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Evaluation of the Adolescent with Heavy Menstrual Bleeding

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Hematology in the Adolescent Female

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Abstract

Bleeding disorders constitute an important etiology of heavy menstrual bleeding in adolescents that require thoughtful planning of the laboratory evaluation. Optimal diagnostic strategies should consider the pretest probability of a bleeding problem based on the patient’s personal and family history of bleeding and should always follow a bleeding history. Physicians, including adolescent medicine, family practice, and obstetrician-gynecologists, should work in coordination with a hematologist for management of heavy menstrual bleeding, including diagnostic evaluation of a bleeding disorder. Such evaluation in adolescent girls should include assessment of anemia from blood loss, including serum ferritin, the presence of an endocrine disorder leading to anovulation, and testing for an underlying bleeding disorder. The highest yield initial tests for diagnosing a bleeding disorder in adolescents with heavy menstrual bleeding include von Willebrand panel and platelet function testing. This chapter will summarize the laboratory evaluation of bleeding disorders in adolescents with heavy periods with an emphasis on practical considerations.

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References

  1. Friberg B, Orno AK, Lindgren A, Lethagen S. Bleeding disorders among young women: a population-based prevalence study. Acta Obstet Gynecol Scand. 2006;85(2):200–6.

    PubMed  Google Scholar 

  2. Jacobson AE, Vesely SK, Koch T, Campbell J, O'Brien SH. Patterns of von Willebrand disease screening in girls and adolescents with heavy menstrual bleeding. Obstet Gynecol. 2018;131(6):1121–9.

    PubMed  Google Scholar 

  3. National Collaborating Centre for Women’s and Children’s Health (UK). Heavy menstrual bleeding. London: RCOG Press; 2007.

    Google Scholar 

  4. Nur Azurah AG, Sanci L, Moore E, Grover S. The quality of life of adolescents with menstrual problems. J Pediatr Adolesc Gynecol. 2013;26(2):102–8.

    PubMed  Google Scholar 

  5. ACOG Committee Opinion No. 651: Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Obstet Gynecol. 2015;126(6):e143–6.

    Google Scholar 

  6. Screening and management of bleeding disorders in adolescents with heavy menstrual bleeding: ACOG Committee Opinion, Number 785. Obstet Gynecol. 2019;134(3):e71–e83.

    Google Scholar 

  7. World Health Organization multicenter study on menstrual and ovulatory patterns in adolescent girls. II. Longitudinal study of menstrual patterns in the early postmenarcheal period, duration of bleeding episodes and menstrual cycles. World Health Organization Task Force on Adolescent Reproductive Health. J Adolesc Health Care. 1986;7(4):236–44.

    Google Scholar 

  8. Bennett AR, Gray SH. What to do when she’s bleeding through: the recognition, evaluation, and management of abnormal uterine bleeding in adolescents. Curr Opin Pediatr. 2014;26(4):413–9.

    PubMed  Google Scholar 

  9. Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Semin Reprod Med. 2011;29(5):383–90.

    PubMed  Google Scholar 

  10. Warner PE, Critchley HO, Lumsden MA, Campbell-Brown M, Douglas A, Murray GD. Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. Am J Obstet Gynecol. 2004;190(5):1216–23.

    PubMed  Google Scholar 

  11. Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol. 2012;207(4):259–65.

    PubMed  Google Scholar 

  12. Zia A, Jain S, Kouides P, Zhang S, Gao A, Salas N, et al. Bleeding disorders in adolescents with heavy menstrual bleeding in a multicentre prospective US cohort. Haematologica. 2019 Oct 17:haematol.2019.225656. https://doi.org/10.3324/haematol.2019.225656. Online ahead of print. PMID: 31624107.

  13. Shankar M, Chi C, Kadir RA. Review of quality of life: menorrhagia in women with or without inherited bleeding disorders. Haemophilia. 2008;14(1):15–20.

    CAS  PubMed  Google Scholar 

  14. Zia A, Lau M, Journeycake J, Sarode R, Marshall J, De Simone N, et al. Developing a multidisciplinary young women’s blood disorders program: a single-centre approach with guidance for other centres. Haemophilia. 2016;22(2):199–207.

    CAS  PubMed  Google Scholar 

  15. Zia A, Rajpurkar M. Challenges of diagnosing and managing the adolescent with heavy menstrual bleeding. Thromb Res. 2016;143:91–100.

    CAS  PubMed  Google Scholar 

  16. James AH, Kouides PA, Abdul-Kadir R, Edlund M, Federici AB, Halimeh S, 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(1):12e1–8.

    Google Scholar 

  17. Nichols WL, Hultin MB, James AH, Manco-Johnson MJ, Montgomery RR, Ortel TL, et al. von Willebrand disease (VWD): evidence-based diagnosis and management guidelines, the National Heart, Lung, and Blood Institute (NHLBI) expert panel report (USA). Haemophilia. 2008;14(2):171–232.

    CAS  PubMed  Google Scholar 

  18. Favaloro EJ. Clinical utility of the PFA-100. Semin Thromb Hemost. 2008;34(8):709–33.

    CAS  PubMed  Google Scholar 

  19. Flood VH, Gill JC, Morateck PA, Christopherson PA, Friedman KD, Haberichter SL, et al. Common VWF exon 28 polymorphisms in African Americans affecting the VWF activity assay by ristocetin cofactor. Blood. 2010;116(2):280–6.

    CAS  PubMed  PubMed Central  Google Scholar 

  20. Patzke J, Budde U, Huber A, Mendez A, Muth H, Obser T, et al. Performance evaluation and multicentre study of a von Willebrand factor activity assay based on GPIb binding in the absence of ristocetin. Blood Coagul Fibrinolysis. 2014;25(8):860–70.

    CAS  PubMed  Google Scholar 

  21. Graf L, Moffat KA, Carlino SA, Chan AK, Iorio A, Giulivi A, et al. Evaluation of an automated method for measuring von Willebrand factor activity in clinical samples without ristocetin. Int J Lab Hematol. 2014;36(3):341–51.

    CAS  PubMed  Google Scholar 

  22. Favaloro EJ. Diagnosis and classification of von Willebrand disease: a review of the differential utility of various functional von Willebrand factor assays. Blood Coagul Fibrinolysis. 2011;22(7):553–64.

    CAS  PubMed  Google Scholar 

  23. Riddell AF, Gomez K, Millar CM, Mellars G, Gill S, Brown SA, et al. Characterization of W1745C and S1783A: 2 novel mutations causing defective collagen binding in the A3 domain of von Willebrand factor. Blood. 2009;114(16):3489–96.

    CAS  PubMed  Google Scholar 

  24. Flood VH, Schlauderaff AC, Haberichter SL, Slobodianuk TL, Jacobi PM, Bellissimo DB, et al. Crucial role for the VWF A1 domain in binding to type IV collagen. Blood. 2015;125(14):2297–304.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Flood VH, Christopherson PA, Gill JC, Friedman KD, Haberichter SL, Bellissimo DB, et al. Clinical and laboratory variability in a cohort of patients diagnosed with type 1 VWD in the United States. Blood. 2016;127(20):2481–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  26. Sharma R, Flood VH. Advances in the diagnosis and treatment of Von Willebrand disease. Hematology Am Soc Hematol Educ Program. 2017;2017(1):379–84.

    PubMed  PubMed Central  Google Scholar 

  27. Doshi BS, Rogers RS, Whitworth HB, Stabnick EA, Britton J, Butler RB, et al. Utility of repeat testing in the evaluation for von Willebrand disease in pediatric patients. J Thromb Haemost. 2019.

    Google Scholar 

  28. Gill JC, Endres-Brooks J, Bauer PJ, Marks WJ Jr, Montgomery RR. The effect of ABO blood group on the diagnosis of von Willebrand disease. Blood. 1987;69(6):1691–5.

    CAS  PubMed  Google Scholar 

  29. Laffan MA, Lester W, O'Donnell JS, Will A, Tait RC, Goodeve A, et al. The diagnosis and management of von Willebrand disease: a United Kingdom Haemophilia Centre Doctors Organization guideline approved by the British Committee for Standards in Haematology. Br J Haematol. 2014;167(4):453–65.

    PubMed  PubMed Central  Google Scholar 

  30. Dumont T, Allen L, Kives S. Can von Willebrand disease be investigated on combined hormonal contraceptives? J Pediatr Adolesc Gynecol. 2013;26(3):138–41.

    PubMed  Google Scholar 

  31. Zia A, Callaghan MU, Callaghan JH, Sawni A, Bartlett H, Backos A, et al. Hypercoagulability in adolescent girls on oral contraceptives-global coagulation profile and estrogen receptor polymorphisms. Am J Hematol. 2015;90(8):725–31.

    CAS  PubMed  Google Scholar 

  32. O’Brien SH. Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist. Blood. 2018;

    Google Scholar 

  33. Gresele P. Subcommittee on Platelet Physiology of the International Society on T, Hemostasis. Diagnosis of inherited platelet function disorders: guidance from the SSC of the ISTH. J Thromb Haemost. 2015;13(2):314–22.

    CAS  PubMed  Google Scholar 

  34. Harrison P, Mackie I, Mumford A, Briggs C, Liesner R, Winter M, et al. Guidelines for the laboratory investigation of heritable disorders of platelet function. Br J Haematol. 2011;155(1):30–44.

    CAS  PubMed  Google Scholar 

  35. Born GV. Aggregation of blood platelets by adenosine diphosphate and its reversal. Nature. 1962;194:927–9.

    CAS  PubMed  Google Scholar 

  36. Hayward CPM, Moffat KA, Brunet J, Carlino SA, Plumhoff E, Meijer P, et al. Update on diagnostic testing for platelet function disorders: what is practical and useful? Int J Lab Hematol. 2019;41(Suppl 1):26–32.

    PubMed  Google Scholar 

  37. Hayward CP, Moffat KA. Laboratory testing for bleeding disorders: strategic uses of high and low-yield tests. Int J Lab Hematol. 2013;35(3):322–33.

    CAS  PubMed  Google Scholar 

  38. Sorokin V, Alkhoury R, Al-Rawabdeh S, Houston RH, Thornton D, Kerlin B, et al. Reference range of Platelet Delta granules in the pediatric age group: an ultrastructural study of platelet whole mount preparations from healthy volunteers. Pediatr Dev Pathol. 2016;19(6):498–501.

    PubMed  Google Scholar 

  39. Bolton-Maggs PH, Patterson DA, Wensley RT, Tuddenham EG. Definition of the bleeding tendency in factor XI-deficient kindreds–a clinical and laboratory study. Thromb Haemost. 1995;73(2):194–202.

    CAS  PubMed  Google Scholar 

  40. Sharief LA, Kadir RA. Congenital factor XIII deficiency in women: a systematic review of literature. Haemophilia. 2013;19(6):e349–57.

    CAS  PubMed  Google Scholar 

  41. Quiroga T, Goycoolea M, Panes O, Aranda E, Martinez C, Belmont S, et al. High prevalence of bleeders of unknown cause among patients with inherited mucocutaneous bleeding. A prospective study of 280 patients and 299 controls. Haematologica. 2007;92(3):357–65.

    PubMed  Google Scholar 

  42. van der Giessen LJ, Liekens D, Rutgers KJ, Hartman A, Mulder PG, Oranje AP. Validation of beighton score and prevalence of connective tissue signs in 773 Dutch children. J Rheumatol. 2001;28(12):2726–30.

    PubMed  Google Scholar 

  43. Kendel NE, Haamid FW, Christian-Rancy M, O'Brien SH. Characterizing adolescents with heavy menstrual bleeding and generalized joint hypermobility. Pediatr Blood Cancer. 2019;66(6):e27675.

    PubMed  Google Scholar 

  44. Hurst BS, Lange SS, Kullstam SM, Usadi RS, Matthews ML, Marshburn PB, et al. Obstetric and gynecologic challenges in women with Ehlers-Danlos syndrome. Obstet Gynecol. 2014;123(3):506–13.

    PubMed  Google Scholar 

  45. Mast KJ, Nunes ME, Ruymann FB, Kerlin BA. Desmopressin responsiveness in children with Ehlers-Danlos syndrome associated bleeding symptoms. Br J Haematol. 2009;144(2):230–3.

    PubMed  Google Scholar 

  46. De Paepe A, Malfait F. Bleeding and bruising in patients with Ehlers-Danlos syndrome and other collagen vascular disorders. Br J Haematol. 2004;127(5):491–500.

    PubMed  Google Scholar 

  47. Apter D. Serum steroids and pituitary hormones in female puberty: a partly longitudinal study. Clin Endocrinol. 1980;12(2):107–20.

    CAS  Google Scholar 

  48. Pena AS, Doherty DA, Atkinson HC, Hickey M, Norman RJ, Hart R. The majority of irregular menstrual cycles in adolescence are ovulatory: results of a prospective study. Arch Dis Child. 2018;103(3):235–9.

    PubMed  Google Scholar 

  49. Maslyanskaya S, Talib HJ, Northridge JL, Jacobs AM, Coble C, Coupey SM. Polycystic ovary syndrome: an under-recognized cause of abnormal uterine bleeding in adolescents admitted to a children’s hospital. J Pediatr Adolesc Gynecol. 2017;30(3):349–55.

    PubMed  Google Scholar 

  50. Bourne AW. Hyperthyroidism in functional menorrhagia. Proc R Soc Med. 1922;15(Obstet Gynaecol Sect):24–30.

    Google Scholar 

  51. Endrikat J, Muller U, Dusterberg B. A twelve-month comparative clinical investigation of two low-dose oral contraceptives containing 20 micrograms ethinylestradiol/75 micrograms gestodene and 30 micrograms ethinylestradiol/75 micrograms gestodene, with respect to efficacy, cycle control, and tolerance. Contraception. 1997;55(3):131–7.

    CAS  PubMed  Google Scholar 

  52. Rosenberg MJ, Meyers A, Roy V. Efficacy, cycle control, and side effects of low- and lower-dose oral contraceptives: a randomized trial of 20 micrograms and 35 micrograms estrogen preparations. Contraception. 1999;60(6):321–9.

    CAS  PubMed  Google Scholar 

  53. Salamonsen LA, Butt AR, Hammond FR, Garcia S, Zhang J. Production of endometrial matrix metalloproteinases, but not their tissue inhibitors, is modulated by progesterone withdrawal in an in vitro model for menstruation. J Clin Endocrinol Metab. 1997;82(5):1409–15.

    CAS  PubMed  Google Scholar 

  54. Galant C, Berliere M, Dubois D, Verougstraete JC, Charles A, Lemoine P, et al. Focal expression and final activity of matrix metalloproteinases may explain irregular dysfunctional endometrial bleeding. Am J Pathol. 2004;165(1):83–94.

    CAS  PubMed  PubMed Central  Google Scholar 

  55. Pennesi CM, Kenney B, Thakkar R, Ching C, Hewitt G, McCracken K. Prolonged vaginal bleeding in an adolescent secondary to a foreign body: need for a comprehensive assessment and complex surgery. J Pediatr Adolesc Gynecol. 2018;31(6):640–3.

    PubMed  Google Scholar 

  56. Deligeoroglou E, Karountzos V, Creatsas G. Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology. Gynecol Endocrinol. 2013;29(1):74–8.

    PubMed  Google Scholar 

  57. James AH. Heavy menstrual bleeding: work-up and management. Hematology Am Soc Hematol Educ Program. 2016;2016(1):236–42.

    PubMed  PubMed Central  Google Scholar 

  58. Arbel-DeRowe Y, Tepper R, Rosen DJ, Beyth Y. The contribution of pelvic ultrasonography to the diagnostic process in pediatric and adolescent gynecology. J Pediatr Adolesc Gynecol. 1997;10(1):3–12.

    CAS  PubMed  Google Scholar 

  59. American College of O, Gynecologists. ACOG Technology Assessment in Obstetrics and Gynecology No. 5: sonohysterography. Obstet Gynecol. 2008;112(6):1467–9.

    Google Scholar 

  60. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand. 2003;82(6):493–504.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Pediatric Hematology-Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, USA

    Ayesha Zia

  2. Department(s) of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA

    Ayesha Zia & May Lau

  3. The University of Texas Southwestern Medical Center, Dallas, TX, USA

    Ayesha Zia & May Lau

  4. Division of Developmental and Behavioral Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, USA

    May Lau

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  1. Ayesha Zia
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  2. May Lau
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Correspondence to Ayesha Zia .

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Editors and Affiliations

  1. Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA

    Lakshmi V. Srivaths

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Zia, A., Lau, M. (2020). Evaluation of the Adolescent with Heavy Menstrual Bleeding. In: Srivaths, L. (eds) Hematology in the Adolescent Female. Springer, Cham. https://doi.org/10.1007/978-3-030-48446-0_1

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  • DOI: https://doi.org/10.1007/978-3-030-48446-0_1

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