1. anovulatory cycles mostly

2. Mild + Hb normal = reassurance + non-hormonal treatments + observation

3. R/O Pregnacy dx, Bleeding dx

4. Hormonal therapy aims to stabilise the endometrium

• Normal menstrual blood loss:

  • pads/tampon changes at ≥3 hour intervals

  • seldom overnight

  • < 21 pads(or tampoons) per cycle

• Excessive menstrual flow:

  • >7 days duration or >80 mL

  • necessitating changing a super pad/tampon more than every 2 hours

  • causing symptomatic anaemia

  • causing lifestyle disturbance

• Menstrual cycles

  • often irregular and anovulatory in the first few years after menarche.

  • The time to establish regular ovulatory cycles increases with increasing age of menarche

• Anovulatory uterine bleeding

  • Excessive noncyclic uterine bleeding related to immaturity of the hypothalamic-pituitary-ovarian axis (in the absence of structural uterine lesions or systemic disease)

• Pregnancy: miscarriage, ectopic pregnancy, gestational trophoblastic disease

• Endocrine: anovulatory, thyroid dysfunction, polycystic ovarian syndrome (PCOS)

• Haematological: von Willebrand Disease, platelet function disorder, thrombocytopenia, other bleeding disorder

• Medication: hormonal contraception, anticoagulants

• Other: trauma, infection, malignancy, structural causes (uncommon in adolescence), gastrointestinal bleeding

1. Haemodynamic stability ie shock index

2. Hb

• Menstrual history

  • menarche

  • last menstrual period

  • frequency (cycle length) eg every 30 days

  • duration

  • flow ?

  • pain

  • flooding

  • large clots (>2cm in diameter)

  • frequency of pad/tampon changes)

• Impact on daily life: missing school, sports, social activities

• Sexual history and contraception

• Symptoms of

  • Anaemia: dizziness, shortness of breath, fatigue

  • Bleeding disorders: epistaxis, bleeding gums, easy bruising

• Past medical history including: coagulopathy, platelet function disorders, recurrent haemorrhagic cysts, chronic medical conditions

• Adolescent assessment (HEADSS screen)

• Vital signs: hypotension, tachycardia

• Skin: pallor, petechiae, bruising

• Abdominal examination: tenderness or pelvic mass

• Secondary signs of PCOS: acne, excess facial or body hair, weight gain

Vaginal examination is rarely indicated in an adolescent. It should be discussed with a senior clinician, and if needed should only be performed once

• Mild: Flow:slight q4wkly + Haemodynamic:stable + Hb:normal

• Mod: Flow:moderate q1-3wkly + Haemodyn: ? + Hb: >100

• Severe: Flow:heavy OR Haemody: unstable OR Hb:<100

• FBE

• Blood group and antibody screen for severe bleeding

• Ferritin

• Coagulation screen

• TSH

• Urine or blood ßhCG (with consent)

• Consider pelvic ultrasound if bleeding accompanied by pain or palpable mass

• If a bleeding disorder is suspected, consider Platelet function assay (PFA) 100 and von Willebrand screen. These tests should not be done during acute bleeding or with recent NSAID use

• Mild & no desire for contraception

  1. Reassurance

  2. Observation

  3. NSAIDS & TXA during menses to be considered

• Moderate

  1. TXA during menses

  2. Hormonal Rx

     • COCP if no contraindications (uncontrolled HTN, CVD, migraine with focal neuro signs, thrombosis risk)

     • POP

• Severe

  1. Resuscitation

  2. TXA

  3. High dose NET

  4. Iron infusion as required or PRBC transfusion if still unstable despite fluid resus

  5. Specialist gyn review, consider admission