MIAMI BEACH – Acute menorrhagia or abnormally heavy and prolonged menstrual bleeding can be a serious condition for any adolescent girl, but it becomes even more so if she has an underlying bleeding disorder, according to an expert.

Hormonal therapy, antifibrinolytic therapy, balloon tamponade, and correction of any specific hemostatic defect are the primary management strategies for acute menorrhagia, Dr. Andra H. James said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "It is not clear which therapy should come first and in what order."

This lack of clarity stems in part from a paucity of evidence-based medicine in the literature, said Dr. James, professor of ob.gyn. and assistant professor of medicine at Duke University Medical Center in Durham, N.C.

She recognized the need for more guidance on acute menorrhagia and was the primary author of consensus guidelines on evaluation and management of acute menorrhagia (Eur. J. Obstet. Gynecol. Reprod. Biol. 2011;158:124-34). Dr. James and some international experts systemically reviewed what was in the literature – primarily case reports and expert opinion – to devise recommendations for acute menorrhagia for girls and women with and without underlying bleeding disorders.

Important elements of patient history, physical exam, medication review, and laboratory testing are outlined in the guidelines, as well as advice on when an ultrasound examination is warranted.

Adolescents with acute menorrhagia differ from adults in some important ways. Anticoagulation therapy is rarely a cause of abnormal bleeding in a young woman, but "anovulatory bleeding is often a precipitating factor in adolescence," she said.

In addition, acute signs of an underlying bleeding disorder can first appear during the teenage years, Dr. James said.

Thrombocytopenia, von Willebrand disease, platelet function disorders, and clotting factor deficiencies are among the most relevant bleeding disorders in this setting. "These bleeding disorders are important to gynecologists [because] the leading symptom in the women and girls with a bleeding disorder is heavy menstrual bleeding," she said.

There also are girls and women who present with rare factor deficiency disorders, and the relatively fewer treatment options for these patients are outlined in the guidelines.

"Acute menorrhagia is not a benign condition for an adolescent, whether or not they have a bleeding disorder. They are often seen in an acute setting," Dr. James said. "Heavy menstrual bleeding is pretty morbid for adolescents."

She recommended an eight-question screening tool to identify bleeding disorders in patients with menorrhagia (Am. J. Obstet. Gynecol. 2011;204:209.e1-7). Dr. Claire Philipp of Robert Wood Johnson Medical School, New Brunswick, N.J., and her colleagues developed this screen to help gynecologists and primary care physicians determine which patients to refer for hemostatic work-up. The screening questions fall into four categories: menorrhagia severity, family history of a diagnosed bleeding disorder, personal history of excessive bleeding after specific challenges, and history of treatment for anemia.

"I feel pretty good if they have one of those four, I am going to go ahead and test them," Dr. James said.

The screen is more than 90% sensitive for identification of von Willebrand disease, for example, "and you can avoid testing everyone who says they have heavy menstrual bleeding," said Dr. James, who is also founder of the Duke University Medical Center Women’s Hemostasis and Thrombosis Clinic.

"Dr. Erik von Willebrand, who described von Willebrand disease, lost his first patient to her fourth menstrual period," Dr. James said. "But [now] acute menorrhagia in adolescence can be evaluated and can be managed."

The guideline authors also proposed a consensus definition of acute menorrhagia: life-threatening bleeding of uterine origin with sufficient volume, in the absence of pregnancy or malignancy that occurs during childbearing years (teen to perimenopause). The condition occurs in patients with or without a previously diagnosed bleeding disorder. Patients present to the emergency department and require immediate evaluation and intervention.

The guidelines highlight considerations for hormonal treatment, antifibrinolytic therapy, balloon tamponade, and correction of hemostatic deficiencies. Even though treatment relies to a great deal on clinician judgment, "many of us feel comfortable starting with hormone therapy," she said.

Regarding balloon tamponade therapy, "there are no randomized trials, but there are multiple case reports of its effectiveness in the very acute situation in the emergency department," Dr. James said. "We all have conversations about how long we leave the balloon in." Jokingly, she added: "None of us want to take it out before the woman goes to college."

With a nod to a lack of rigorous studies in the literature, Dr. James proposed that groups such as NASPAG establish registries to collect data on acute menorrhagia evaluation and management. She also recommended www.fwgbd.org, the site for the Foundation for Women & Girls with Blood Disorders, for additional information on bleeding disorders. Dr. James is a board member of the foundation.

Dr. James said that she receives research funding from CSL Behring and Grifols. She is also a member of the von Willebrand disease medical advisory board sponsored by CSL Behring, Octapharma, and Baxter.

Acute Menorrhagia: Deadly Problem for Teens With Bleeding Disorder