January 14, 2022
Heavy menstrual bleeding can lead to profound loss of blood and disabling symptoms of fatigue, shortness of breath and dizziness. On this episode of Talking Pediatrics, Dr. Gabi Hester speaks with pediatric gynecologist Dr. Rachel Miller and pediatric hematologist Dr. Kate Garland about the symptoms, diagnostic workup, and management recommendations for children and young adults with symptomatic heavy menstrual bleeding.
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Dr. Angela Cade-Goepferd: Welcome to talking pediatrics. I’m your host, Dr. Angela Cade-Goepferd. Heavy menstrual bleeding, a topic that many of us struggle with on our primary of care practices is something that can surprisingly lead to profound loss of blood and disabling symptoms like fatigue, shortness of breath and dizziness. On this episode of guidelines with Gabi, Dr. Gabi Hester speaks with pediatric gynecologist, Dr. Rachel Miller and pediatric hematologist, Dr. Kate Garland about this symptoms, diagnostic workup, and management recommendations for kids and young adults with symptomatic heavy menstrual bleeding.
Speaker: Welcome to Guidelines with Gabi.
Dr. Gabi Hester: While other people have been baking bread during the pandemic, one of my pandemic past times has been coming up with medical jokes for kids, much to the chagrin of my coworkers and family. And one of my personal favorites is this, why did the female sheep need to go to the hospital? Because she had abnormal ewe-terine bleeding. Get it? Ewe-terine bleeding.
Today we will talk about that, but with teens not sheep. Abnormal uterine or menstrual bleeding and what we should do when kids seek care. I do want to note before we begin that while we may be using the pronouns, she and her or female and girls in our conversation today, anyone with a uterus can experience menstrual bleeding. I’ll be joined by two experts today, Dr. Kate Garland, pediatric hematologist, and Dr. Rachel Miller, medical director of pediatric and adolescent gynecology at Children’s Minnesota, an adjunct assistant professor at the University of Minnesota department of obstetrics gynecology and women’s health. Kate, Rachel, thanks so much for joining today.
So one guideline that I found really to be helpful for this topic is the screening and management of bleeding disorders in adolescents with heavy menstrual bleeding, which was published in 2019 by the American college of obstetricians and gynecologists committee on adolescent healthcare. And I was wondering, Rachel, if you can just start us off by talking a little bit about what is considered to be heavy menstrual bleeding?
Dr. Rachel Miller: The definition is actually more than 80 milliliters of blood loss per menstrual period, which is not especially clinically useful. So other things that are more clinically useful would be bleeding for longer than seven days. And something called the Warner criteria, which are clinical features that are most strongly associated with heavy menstrual bleeding. So those would be things like frequent changing of sanitary products during the full flow, a poor iron status, like a low ferritin, size of the clot. So something larger than a quarter, using a greater number of products used. So something more than five or six pads or tampons a day, and then new needing to set an alarm to get up in the middle of the night to change your overnight protection. So those would be things that are much more sort of clinically useful for defining heavy menstrual bleeding.
Dr. Gabi Hester: When you think about heavy menstrual bleeding from a gynecological perspective, are there any risk factors that might lead patients to have this condition?
Dr. Rachel Miller: In the pediatric or adolescent and young adult age group, we really don’t even significantly consider structural causes. So though that’s a major cause in adult women, it’s not a significant number at all in adolescents. So the biggest things that we about are going to be ovulatory dysfunction. And the two most common causes of ovulatory dysfunction are an immature hypothalamic pituitary ovarian access. And the second is polycystic ovary syndrome, or PCOS for short. And then the other is going to be a coagulopathy, which I know Kate will address. And the others are going to be more infectious. So pelvic inflammatory disease or iatrogenic because bleeding is a common side effect of multitude of contraceptives.
Dr. Gabi Hester: So Kate, Rachel mentioned that coagulopathy might be one of the larger areas that would cause heavy menstrual bleeding. Can you tell me a little bit about some of the conditions that you look for there?
Dr. Kate Garland: Yes. When girls present with heavy menstrual bleeding, it is often the first sign or symptom of a underlying bleeding diathesis. And so we will work towards helping to diagnose that. So some of the most common disorders that we can see that present with heavy menstrual bleeding are things like Von Willebrand disease or factor deficiencies, such as mild hemophilias. Sometimes we can even rarely pick up some platelet disorders when platelets don’t clump together properly.
Dr. Gabi Hester: When someone presents with heavy menstrual bleeding, are there any options that the outpatient providers can take to try to help keep this kid out of the hospital?
Dr. Kate Garland: Yes. It’s a hard line to walk because working up for a bleeding disorder is sometimes challenging in the sense of trying to interpret results at the time of heavy menstrual bleeding. But oftentimes what we will do is at the very first thing is to look for iron deficiency or severe anemia. But our typical workup per se, for heavy menstrual bleeding might include things such as coagulation studies, which are your or PT, PTT, and fibrinogen, as well as things like Von Willebrand screen, which include how much Von Willebrand you have, your Von Willebrand antigen, as well as its function called ristocetin and cofactor activity or Von Willebrand activity, which also includes your factor eight levels as well.
Oftentimes we will also include platelet function analyses, which is a basic screening for platelet function defects. But oftentimes these tests are challenging to run from a general pediatrics office. So I think if that is not something that is easily accessible for the pediatrician, I think making a referral to our adolescent and young adult combined hematology and gynecology clinic would be beneficial.
Dr. Gabi Hester: And Rachel, from a gynecology standpoint, are there any interventions or workup that you’d recommend in an outpatient clinic setting prior to coming to your services?
Dr. Rachel Miller: One of the first things that’s important to do is exclude pregnancy as a complication for abnormal vaginal bleeding. Others would be looking at other endocrinopathies that could cause that like thyroid disorder would be one of the more common ones. And then consideration for whether the patient could have sexually transmitted infection. So most commonly it would be chlamydia, gonorrhea, maybe trichomoniasis.
Dr. Gabi Hester: At what point should patient be admitted to the hospital?
Dr. Kate Garland: That’s a good question. We actually have a guideline that helps to address that. And the criteria is based on the hemoglobin level at presentation. Girls who have abnormal uterine bleeding or heavy menstrual bleeding are at risk for bleeding a lot and severely and not being able to compensate for it on their own. And so we typically ask providers to refer to our guideline that can help address some of those questions.
Dr. Gabi Hester: And Kate understanding that heavy blood loss can lead to anemia. What are some of the symptoms that these patients might be presenting with when they’re in a period of heavy menstrual flow?
Dr. Kate Garland: Some of the symptoms of severe anemia are your typical vague symptoms such as extreme fatigue, pallor, very pale. You can get pretty big headaches as a result of severe anemia. Sometimes you won’t sleep as well or you’ll have disordered sleep. It’s kind of hard to discriminate some of these vague symptoms from other things that you might be experiencing. But if you hear a story with these vague symptoms in conjunction with heavy menstrual bleeding, I would certainly at the very, very minimum check a CBC to look for severe anemia.
Dr. Gabi Hester: Once they are admitted to the hospital, help me understand a little bit of the management. And Rachel, maybe you could start with talking to me about some of the hormonal therapies and how those actually work. What’s the goal with some of those treatments?
Dr. Rachel Miller: The goal is generally to stabilize the uterine lining or the endometrium. At the same time, then that allows the spiral arteries, which are the little arteries that are oozing from the uterus to stop bleeding. And our goal is usually to get that bleeding stopped as quickly as possible, and then keep it stopped while the patient hopefully can rebuild their hemoglobins to near normal before allowing them to have any further periods.
Dr. Gabi Hester: And is there a period of time that you typically expect those treatments to take effect? What would you consider to be failure of the treatment in your mind?
Dr. Rachel Miller: We actually have studied this at children’s and using our protocol. We found that we were only able to look at time to discharge and it usually took one to two days to where they completely stopped bleeding. They’d completed any blood transfusions and were able to discharge home. We weren’t exactly able to look at what point they stopped bleeding because I’ve now learned there’s lots of reasons for delaying discharges that are not related to this directly. But generally we found that with this protocol, the patients would stop bleeding in about 24 hours, as long as they immediately started it in the emergency department.
Dr. Gabi Hester: And Kate, from a hematologic perspective, what are some treatments that we can use in the hospital setting?
Dr. Kate Garland: So for girls that present with heavy menstrual bleeding with hemoglobins less than seven, or with hemoglobins less than eight with symptomatic anemia, we will often recommend transfusing packed red blood cells, knowing that they can continue to bleed pretty profusely until we can get those hormones to kick in. We do have options for receiving iron products and helping for those patients who might not be a minimal or agreeable for a blood cell transfusion as well.
Dr. Gabi Hester: And it sounds like because of that ongoing blood loss that you expect and the time that it takes to build up red blood cells even after iron, that if a child is below seven or symptomatic that you or preference in most cases would be the packed red blood cells. Is that correct, Kate?
Dr. Kate Garland: That’s correct. Yes. Giving iron or IV iron allows your body to receive the necessary ingredients to make red blood cells, but it does take time. And what we don’t want to see is continued decline in hemoglobin leading to things such just cardiogenic shock. So we utilize packed red blood cells to replace what these girls are missing. We also use medicines such as tranexamic acid to help stabilize clots so that they don’t continue to bleed. Tranexamic acid is an antifibrinolytic medication. That the way I crudely think about it, it just helps, again, to stabilize clots and prevent rebleeding. So we use this medicine in the form of an IV when they come into the hospital. And then we ask that they continue the oral form of the medication at discharge, again, to prevent rebleeding.
Dr. Gabi Hester: Rachel, we talked a little bit about when you would expect the bleeding to start to slow down after initiation of these therapies. Is there any additional workup that you would recommend such as imaging or additional lab work if the bleeding continues?
Dr. Rachel Miller: If the patient doesn’t seem to be responding to therapy at all, then we would consider starting probably with an ultrasound to look at the uterus. It’s a little bit different depending on probably the gynecologic age of the patient. So if the patient presented with menarche with profuse heavy vaginal bleeding, then the reason for imaging would be more to look for a vascular malformation, for example. Something really unusual versus if you had an older patient, you might be thinking something more like a little bit of uterine atony, which you think of more an obstetrics, but we’ll see patients just developing clot in the uterus and then they are unable to contract that uterine muscle. And without being able to do that, then they’re not able to stop bleeding either. But those are kind of the two scenarios where we might get an ultrasound. It’s actually really uncommon for us to need to image somebody. Because again, the incidence of finding some structural abnormality is just incredibly low.
Dr. Gabi Hester: So it sounds like routine imaging, routine ultrasounds are not indicated, but there might be a few rare, specific scenarios where you would embark on that, likely under the guidance of a pediatric gynecological specialist is my understanding. Is that what you would recommend?
Dr. Rachel Miller: Yeah, I think it would. That would be an ideal thing. I recognize there might be people listening to this podcast who don’t have access to someone with my training, so you might be utilizing an adult gynecologist. So it would just be ideal if they have a lot of experience in the adolescent population, because it is a little different than managing the abnormal uterine bleeder who’s perimenopausal, for example.
Dr. Gabi Hester: Are there any new treatments in the pipeline or anything exciting on the research horizon for this patient population?
Dr. Rachel Miller: I think reviewing those results with the hematologist, getting to the underlying problem, whether it’s just initiation of menarche or whether there’s a true underlying bleeding disorder. I think there are some novel therapies if you identify a bleeding disorder, but in general, we just got to get the bleeding to stop and get the iron replaced, get the blood replaced. And then further down we can look at is there an underlying cause on what treatments do we have for that?
I do think it would be cool to point out that our clinical pathway that involves using both combination hormonal contraceptive, or an oral progesterone in combination with tranexamic acid is a little novel. That’s not something that you’ll find people doing all over the country or world because there’s been pretty significant concern about risk of thromboembolism. But there’s emerging data and commentary about that it really is safe. And in our patient population in particular, given that they’re so young, they seem to really tolerate it well. And Kate, maybe you can correct me, but I don’t think we ever had a patient who’s had a clot, ever. And our numbers are in the hundreds.
Dr. Kate Garland: Yeah, you’re right. Rachel, we’ve not had any incidents of venous thromboembolism as a result of this pathway.
Dr. Gabi Hester: As far as supportive care for these patients after their sort of emerging from their acute presentation, are there any recommendations that you have for them for subsequent periods or preventative measures for future?
Dr. Kate Garland: From a bleeding or anemia standpoint, we do recommend that they are discharged or have ongoing iron supplementation orally until they are replete. And the definition of repletion is usually based on your ferratin or iron store levels, knowing that hopefully your menses are what I say, we have slowed the flow. We have decreased the amount of blood loss. But ongoing treatment usually at least involves iron for some said amount of time.
Dr. Rachel Miller: I agree with Kate. I’ve been told by some of the people who work in our blood bank that adolescent girls are known to be iron deficient, even if they’re not anemic, which is why they’re not allowed to donate blood any more frequently than every six months rather than adult women. So I think maybe that’s a commentary on nutritional status as well. I think a lot of our teenage girls do not have a lot of reserve if they have a few heavy periods.
And so we’ll often try to suppress periods altogether until their hemoglobin’s normal. And then at a minimum, manage periods until their iron is replete. And the management of their periods, it’s kind of depends on what the etiology was for their abnormal uterine bleeding. So if you have PCOS for example, that’s probably not going anywhere. And so that’s going to have to be managed along a PCOS pathway because you’re always going to be at some risk of abnormal uterine bleeding. If you have an ovulation just related to an immature hormone access, then with time that should improve. So by the time you’re about three years out from your first period ever, somewhere around 70, 80% of adolescents will have regular ovulatory, menses much like adult women.
So you can sort of point to that as I think you’re going to probably most likely statistically be fine if you can get to here. But if you’re only three months in, that’s a ways. And so we might have to think about doing some kind of management strategy before that. And Kate isn’t there some recommended if you have a history of anemia that you have fairly regular hemoglobin or iron status checks.
Dr. Kate Garland: So the CDC recommends that for any child entering adolescence, that you get a baseline CBC. Oftentimes our kids are not following up with their pediatricians when they enter adolescence, but that is a recommendation that is often overlooked. But if you have a person, and more commonly women that has a history of anemia or a history of a bleeding disorder, it is recommend that you screen for anemia and or iron deficiency at least once per year. So for instance, these women who have a history of abnormal uterine bleeding are often either anemic, iron deficient or both. We often recommend annual screenings with CBCs and iron studies.
Dr. Gabi Hester: So many patients use supportive therapies and analgesics like ibuprofen or Aleve or some of those other nonsteroidal anti-inflammatory products when they’re having menses. Are there any contraindications or caveats to that in this patient population?
Dr. Rachel Miller: I think they should absolutely be used. Oftentimes.
Dr. Gabi Hester: Yeah.
Dr. Rachel Miller: Oftentimes we don’t find out about a bleeding disorder until the labs come back or later. So I would not hesitate to use these medications up front for these patients. And we can cross the bridge later if we have a diagnosed bleeding disorder to use medications such like Celebrex, which do not cause platelet dysfunction, but is a nonsteroidal. Many patients use it because they’re having painful periods, but nonsteroid inflammatory drugs have been shown to actually decrease menstrual blood loss as well when taken in a appropriately dose, regular we scheduled fashion. But yeah, if you have a proven platelet disorder of Von Willebrands or something, then we’ll have to use one of the COX-2 inhibitors instead.
Dr. Gabi Hester: Well, thank you both so much for joining me today and helping me to understand this patient population. It sounds like a really important area of ongoing investigation and research. And I’m so grateful that you both are doing a lot of this exciting work here at Children’s Minnesota. So thank you so much for joining today.
Dr. Rachel Miller: Thanks Gabi.
Dr. Kate Garland: Thanks for having us.
Speaker: Take home point.
Dr. Gabi Hester: Number one, while there are many potential causes for heavy menstrual bleeding, including pregnancy, ovulatory dysfunction, infections or iatrogenic causes, coagulopathy is the most common cause and most patients should be evaluated for a bleeding disorder.
Number two, patients with symptoms related to heavy menstrual bleeding and severe anemia should be admitted to the hospital for treatment until their bleeding stops, symptoms improve, and the hemoglobin is above target.
Number three, guidelines for heavy menstrual bleeding are available on Starnet or at www.childrensmn.org health professionals page.
Number four, patients with abnormal menstrual bleeding can be referred to the Children’s Minnesota adolescent and young adult combined hematology gynecology clinic.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Lexi Dingman is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.