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By Nneka Holder, MD The Challenges of Diagnosing Heavy Menstrual Bleeding in Adolescent Girls +++++++++++++++++++++++++++++++++++ + +++ + +++ +++++++++++++++++++++++++++++++++++ SPECIAL SECTION: PEDIATRICS ❯ N OT LONG AGO, I was called in to offer consultation on an Amish girl who had been admitted to the emergency room for a blood transfusion. The 14-year-old had been having two-week-long menstrual cycles, and this time she'd become anemic. As I talked about the patient's condition with her parents, her mother mentioned she had two-week-long periods, too. Both thought their condition was normal since no one really talked to them about their periods. While this may be an extreme example, it illustrates the risks of heavy menstrual bleeding in young women, as well as why it's critical for physicians to discuss their menstrual cycles with this patient population. Defining what's normal in terms of an adolescent girl's menstrual cycle can be difficult – there is a broad range. In general, teen girls have a period every 28 days. Although some girls may have their periods twice a month, every 21 days or even every other month, as long as that pattern is consistent that is her normal. The average flow is around three ounces of blood, which can seem like a lot to an adolescent but it's well within an expected amount. Heavy menstrual bleeding involves flow that is persistently lasting longer than seven days, with patients needing to use more than seven absorption products a day. It should be noted that these patients often express feelings that their menstrual cycle is significantly impacting their lives. In the past, heavy menstrual bleeding may have been called dysfunctional uterine bleeding, or DUB, but that defini- tion is being used less frequently since it implies a dysfunction to the exclusion of other problems. Quite honestly, we, as physicians, have not really been strict about our terminolog y. Technically speaking, menorrhagia (hypermenor- rhea) is used to indicate a prolonged period, metrorrhagia means an irregular period — menometrorrhagia is the two combined. For patients, many physicians are now using the term heavy menstrual bleeding or abnormal uterine bleeding. It's important to keep in mind that what affects an adolescent's uterus is very different from that of adult women, meaning that what may seem like a disor- der may be the patient's body's attempting to at fine-tuning the menstrual cycle. The mechanisms behind the function of the menstrual cycle, the HPO-axis, or hypothalamic-pituitary-ovarian axis, are complex and rely on a fine-tuned system that as physicians we still don't yet completely understand completely. T h e a p p r o a c h t o t r e a t m e nt i s a lso different in young girls when compa red to adult women. W hile correcting abnormal menstrual f low is important, diagnosing the cause becomes the overlying concern. For example, bleeding disorders can take some months to diagnose. For some patients it may be appropriate to take a wait-and-see approach, while for others with serious bleeding disorders, if they have even one period, they're going to wind up needing a blood transfusion in the hospital. The concern with heavy adolescent menstrual bleeding is determining what may be causing the issue. Common underlying causes include: + Bleeding disorders, such a s von Willebrand disease (vWD) + Infections, like sexually transmitted diseases (STDs) + H o r m o n a l p r o b l e m s , s u c h a s thyroid disorders Keeping the lines of communica- tion open between physicians and adolescent young women is vital for these patients. W hat I find usef ul is to consider periods the fifth vital sign for adolescent girls. Along with re g u la rly mon itor i n g a pat ient's temperature, pulse rate, respiration and blood pressure, there should be a discussion of when she had her last period and the length of that period. These conversations open the doors for patients to explain any concerns they may be experiencing. Dr. Nneka Holder, MD, is an adolescent medicine specialist in the Adolescent Medicine Department and the Young Women's Bleeding Disorder Clinic at Akron Children's Hospital. She is a member of the American Board of Pediatrics with certification in Adolescent Medicine. ■ 2 4 | Cleveland/Akron/Canton MD NEWS ■ M D N E W S . CO M ■ S E P T E M B E R /O C T O B E R 2 0 1 4