has been attributed to improved
the Women’s Health Strategy for England, emphasising the nutritional status and reduction in chronic disease.11
potential impact on education and workplace attainment as a African American ethnicity, higher childhood body mass
direct result of unmet need.2 index, oestrogen receptor-a and leptin gene polymorphisms
Heavy menstrual bleeding (HMB) is the most common are also associated with earlier menarche.11,12
gynaecological reason for referral of adolescents to secondary A typical adolescent period lasts between 2–7 days and
care. The prevalence of HMB in adolescence varies widely in occurs every 21–45 days.13 In the first year following
population-based studies, ranging from 4.8%–37%3-5 menarche, 50% of menstrual cycles are anovulatory,
depending on definition, geographical location and although by 2–3 years post menarche 75% of adolescents
socio-economic status. The National Institute for Health are ovulating regularly.14 Therefore, the most common cause
and Care Excellence (NICE) defines HMB as excessive of HMB in adolescence is anovulatory cycles resulting from
menstrual loss which impacts an individual’s quality of life, hypothalamic-pituitary ovarian (HPO) axis immaturity.13
or where sanitary products are changed 1–2 hourly or where HMB commonly improves with time, and reassurance may
menses last longer than 7 days.6 HMB has physical and be all that some adolescents and their carers need from a

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Walter et al.

healthcare professional. Others need a greater level of

Box 1. Clinical history for heavy menstrual bleeding in
support, and this article will outline the evaluation of an adolescence
adolescent presenting with HMB, guiding further
investigations and navigating the range of management Menstrual history: age of menarche, cycle length/ regularity, number
options available. of pads/ tampons used, impact of bleeding symptoms
Associated symptoms: dysmenorrhoea, cyclical or non-cyclical pelvic
pain, dyspareunia, dyschezia, bowel symptoms, weight gain/loss,
hirtsuitism, epistaxis, bruising
Clinical evaluation for heavy menstrual Sexual history: risk of pregnancy/STIs, contraception, consent
bleeding Past medical history: chronic illness, bleeding history
Drug history: regular and over-the-counter medications
Although some girls are familiar with medical settings, for Family history: bleeding disorders, polycystic ovary syndrome (PCOS),
many this will be their first hospital visit. They may feel endometriosis, autoimmune conditions, hormone sensitive cancers
anxious, and negative experiences can affect future Social history: school absenteeism, concerns re bullying, self-
confidence, effect of symptoms on relationships.
engagement in health care. Attention should be taken to
create a comfortable clinical environment to make girls feel at
ease and empower them to express their opinions and heavy bleeding is suspected. When suspicion of a bleeding
concerns surrounding their symptoms and treatment. disorder is high, this should include a von Willebrand disease
screen and testing for factor VIII levels.
History A hormonal profile may help establish any underlying
The clinical history should be ideally taken both with and conditions that may be associated with an irregular bleeding
without a parent or carer present to allow clinicians to pattern. An elevated thyroid stimulating hormone (TSH) and
explore sensitive or confidential subjects. Questions should low thyroxine level is consistent with hypothyroidism, and an
focus on establishing the frequency and heaviness of bleeding, elevated prolactin >1000 warrants further investigation.
associated symptoms or risk factors for an underlying Where polycystic ovary syndrome (PCOS) is suspected,
pathological causes, impact of on quality of life and clinicians should measure their serum testosterone,
highlight any safeguarding issues (Box 1). Girls should be sex-hormone binding globulin (SHBG) and calculate the
encouraged to keep a diary of their menstrual cycles on a free androgen index (FAI).
phone app or paper to aid evaluation. A sexual history should STI screening and a urinary pregnancy test should be
always be taken in the absence of a caregiver, including details performed in a sexually active adolescents presenting with
and ages of partners and assessment of any potential issues abnormal vaginal bleeding with abdominal or pelvic pain,
that would raise safeguarding concerns. abnormal discharge or cervical excitation. In sexually active
adolescents, swabs should be taken to assess for bacterial
Examination vaginosis, candida, Chlamydia trachomatis, Mycoplasma
An examination is rarely needed, however when performed it genitalium, Neisseria gonorrhoeae and Trichomonas
should assess for complications from bleeding or signs of an vaginalis.15 In the case of a positive result, girls should be
underlying cause. It may be useful to reassure the girl at the treated in accordance with British Association for Sexual
start of the consultation if an examination will not be needed, Health and HIV (BASHH) guidance16 and referred to a
as this may reduce appointment-based anxiety. genito-urinary medicine clinic for further virology screening,
A chaperone must be present for any clinical examination, contact tracing and contraception counselling.
with the girl having the choice of a parent or carer Ultrasound is useful in characterising pelvic masses or
present too. assessing congenital uterine anomalies. A pelvic ultrasound
showing normal uterine development and normal (for age)
Investigations: when and how? adolescent ovaries can be very reassuring for both the girl and
Generally, treatment can be initiated without additional parents. Typically, transabdominal ultrasounds are
investigations, although NICE recommends that a full blood performed, however a transvaginal ultrasound may provide
count (FBC) should be carried out for all women presenting a more comprehensive assessment of the pelvis in girls who
with HMB in conjunction with treatment.6 The British Society are sexually active.
for Paediatric and Adolescent Gynaecology (BritSPAG)
recommend that ferritin is checked alongside a FBC and a
Pathological causes of heavy menstrual
coagulation screen including fibrinogen, prothrombin time
bleeding
(PT) and activated partial thromboplastin time (aPTT).7
Further investigations are appropriate for girls who either Bleeding disorders
fail to respond to medical therapy, or when an underlying Bleeding disorders should be considered in adolescents
pathological cause or complications from acute or prolonged presenting with any of the following: HMB from the onset

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Heavy menstrual bleeding in adolescence

of menarche, history of recurrent epistaxis, excessive endometrium, which becomes prone to heavy and irregular
bruising, prolonged or unexpected bleeding with injuries or bleeding. Diagnosing PCOS in adolescents is challenging
surgical procedures, a family history of bleeding disorders, because irregular menstrual cycles, hyperandrogenism and
evidence of anaemia or failure to respond to conventional multi-follicular ovaries are common in the healthy adolescent
hormonal therapy.17 population.20 In 2023, revised international guidelines made
Von Willebrand disease (VWD) is the most common specific recommendations to improve diagnostic accuracy
bleeding disorder in the UK. Menorrhagia associated with and avoid over-diagnosis of adolescent PCOS.21
VWD may be worse following menarche owing to the dual
effect of anovulatory cycles with underlying bleeding Connective tissue disorders
tendencies. There are three main types of VWD. Type 1 Ehlers Danlos syndrome (EDS) is a rare but recognised cause
(the most common) is the mildest form and caused by a of HMB, with multifactorial pathophysiology including
quantitative deficiency of von Willebrand factor (vWF). platelet functional abnormalities and weakness within the
Type 2 results from a functional abnormality of vWF, and subendothelial collagen, altering platelet plug formation.22,23
type 3 is associated with a severe deficiency in vWF and factor Childhood-onset systemic lupus erythematosus (SLE) is
VIII. vWF levels can rise with acute stress, inflammation, associated with HMB in up to 50% cases owing to
illness or high-dose oestrogen therapy.17 A haematology associated thrombocytopenia.24,25 Lupus anticoagulant
opinion should be sought when interpreting results in hypoprothrombinaemia syndrome is a rare complication of
these circumstances. SLE where acquired lupus anticoagulant and factor II
Immune thrombocytopenia (ITP) is the most common deficiency result in severe bleeding tendencies. Case series
platelet disorder in adolescence, accounting for 7% of girls reports describe prolonged or severe menorrhagia in
presenting with HMB.17 The diagnosis of ITP is typically adolescents with this condition which were all successfully
made on a FBC and peripheral blood film to exclude other managed with tranexamic acid and steroids.26,27
causes of thrombocytopenia.
Inherited factor VIII and factor IX coagulation defects Endometriosis
should be considered in adolescents with heavy menstrual Endometriosis is a chronic inflammatory condition with
bleeding and a family history of haemophilia. Although variable manifestations in adolescence. Whilst endometriosis
haemophilia is an X-linked recessive disorder, girls (carriers) may be asymptomatic for some, the most common reported
may display bleeding tendencies. Rarer factor II, V, VII, X symptoms are dysmenorrhoea, chronic pelvic pain, HMB,
and XIII deficiencies may be considered if there is a positive dyspareunia and intestinal symptoms.28,29
family history or the patient is of Ashkenazi Jewish descent. A Whilst endometriosis is not a common cause of HMB,
clotting screen (PT and aPTT) may guide further where an adolescent presents with HMB and cyclical or
investigation with input from a clinical haematologist. chronic pelvic pain, endometriosis should be considered.

Endocrinopathies Chronic systemic diseases and their treatments

HMB is an under-recognised consequence of many common
Thyroid disease chronic conditions and their treatments.
Hypothyroidism is an important potential cause of HMB. Supraphysiological insulin treatment in type 1 diabetes, or
Autoimmune thyroid disease affects 1 in 3500 children in the hyperinsulinaemia secondary to ovarian insulin resistance in
UK.18 Other causes of hypothyroidism include thyroidectomy, type 2 diabetes, results in hyperandrogenaemia and
hypopituitarism, iodine deficiency or radiation. Clinical anovulation leading to heavy or irregular cycles.30
features include heavy or irregular menstrual bleeding with a Optimising glycaemic control is associated with a reduction
goitre, fatigue, myalgia, cold sensitivity, constipation, dry or in menstrual dysfunction.30
thinning hair and skin, low mood and reduced concentration. Sodium valproate, carbamazepine, oxcarbazepine and
There may be a family history of thyroid disease or lamotrigine, used for epilepsy and bipolar disorder,
autoimmune diseases. The diagnosis is made based on potentiate androgen biosynthesis in ovarian theca cells,
elevated thyroid-stimulating hormone levels and low resulting in heavy or irregular bleeding.31,32
thyroxine with or without thyroid autoantibodies. Enzyme inducers, e.g. carbamazepine, phenytoin,
phenobarbital, rifampicin and high-dose topiramate >200
Polycystic ovary syndrome mg/day, reduce the efficacy of combined hormonal
PCOS is a common metabolic disorder affecting 8–11% of contraception (CHC) or oral progestogens, therefore
adolescents.19 Hallmark features include oligo- or increasing the likelihood of breakthrough bleeding and
amenorrhoea, hirsuitism and acne. Prolonged unopposed contraception failure.33 For individuals taking this
oestrogen exposure leads to proliferation of the medication, an intra-uterine system e.g. the MirenaTM or

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Walter et al.

associated with underlying bleeding disorders has not been

Box 2. Online educational resources
systematically assessed but it is commonly used. Side effects
 ‘Lets talk periods’ COR2ED for BRitsPAG 2022. available from: include gastro-intestinal disturbances, and it is
https://britspag.org/lets-talk-periods/ contraindicated in fibrinolytic conditions, convulsions or
 ‘Bleeding disorders and periods: what to expect’ COR2ED for thromboembolic disorders.
BRitSPAG 2022. available from: https://britspag.org/bleeding-
disorders-and-periods-animation-video/
 Heavy Periods in Adolescence patient information leaflet. BRitSPAG Non-steroidal anti-inflammatory medications. Non-
2019. Available from: https://britspag.org/patient-info/leaflets/ steroidal anti-inflammatories (NSAIDs) help to reduce
 Managing periods in girls with learning disabilities. BRitSPAG 2019
HMB. There is no evidence of any particular NSAID being
https://britspag.org/patient-info/leaflets/
superior over another for this indication. Ibuprofen is readily
and cheaply available over the counter, including at paediatric
doses. Mefenamic acid is generally avoided owing to the
the depot medroxyprogesterone acetate (DMPA) injection is dose-related increase in seizure risk.37
recommended for those who are medically eligible.33
Vascular liver diseases including extrahepatic portal vein Iron replacement. Symptomatic iron deficiency anaemia
obstruction, Budd-Chiari syndrome and porto-sinusoidal should be managed through iron replacement and dietary
vascular disease are associated with clinical or biochemical modifications. In most cases iron should be replaced orally,
hyperandrogenism and 21% experienced HMB.34 with a dose of elemental iron of 3–6 mg/kg (max 200 mg)
daily given in two to three divided doses.35
Management of heavy menstrual bleeding
Hormonal therapy
Most adolescents can be managed in outpatient care, The UK Medical Eligibility Criteria for Contraceptive Use
however admission to an acute gynaecology or children’s (UKMEC) guidance is used by clinicians to assess the safety of
unit (for those under the age of 16) should be arranged if prescribing contraceptive treatments.33 When using established
bleeding heavily, haemodynamically compromised or contraceptives for treating HMB (often alongside co-existent
significantly anaemic (Hb <80 g/dl). conditions such as PCOS, premenstrual dysphoric disorder or
Patients with HMB will be primarily managed by a possible endometriosis), the risk versus benefit profile of
gynaecologist with a specialist interest in paediatric and contraceptive agents vary, and clinical judgment must be
adolescent gynaecology; however, involvement of the applied alongside user preference and informed choice.
multi-disciplinary team including haematologists,
endocrinologists and psychologists should be sought in more Combined hormonal contraceptives. Hormonal
complex cases. Outpatient appointments may be in person or preparations containing estrogen and progestogen are first-line
virtual and ideally timed to minimise schooling disruption. treatments in adolescents without contraindications.
Consultations provide clinicians with an opportunity to Preparations can be taken cyclically or continuously and
educate girls about their menstrual and sexual health. HMB include oral tablets (combined oral contraceptive pill; COCP),
management should consider their physical, psychological transdermal patches or vaginal rings. If they wish, girls can time
and social wellbeing. Although a parent or carer may be their periods and avoid bleeds during important times such as
present during the consultation, girls should be encouraged exams, holidays or social events, which relieves anxiety and
to make autonomous decisions about their treatment. It may minimises disruption to their education. When compared to
be appropriate to discuss this with them alone. Verbal placebo, the COCP reduces menstrual blood flow by 6
information should be supplemented with adolescent specific months’ use.38
leaflets or online resources (Box 2). A monophasic COCP with 30 mcg ethinylestradiol and
levonorgestrel is generally considered first line.7 The
Pharmacological therapy diagnosis and comorbidities will help to guide preparation
selection (Table 1). The ethinylestradiol content can range
Non-hormonal therapy from 20–35 mcg. If a patient develops side effects related to
estrogen excess (nausea, bloating, breast tenderness, vaginal
Antifibrinolytics. Tranexamic acid (500–1000 mg three discharge) then consider reducing to a 20 mcg preparation or
times a day [TDS] from the onset of menstruation for up to moving to transdermal contraceptive. Higher rates of
4 days) is first-line therapy for HMB.35 It prevents excessive breakthrough bleeding are associated with lower estradiol
fibrin dissolution through blocking plasmin formation. In doses.7 For progestogen-related side effects (acne, headache,
idiopathic HMB, tranexamic acid reduces mean menstrual depression, breast symptoms) consider switching to a
blood loss by 47%.36 Tranexamic acid’s effect on HMB non-androgenic progestogen. The vaginal ring may be a

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Heavy menstrual bleeding in adolescence

Table 1. Summary of treatment options for the management of heavy menstrual bleeding7,33,35

Preparation Dose Side effects Contraindications Additional information

Non-hormonal preparations

Tranexamic acid Aged 12–17y: 1 g 3 Nausea, vomiting, diarrhoea, Fibrinolytic conditions, Recommends considering cause of
times/day up to allergic dermatitis, colour vision history of convulsions, menorrhagia before empirical
4 days (max 4 g/ changes, seizure, thrombosis thromboembolic treatment
day) disease Avoid in severe renal impairment

Mefenamic acid Aged 12–17y: 500 Nausea, vomiting, diarrhoea, Active gastrointestinal Avoid in renal impairment
mg up to 4 times/ headache, dizziness bleeding or ulceration, Avoid in inflammatory bowel disease
day caution in cardiac Seizure risk with overdose
disease

Combined hormonal contraception

Microgynon 30/ Ethinylestradiol 30 Unscheduled bleeding, BMI ≥35, personal 1st line OCP, use in conjunction with
Rigevidon / mcg/ headaches, mood changes, history or 1st degree UKMEC guidance and use additional
Ovranette / Levest Levonorgestrel 150 breast tenderness relative with history of barrier contraception to minimise STI
mcg daily for VTE, hypertension, risk
21 days/cycle or migraine with aura 70-80% amenorrhoea rate at 1 year if
continuous Caution with enzyme taken continuously
inducing medication

Marvelon/ Mercilon/ Ethinlyestradiol 20– As above As above Select estradiol dose based on
Gedarel 30/150 or 30 mcg/ symptoms and risk factors
20/150 Desogestrel 150
mcg daily for
21 days/cycle or
continuous

Yasmin Ethinylestradiol 30 As above As above Anti-androgen component useful for

mcg / drospirenone acne. Higher VTE risk. Choice for
3 mg daily for those with PMDD or mood variance.
21 days Useful for acne or hirsuitism

Loestrin 20 Ethinylestradiol 20 As above As above Lowest estradiol content useful in

mcg / lower BMI to minimise side effects,
norethisterone 1 may have breakthrough bleeding
mg

Lizinna / Cilique Ethinlyestradiol 35 As above As above Highest estradiol content may be

(previously Cilest) mcg / norgestimate useful switch if problematic
250 mcg unscheduled bleeding

Qlaira Estradiol valerate / As above As above Continuous phasic preparation

dienogest (helpful in compliance), variable dose
1 active tablet for of the 2 components (must be taken
26 days then 1 in order), natural estrogen,
inactive tablet for comparatively expensive.
2 days Licensed for HMB, shorter and lighter
withdrawal bleeds

Co-cyprindiol Ethinylestradiol 35 Breast tenderness, mood changes Acute porphyrias, Do not consider 1st line
(Dianette) mg/ cyproterone and depression, weight gain and gallstones, migraines Higher VTE risk than 2nd generation
acetate 3 mg day 1 fluid retention, headaches with aura, personal or progesterones so consider alternative
–21 of cycle family history (1st in longer term use (>2 years). Anti-
degree relative) of VTE androgen component useful in
hirsuitism and acne

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Walter et al.

Table 1. (Continued)

Preparation Dose Side effects Contraindications Additional information

Combined transdermal Ethinylestradiol 33.9 As above As above Continuous use may be associated
patch (Evra) mcg / with fewer days breakthrough
Norelgestromin bleeding than cyclical use. Reduced
203 mcg/24h efficacy in weight >90 kg.
apply below waist
weekly for weeks 1–
3 of cycle (week 4
patch free), tricycle
or continuous

Combined vaginal ring Ethinylestradiol 2.7 As above As above Avoid where not sexually active
NuvaRing/ mg/ Etonorgestrel
SyreniRing 11.7 mg day 1–22
of cycle or
continuous

Progesterone-only preparations

Norethisterone 5 mg TDS for Weight gain, headaches, Acute porphyria, Caution with prolonged use in people
21 days (to arrest menstrual irregularities history of venous with COCP contraindications as NET
bleeding), 5 mg thromboembolism, is metabolised to ethinylestradiol.
TDS day 5–26 Long-term use associated with
cyclically hepatic adenomas.
Short term use only

Medroxy-progesterone 10 mg BD or TDS Breast abnormalities, mood Acute porphyria,

acetate (Provera) 21 days (to arrest changes, increased appetite, arterial disease
bleeding), 5–10 mg fluid retention, constipation, skin
BD day 5–26 reactions, irregular menstrual
cyclically bleeding, weight gain
Short-term use only

Desogestrel Desogestrel 75 mcg Breast abnormalities, depressed Acute porphyria, breast Progestogens can reduce glucose
(Cerazette, Cerelle) daily mood, headache, reduced libido, cancer tolerance – caution in diabetes
150 mcg daily menstrual cycle irregularities, Caution: history of 150 mcg preparation useful for those
(unlicensed) increased weight breast cancer, history unable to take oestrogen containing
of VTE, cardiac compounds where 75 mcg dose has
dysfunction, liver not been effective
tumours

Implant (Nexplanon) Etonogestrel 68 mg / As above As above Not licenced under 18 years

3 years subdermal
implant

LNG-IUS 20 mcg/24h Ovarian cysts, device expulsion, Active pelvic infection, Significantly more effective in
Mirena or Levosert levonorgestrel ectopic pregnancy, mood uterine cavity reducing HMB than oral
changes, reduced libido, breast abnormalities, active progestogens or COCP
changes, weight changes trophoblastic disease Some girls will require a general
anaesthetic for fitting.

Depot injection Depo-provera 150 Gastrointestinal discomfort, Acute porphyria, Long term use >5 years associated
mg or Sayana vulvovaginal infection, anxiety, arterial disease with osteopenia therefore consider
Press 104 mg Breast abnormalities, mood only whether other methods are
every 12 weeks changes, increased appetite, unsuitable. Osteopenia is thought to
fluid retention, constipation, skin be reversed with cessation of use
reactions, irregular menstrual
bleeding, weight gain

Abbreviations: BMI = body mass index; COCP = combined oral contraceptive pill; HMB = heavy menstrual bleeding; NET = norethisterone; OCP = oral
contraceptive pill; PMDD = premenstrual dysphoric disorder; VTE = venous thromboembolism.

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Heavy menstrual bleeding in adolescence

consideration in those with nausea or significant mood The LNG-IUS can be fitted in gynaecology outpatients;
changes associated with the COCP. however, specific groups may benefit from placement under
CHCs are commonly used as first-line therapy in adolescents general anaesthesia: girls who are not sexually active or those
with HMB secondary to bleeding disorders. They can help to with learning disabilities.42 Consideration should be given to
regulate and establish predictable cycles and can also be used the list order and location of post-operative care to minimise
continuously in patients with bleeding disorders who present anxiety and maintain dignity. The hymen may become
with anaemia or acute heavy bleeding.17 In SLE, CHCs are inadvertently stretched during the procedure and it is
considered acceptable for patients in the absence of important that girls and carers are aware of this possibility.
antiphospholipid antibodies.25 If antiphospholipid antibodies DMPA is an appropriate alternative when the CHCs are
are present, progestogen only preparations are an acceptable contra-indicated, when there are compliance difficulties with
alternative and do not increase VTE risk.25 oral medication or when other treatment has failed. Irregular
bleeding may occur following the first injection, however 50–
Progestogen-only preparations. Progestogen-only 60% of users are amenorrhoeic at 12 months and 70% at 24
preparations may be considered by adolescents with HMB months.43 Prolonged use >5 years may be associated with
seeking long-active reversible contraception (LARC) or those irreversible osteopenia and it is associated with higher rates of
with contraindications to CHC. weight gain than other treatment options.33 The risks and
Desogestrel 75 mcg once daily is the first-line benefits should be considered and it requires regular review.
progestogen-only pill for adolescents with HMB who do Sayana Press is a subcutaneous depot injection of
not want to, or cannot, take CHC.7 Amenorrhoea is often medroxyprogesterone acetate which can be self-administered.
desired by patients, which is only achieved by half to The etonogestrel-releasing implant is a contraceptive
one-third of patients after 9–12 months.39 An unlicensed device not licensed in the under-18 age group,7 but its use
double-dose (150 mcg) may increase amenorrhoea rates and as a contraceptive is supported by the Faculty of Sexual and
could be trialled after 3 months if required/desired.40 Side Reproductive Healthcare (FSRH) from age of menarche.44
effects include breast tenderness/enlargement, low mood, The resulting bleeding pattern is unpredictable and for some
reduced libido, acne, weight gain and headaches. These may may be frequent or prolonged.44 For this reason it is not used
be more pronounced at higher doses. as a treatment for HMB.
Norethisterone 5mg TDS or medroxyprogesterone acetate
5–10 mg twice a day can be used cyclically to promote a Consent in adolescence
monthly withdrawal bleed. It should be started on day 5 of Safe care in adolescence depends upon understanding the
the menstrual cycle and continued until day 26. principles of consent and capacity.45
Using progestogens, for example medroxyprogesterone Effective communication is required for the adolescent to
acetate 10 mg daily for 12 days every 3–4 months, will induce provide informed consent.45 Information regarding their
a withdrawal bleed and protect against endometrial condition, the proposed treatment or investigations,
hyperplasia and HMB associated with prolonged likelihood of success, risks and alternatives including the
anovulatory cycles. right to obtain a second opinion should all be provided in a
Norethisterone 5 mg TDS is associated with an increased way appropriate to the patients age and maturity. For an
risk of venous thromboembolism (VTE) owing to its individual to be deemed to have capacity they must be able to
metabolism to ethinylestradiol.35 Norethisterone is associated understand the proposed treatment, understand the risks,
with androgenic side effects.35 Where the CHC is benefits and alternatives, weigh up and retain the
contraindicated owing to VTE risk, medroxyprogesterone information and communication their decision freely.45
is preferred to norethisterone. A consent form will be needed for insertion of an
The LNG-IUS is more effective in reducing excessive LNG-IUS under anaesthetic. In the UK, young people over
menstrual loss than the COCP, medroxyprogesterone acetate, the age of 16 can provide consent using an adult ‘Consent
norethisterone acetate, mefenamic acid and tranexamic acid.39 Form 1’ provided they are deemed to have capacity.46 For
The LNG-IUS can cause irregular bleeding for up to 6 months, those aged 14–16 years, a ’Consent Form 2’ for children
but 65% have amenorrhoea or reduced blood loss by 12 months.7 should be used where the parent provides consent for
LNG-IUS users have higher quality of life scores than other treatment although the child is encouraged to sign to show
medical therapies and no higher rates of severe adverse effects.39 their understanding of the treatment and to move towards
Evidence supports the use of LNG-IUS in bleeding disorders and shared decision making.
Ehlers-Danlos syndrome because of the high acceptability and
amenorrhoea rates.17,41 Cardiologist involvement should be Follow-up
sought in girls with increased risk of arrhythmias. Antibiotics are Following their outpatient appointment patients should be
not routinely required to protect against infective endocarditis.41 provided with a written copy of their treatment plan and

90 ª 2024 Royal College of Obstetricians and Gynaecologists.

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Walter et al.

point of contact. BritSPAG recommends that adolescents transfused as first line. Platelets may be indicated in severe
should have a medical review 6 months after starting thrombocytopenia (<50) or in known platelet disorders. Clotting
hormonal therapy.7 The review should focus on their factor replacement (plasma-derived or recombinant factor
current symptoms and change over the past 6 months, specific) may be indicated if there are severe deficiencies. The
compliance to therapy, acceptability of treatment and the blood transfusion laboratory and on call haematologist should
impact of their symptoms of their quality of life. consulted for guidance, particularly if there is a known
clotting disorder.
Special circumstances When the patient is haemodynamically stable but
symptomatic and has moderate anaemia (Hb>80–100 g/dl)
Adolescents with HMB and learning disabilities an iron transfusion is appropriate.
Girls with learning disabilities may find monthly bleeds A targeted clinical history should elicit the onset and
distressing and problematic to deal with hygienically. severity of bleeding, associated symptoms (anaemia, pelvic or
Continuous or long-acting preparations with high abdominal pain), history of gynaecological conditions,
amenorrhoea rates or where bleeds can be ‘scheduled’ are bleeding disorders or medical conditions. A drug history,
preferred. Continuous extended use CHC is a popular choice including prescribed and non-prescribed medications, should
to reduce menstrual severity, pain and allow scheduling be elicited. Clinicians should take a sexual history to assess
of withdrawal bleeds. Consideration should be given to the patient’s risk of pregnancy, sexually transmitted
co-morbidities and drug interactions, especially anti-epileptic infections or sexual assault.
enzyme-inducing medications. A clinical examination should be conducted in the
Transdermal CHC preparations are an option when there presence of a chaperone. The abdomen should be palpated
is difficulty taking tablets. DMPA has high amenorrhoea rates to exclude abdominal or pelvic masses and pads or towels
and is suitable for girls in whom CHC is contraindicated, but inspected to assess ongoing bleeding and estimate total blood
the risk of osteoporosis should be considered. The LNG-IUS loss. If trauma is suspected then the vulva, vagina and
is an appropriate alternative but would usually need to be perianal area should be inspected. It may be appropriate to
placed under general anaesthesia. do this under anaesthesia to aid full evaluation and repair.
Girls with learning disabilities will usually be accompanied The child safeguarding lead and police will need to be
by a parent or carer; however, the consultation should be informed in the instance of sexual assault and appropriate
directed with the girl as much as possible. Information forensic swabs taken. Injuries should be documented on a
should be delivered multi-modally using verbal, visual and standardised body map.
written information appropriate for their intellectual Hormonal therapy is first-line treatment in the
abilities. Hospital Learning Disability teams may attend management of acute HMB and various options are
appointments to support medical teams. Independent patient available. Both CHC and oral progestogens are effective;
advocates should be sought in best interest discussions. however, common UK practice is to use oral progestogen as
first line. A single retrospective study comparing
medroxyprogesterone acetate 20 mg TDS vs 1 mg
The management of acute heavy menstrual
norethidrone and 35 mcg ethinylestradiol TDS found that
bleeding
bleeding had ceased in 88% of the CHC group and in 76% of
Acute heavy menstrual bleeding is a medical emergency and the progestogen group within 3 days.47 A further review
initial management should focus on stabilising the patient found no benefit to high-dose CHC versus standard dosing
haemodynamically. Most patients will present to the CHC (once daily) in shortening bleeding time,48 therefore
emergency department where they will be triaged to a standard dosing should be considered first line.
monitored area, however if they present to an acute Norethisterone 10–30 mg daily is a safe alternative
gynaecology or paediatric assessment unit then senior to medroxyprogesterone.
nursing and medical staff should be alerted to enable an Tranexamic acid 1 g orally or IV TDS is commonly used in
urgent review. the acute setting, however there are no studies evaluating its
We recommend that clinicians use a systematic approach in use in adolescent acute HMB or in bleeding disorders.
acute haemodynamic compromise and in the absence of a Nevertheless, it would be reasonable to consider in
national guideline we suggest the management pathway outlined adolescents without contraindications.
in Figure 1. A full blood count, coagulation screen, group and Surgical therapy for acute HMB is rarely indicated,
save, urea & electrolytes and venous blood gas should be taken for however there are case reports where Foley catheters
analysis. In the instance of significant anaemia (Hb <80 g/dl) or provided intra-uterine tamponade in girls with acute
bleeding with haemodynamic compromise, blood products anovulatory peri-menarchal bleeding and underlying
should be replaced. Group-specific packed red cells are bleeding disorders.49,50

ª 2024 Royal College of Obstetricians and Gynaecologists. 91

 17444667, 2024, 2, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/tog.12924, Wiley Online Library on [17/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Heavy menstrual bleeding in adolescence

Evidence of haemodynamic
compromise?

Pathway 1 Pathway 2
Yes No

x2 wide bore cannula Clinical history

FBC, U+Es, G+S, Clinical examination

clotting screen, venous blood gas Urinary pregnancy test
Urinary pregnancy test FBC, clotting screen
Consider transabdominal
pelvic ultrasound
Additional investigations
as indicated
Clinical history
Clinical examination

Tranexamic acid 500–1000 mg

orally TDS for up to 4 days, if
no contraindications
Alert child safeguarding
team and police if sexual
assault or non-accidental
genital trauma
Acute anaemia Hb <80 g/dl or Iron infusion for anaemia
active bleeding with without haemodynamic
haemodynamic instability compromise

Oral iron replacement

for mild anaemia

Yes No
Hormonal treatment:
Commence treatment Medroxyprogesterone
pathway 2 acetate 10 mg BD–TDS for 21
O-negative paced red cells x2 units days
Platelet transfusion if plts <50 Consider longer term need for
contraception and HMB
management

Tranexamic acid 1 g IV
Discharge planning:
Treatment plan

Medroxyprogesterone acetate Outpatient follow-up

10–20 mg orally up to 8-hourly Contact details

USS +/- EUA

Balloon tamonade using Foley

catheter if underlying bleeding
disorder or haemodynamic
compromise not responding to
hormonal therapy

92 ª 2024 Royal College of Obstetricians and Gynaecologists.

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Walter et al.

Figure 1. Algorithm for the management of acute heavy menstrual bleeding.Abbreviations: BD = twice a day; BMI = body mass index;
EUA = examination under general anaesthetic; FBC = full blood count; G + S = group and save; TDS = three times a day; U + Es = urea and
electrolytes; USS = ultrasound scan.

Girls should remain inpatient until the bleeding has 6 National Institute for Health and Care Excellence. Heavy menstrual bleeding:
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Cambridge university press; 2023. Chapter 6, Polycystic ovary syndrome in
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21 Teede H, Tay CT, Laven J, Dokras, A, Moran L, Piltonen T, et al. on behalf
of the International PCOS Network in collaboration with funding, partner
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94 ª 2024 Royal College of Obstetricians and Gynaecologists.