Latest / Pediatrics in Practice: A CME Podcast / What Causes Heavy Menstrual Bleeding in Teens?

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What Causes Heavy Menstrual Bleeding in Teens? · Pediatrics in Practice: A CME Podcast

• 0:03
  Sarah Gubara, PhD (Host): Welcome to Pediatrics in Practice, a CME podcast.
• 0:07
  I'm Dr.
• 0:08
  Sarah Gubara.
• 0:08
  And today, I'm joined by Dr.
• 0:10
  Lauren Amos, Program Director for Pediatric Hematology and
• 0:15
  Oncology Fellowship at Children's Mercy Kansas City, and Dr.
• 0:19
  Ashli Lawson, pediatric and adolescent gynecologist and Program
• 0:23
  Director of their Fellowship.
• 0:25
  Today, we're discussing heavy menstrual bleeding in adolescents.
• 0:31
  Thank you both for taking the time to join me this morning.
• 0:35
  Ashli Lawson, MD, MS: Happy to be here.
• 0:36
  Lauren Amos, MD, MS: Yep.
• 0:36
  Thank you so much for having us.
• 0:38
  Host: Of course.
• 0:39
  So as we're discussing heavy menstrual bleeding, it's a
• 0:42
  common complaint in adolescents.
• 0:44
  Dr.
• 0:45
  Amos, what features should make providers think about whether or not
• 0:49
  there's an underlying bleeding disorder?
• 0:52
  Lauren Amos, MD, MS: Yeah, thanks for that question.
• 0:53
  I always like to start and state up to 30% of adolescents with heavy
• 0:57
  menstrual bleeding will ultimately be diagnosed with a bleeding disorder.
• 1:02
  And so, increased awareness and referrals are really key to avoiding
• 1:06
  making that diagnosis later in life.
• 1:09
  The things that are really important when sorting out, if this can be
• 1:12
  a bleeding disorder versus another source of heavy menstrual bleeding,
• 1:17
  start with certainly a family history.
• 1:20
  So really, seeing if there are others in the family who have had significant
• 1:24
  heavy menstrual bleeding requiring blood transfusions or early interventions in
• 1:30
  life, such as hysterectomies, evaluation for maternal postpartum hemorrhage
• 1:35
  or postoperative bleeding, and then also focusing in on your patient.
• 1:40
  So, are there other bleeding signs such as nosebleeds or easier excessive bruising?
• 1:47
  But a lot of times, those features are absent.
• 1:49
  And so then, just focusing on, is the heavy menstrual bleeding
• 1:52
  even enough that's impacting the patient's quality of life?
• 1:55
  Are they missing school or work?
• 1:57
  Is it causing symptomatic anemia?
• 2:00
  And if any of those features are present, then the patient really
• 2:03
  should be referred for further workup.
• 2:06
  Host: That makes a lot of sense.
• 2:07
  Going off of that, Dr.
• 2:09
  Lawson, how do you distinguish normal early adolescent menstrual irregularities
• 2:14
  from bleeding that warrants further evaluation or even a referral to Dr.
• 2:19
  Amos?
• 2:20
  Ashli Lawson, MD, MS: I'm actually going to back up and just add on to some of Dr.
• 2:23
  Amos' last answer, because there is this really good mnemonic that I
• 2:27
  use with my trainees called 7-2-1.
• 2:30
  In fact, not to prop up other podcasts, but there's a whole podcast called
• 2:34
  7-2-1 put out by the Foundation for Women and Girls with Bleeding Disorders.
• 2:39
  And these numbers can help you remember some quick, easy numbers for
• 2:43
  what bleeding is too much bleeding.
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  Seven stands for how many days they're bleeding.
• 2:48
  So if they're bleeding more than seven days in a row, that's concerning and
• 2:53
  should start triggering your mind to think about a workup for a bleeding disorder.
• 2:57
  Two stands for how long each product will last you.
• 3:01
  So if they're soaking a tampon or soaking a pad every two hours or
• 3:06
  more, that should be another trigger.
• 3:08
  And the one stands for one inch, which is about the size of a
• 3:11
  quarter if you have patients who don't know how big an inch is yet.
• 3:16
  So if they're having blood clots that are an inch or larger or bigger than
• 3:20
  a quarter, then that should trigger a workup for a bleeding disorder as well.
• 3:25
  And so, if you're ever unsure or on the fence, that 7-2-1
• 3:28
  is a good place to start.
• 3:30
  Host: That sounds like a fantastic mnemonic.
• 3:33
  Ashli Lawson, MD, MS: Back to your question though of how do we distinguish
• 3:37
  abnormal bleeding early on from something that warrants a further
• 3:41
  workup though is a little bit trickier.
• 3:45
  Most people, or at least for most females, when you start talking about
• 3:50
  your first period, everyone remembers that first period that they had.
• 3:53
  There's some sort of story that goes along with it.
• 3:56
  Whether it was Christmas morning or your birthday or at Girl Scout camp,
• 4:00
  we all have these memories of it.
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  But what we forget is that year that follows it that was super
• 4:05
  irregular and also unpredictable.
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  I say that starting a period is kind of like learning to play a new sport
• 4:13
  or learning to play an instrument.
• 4:14
  It takes some time for your brain and ovaries and uterus to figure out this
• 4:19
  beautiful rhythm of ovulate and roughly two weeks later have a period, ovulate,
• 4:25
  two weeks later roughly have a period.
• 4:27
  And so, there can be lots of irregular patterns in that first year.
• 4:31
  And when your period isn't coming along with an ovulation, it can lead to it
• 4:37
  being heavier or more unpredictable.
• 4:40
  So within that first year, try to give these patients a little
• 4:44
  bit of grace, meaning they can skip up to a month or two.
• 4:50
  But if they're skipping more than three months, that might be a sign
• 4:53
  that something else is going on.
• 4:55
  With regards to bleeding though, I fall back on that 7-2-1.
• 4:59
  If they are having bleeding that's lasting longer than seven days, at least begin the
• 5:04
  workup or begin the referral to getting someone else to take a look at this.
• 5:09
  I think it's also important to remember to trust women, to trust girls.
• 5:14
  If they're coming to you saying, "This is heavy bleeding.
• 5:18
  This is not normal," it's very likely that this has been going
• 5:21
  on longer than they're letting on.
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  And if the bleeding's heavy enough to be impacting their quality
• 5:26
  of life, that's a sign that bleeding is heavier than average.
• 5:30
  Dr.
• 5:30
  Amos, do you have anything else to add?
• 5:32
  Lauren Amos, MD, MS: Yeah.
• 5:33
  Dr.
• 5:33
  Lawson, I would completely echo that.
• 5:35
  I think, sometimes as girls start to have their periods, they're not
• 5:41
  keeping close track on all of the details that sometimes you need to
• 5:44
  check those boxes that this is heavy.
• 5:46
  But if they're really reporting things like they are missing sports
• 5:50
  practices or not being able to get to the bathroom from class in time,
• 5:55
  things like that, it's better just to go ahead and start that workup.
• 5:59
  You don't want to delay these diagnoses.
• 6:01
  And we see that time and time again that, you know, men with bleeding get diagnosed
• 6:05
  much earlier in life than females do.
• 6:08
  And so, the earlier you can see that something is wrong and start the process
• 6:12
  of figuring out what it is, the better off those patients are going to be.
• 6:16
  Host: I love the focus on quality of life.
• 6:19
  I think that's really, really important, as a psychologist because there's a lot of
• 6:24
  conversations we have about that as well.
• 6:27
  Now, you both mentioned some of the workups that would be
• 6:32
  needed for further evaluation.
• 6:34
  What initial laboratory workup should primary care providers
• 6:37
  consider before referring?
• 6:40
  Lauren Amos, MD, MS: So certainly, from a hematology standpoint, anytime we're
• 6:43
  thinking about heavy menstrual bleeding, the first thing you're wanting to get is a
• 6:47
  complete blood count or a CBC, because you want to assess for the presence of anemia,
• 6:52
  and you want to catch that early before that anemia progresses to a degree that
• 6:57
  would require further intervention, like a blood transfusion or hospitalization.
• 7:01
  You also want to assess iron stores because iron deficiency is
• 7:05
  incredibly prevalent among females with heavy menstrual bleeding.
• 7:09
  And I recommend getting a ferritin, which is the most reliable marker of
• 7:14
  your iron stores, to see if they're iron deficient, and acting on that.
• 7:19
  So, those are kind of my first-line things that a primary care provider
• 7:22
  can do and make sure that the patient isn't going to need immediate attention.
• 7:27
  Following that, certainly, you can get other screening bleeding disorder labs.
• 7:32
  But really, I feel that those are best obtained in a hematologist's office
• 7:36
  where we can run those labs on-site and get the most accurate levels.
• 7:40
  There have been studies that have shown that if you run testing like von
• 7:43
  Willebrand panels or factor levels, and those are send out labs, that just due to
• 7:48
  the sensitive nature of those tests, there can be false positives or false negatives
• 7:52
  that also lead to the diagnosis delay.
• 7:54
  So, I think if you start with that screening CBC and ferritin, see what
• 7:58
  those levels are, and then get them in touch with a hematologist and get
• 8:02
  them plugged in, we can take over the workup to look for bleeding disorders
• 8:06
  and do it in a very accurate way.
• 8:08
  I'll let Dr.
• 8:09
  Lawson weigh in more on the gynecology aspect of those things.
• 8:12
  Ashli Lawson, MD, MS: Yeah, I usually throw in a TSH there as well if they're
• 8:16
  having irregular periods going along with heavy bleeding too, and if the TSH hasn't
• 8:21
  been done within the past twelve months.
• 8:23
  It's more rare for us to be catching a thyroid abnormality in these patients.
• 8:27
  But every now and then, we do find it, and that can help explain
• 8:30
  either the irregularity or the heaviness going along with it too.
• 8:35
  Sometimes people will ask me about a pelvic sono and whether or not
• 8:38
  that's needed, and there aren't clear guidelines stating you do
• 8:43
  or you do not have to do this.
• 8:45
  And so, I tend to make that decision based on each individual patient.
• 8:50
  Ultrasounds are pretty low risk and low cost.
• 8:53
  We do them all transabdominal, meaning this is not going to be a probe into
• 8:57
  the vagina, but it helps get us a better look at the uterus and the ovaries.
• 9:02
  Both of those can help rule out that there's a structural problem, things
• 9:06
  like fibroids, which are pretty rare in teenagers, but it can help rule out a
• 9:11
  structural cause of uterine bleeding, or it can rule out an adnexal mass,
• 9:15
  something like a hormonally secreting tumor causing abnormal bleeding.
• 9:20
  That's also pretty rare in teens.
• 9:23
  Sometimes it does give the patients or the parents a little bit of reassurance.
• 9:26
  And so, again, low risk, low cost intervention, but helps rule out things.
• 9:33
  Certainly, if they're having any bulk symptoms, things like chronic constipation
• 9:37
  or urinary urgency that might be signs of like a mass pushing there, then of course
• 9:42
  lean towards getting that ultrasound.
• 9:45
  Or if they're not responding to therapy, like something you've already
• 9:48
  started them on and they are still having bleeding through that, then
• 9:52
  I would certainly get an ultrasound then as you're referring to someone
• 9:55
  else to take a look at this patient.
• 9:57
  Host: Wonderful.
• 9:58
  So as we're taking a look at patients, when should they be referred to either
• 10:03
  gynecology or hematology, or is there an opportunity to refer to both?
• 10:09
  How can you help us tease that out a little bit more?
• 10:12
  Lauren Amos, MD, MS: I think from a hematology standpoint, anytime
• 10:16
  heavy menstrual bleeding is present and you've identified it, you should
• 10:19
  refer to hematology to evaluate for underlying bleeding disorders.
• 10:24
  Certainly, if that is affecting why the patient is having heavy
• 10:29
  menstrual bleeding, we can really add to the management and it's
• 10:32
  going to affect them lifelong in terms of planning for surgeries,
• 10:37
  injuries, accidents, and childbirth.
• 10:39
  So, to me, if you think they have heavy menstrual bleeding, please send them
• 10:43
  on to us in hematology so that we can work them up for bleeding disorders.
• 10:47
  Ashli Lawson, MD, MS: I feel very similarly.
• 10:49
  We are always here.
• 10:50
  We're always available.
• 10:51
  And this is something that we train extensively in, so
• 10:54
  we're happy to help with.
• 10:56
  I think many pediatricians feel comfortable either starting tranexamic
• 11:00
  acid or starting different types of hormones to help with things.
• 11:05
  And so, I think that's very appropriate, both from a scope of practice and from
• 11:10
  a patient safety standpoint, is to initiate treatment of this and begin
• 11:14
  the workup as you get a referral in.
• 11:16
  But if a patient is having heavy bleeding that's impacting their
• 11:19
  life, that's causing anemia or iron deficiency, then they should
• 11:24
  be sent on to see a specialist.
• 11:27
  Lauren Amos, MD, MS: And I will piggyback off of Dr.
• 11:28
  Lawson on that.
• 11:30
  I think, you know, if they come to me for heavy menstrual bleeding, almost always I
• 11:34
  end up sending on the referral then to Dr.
• 11:37
  Lawson and her colleagues because it's that co-management of, first of all,
• 11:41
  making sure it's not just a hematologic issue, but also the management using,
• 11:46
  you know, specific hormonal methods.
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  And they just offer an advanced level of care for this unique patient population
• 11:53
  and do it in a way that's incredibly comfortable for these patients.
• 11:55
  And oftentimes, families and patients aren't even aware of the options for
• 11:59
  controlling heavy menstrual bleeding that extend beyond just, you know,
• 12:02
  a combination oral contraceptive.
• 12:05
  So, I think if you send the referral to both of us simultaneously, you're
• 12:10
  providing excellent care for your patient and really going to address
• 12:13
  everything in a full scope manner.
• 12:15
  Host: I love that teamwork.
• 12:17
  That sounds wonderful.
• 12:19
  In regards to collaborative care, I'm curious how you both help families
• 12:23
  manage some of the natural anxiety that comes with coping with heavy bleeding.
• 12:29
  I would love to hear from both of you about some strategies for that.
• 12:34
  Ashli Lawson, MD, MS: I call myself a gyneciatrist, and that's probably
• 12:37
  not fair because I did not go through psychiatry residency and they
• 12:41
  have a whole different skill set.
• 12:43
  But almost every single day, we are dealing with, the stigmas going along
• 12:49
  with reproductive care or menstrual care, and the mom's or caregiver's
• 12:54
  story of what they have experienced.
• 12:56
  And I just hope each passing generation we're doing better and
• 13:01
  better for the care for women.
• 13:02
  As far as how do we provide this comprehensive care, I think that we turn
• 13:08
  on our listening ears and we think about the patient as more than just numbers.
• 13:12
  So despite some of my patients with heavy menstrual bleeding, having normal
• 13:17
  hemoglobins or normal iron counts, and a normal thyroid check and no signs of a
• 13:22
  bleeding disorder, they're still telling me that their periods are heavy and they
• 13:25
  can't go to cheer practice because they never know when they're going to bleed.
• 13:29
  And when they do, they're going to flood the base that's holding them up.
• 13:32
  And so, to provide that care, we have to listen to what their goals are.
• 13:36
  Are their goals to have just a monthly period that's lighter?
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  Are their goals for their period to go away?
• 13:44
  Are their goals for them to just be reassured that their blood
• 13:47
  counts are normal and that they don't need a blood transfusion?
• 13:51
  And so, really individualizing what the patient needs from a medical
• 13:56
  standpoint and what they need from a social integration standpoint is helpful.
• 14:01
  We also have a combined clinic, which I hope I'm not stealing Dr.
• 14:05
  Amos' thunder, but we have a combined clinic for our
• 14:08
  girls with bleeding disorders.
• 14:10
  It's called ABC, the Adolescent Bleeding Clinic, and that's where we can
• 14:14
  provide multidisciplinary care with our hematologists as well as gynecologists.
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  We also have social workers there because we know this impacts their
• 14:22
  needs at school among other things.
• 14:25
  And so, that clinic really helps our most at-risk teens, navigate
• 14:30
  through their adolescence.
• 14:33
  Lauren Amos, MD, MS: And I absolutely agree with everything that Dr.
• 14:35
  Lawson said.
• 14:36
  I reassure these patients and families that, you know, this is a conversation I
• 14:41
  have every single day, and that there are so many other girls and moms and families
• 14:46
  who have experienced the same thing of not being acknowledged or feeling that
• 14:52
  nobody is believing or listening to their concerns about heavy menstrual bleeding.
• 14:56
  So, just normalizing it, you know, I talk about blood, I talk about
• 14:59
  bleeding, I talk about bleeding all the time in different ways.
• 15:02
  And this is just one aspect of that.
• 15:04
  And it's nothing that is something that should be embarrassing or
• 15:08
  concerning, and that our job is really to help and to make things better.
• 15:13
  And just providing that support and meeting the goals
• 15:16
  of the patient, just like Dr.
• 15:17
  Lawson said.
• 15:18
  It's not enough to say, "Oh, your hemoglobin is normal."
• 15:21
  I mean, there's a lot of dismissal over that.
• 15:23
  They're not anemic, you know.
• 15:25
  So, this can't really be that big of a deal, and that's just not the truth.
• 15:29
  We want, you know, if you're a competitive swimmer or if you're on
• 15:32
  the soccer field or you have a job where you're not able to take breaks
• 15:36
  in time, you know, those things are extremely detrimental to our patients.
• 15:40
  And so, it's really just listening, acknowledging, understanding and, you
• 15:47
  know, letting these girls, and oftentimes their moms have stories just like Dr.
• 15:51
  Lawson said.
• 15:52
  And I end up referring them to our adult side of our bleeding disorder
• 15:56
  clinic, because they often have bleeding disorders too that have been not
• 16:00
  acknowledged and missed until, you know, their daughter came to medical care.
• 16:03
  And so, I think, you know, our responsibility is really to be
• 16:06
  advocates for this population and acknowledge and support them.
• 16:11
  Host: Thank you for sharing so much about collaborative care and the
• 16:15
  thoughtfulness in validating the experience of some of these patients.
• 16:20
  What are some opportunities for earlier intervention that can improve outcomes
• 16:25
  and quality of life for these patients?
• 16:27
  Ashli Lawson, MD, MS: I'm going to let Dr.
• 16:28
  Amos take this one with the, one of the newest AAP guidelines that came out that
• 16:34
  I think all of us were in the bleeding disorder world were very happy to hear.
• 16:37
  Lauren Amos, MD, MS: Yeah, absolutely.
• 16:39
  So, the screening guidelines for evaluating for anemia and iron deficiency
• 16:45
  have been really focused on the toddler population for quite some time.
• 16:50
  And we recognize in the adolescent group that that's, you know, another
• 16:56
  very critical time where iron deficiency and anemia goes unnoticed.
• 17:00
  And in girls, the number one culprit is going to be heavy menstrual bleeding.
• 17:04
  So, those guidelines have just come out that for menstruating females with
• 17:08
  their first period, they should have a screening CBC and ferritin, and to
• 17:13
  continue that routinely with menstruation.
• 17:16
  And so, I think that's going to be a really ideal outcome because even
• 17:19
  if the girl doesn't recognize that her periods are too heavy or is in
• 17:23
  a family that unfortunately has had generations of heavy menstrual bleeding.
• 17:27
  So, they think something's normal, it's not.
• 17:29
  They're going to get those lab markers that are showing something's going on.
• 17:32
  So, that's going to be a first opportunity for intervention that we haven't had
• 17:35
  before with such a standardization across pediatric and adolescent care.
• 17:40
  So, I'm incredibly excited about those guidelines.
• 17:43
  And not to plug something else, but at the Clinical Advances in Pediatric Symposium
• 17:48
  that Children's Mercy is hosting, I'll be giving a talk about those updated
• 17:51
  guidelines and iron deficiency and recognizing and treating it earlier.
• 17:55
  So, just supporting that that's a great opportunity for early intervention.
• 18:00
  I think another way is just to make sure that you include a careful assessment
• 18:04
  of menstrual cycles in your well-child check or your adolescent physical.
• 18:10
  It should be almost like another vital sign.
• 18:12
  I had a mentor talk to me about that, and I truly agree.
• 18:15
  and it's really got to be a detailed question.
• 18:17
  It cannot just be, "Do you have heavy periods?"
• 18:20
  Or, "Do you think your periods are normal?"
• 18:22
  Or, "Are your periods bothering you?"
• 18:23
  I mean, these are sometimes incredibly hard for people.
• 18:25
  So if you just pull it out, ask those questions, that mnemonic that Dr.
• 18:30
  Lawson gave is incredible.
• 18:32
  That can really help you in actually identifying sooner.
• 18:36
  But instead of just kind of asking a question where you may just get
• 18:38
  a, "Yeah, I think they're fine," and move on and miss that opportunity.
• 18:42
  So, I think those are two great ways to really catch it
• 18:44
  and refer in a faster manner.
• 18:47
  Ashli Lawson, MD, MS: I think an opportunity for early intervention
• 18:50
  outside of the hospital or clinic setting is reaching out to these
• 18:54
  kids where they are, and almost all of them are going to be in school.
• 18:58
  And so, making sure that in health education classes, that they're getting
• 19:02
  comprehensive reproductive health care that is inclusive of menstrual
• 19:07
  cycle normality and abnormality.
• 19:11
  Teachers can't do it all themselves.
• 19:13
  They're experts in teaching the next generation, and I hope that they are
• 19:19
  equipped through their school with what to be teaching in these classes.
• 19:23
  But I hope that there are physicians out there who are also equally involved in
• 19:28
  advocacy and interested in doing outreach to these schools so that we can meet
• 19:32
  these kids in their health education classes and talk about it too, because
• 19:36
  unfortunately, not every child is getting routine care with their PCP and someone
• 19:42
  to check in with them on these things.
• 19:44
  Host: Thank you both for helping us be so much more confident
• 19:48
  treating this patient population.
• 19:51
  I appreciate how much that you've shared with us about heavy menstrual bleeding and
• 19:56
  how to refer, and as well as some workups and considerations for quality of of life.
• 20:03
  Ashli Lawson, MD, MS: Thank you for having us.
• 20:05
  Lauren Amos, MD, MS: Yes, I really appreciate this opportunity.
• 20:07
  Dr.
• 20:07
  Lawson and I both feel really passionately about this topic, and
• 20:11
  I think if you can intervene at a critical point in an adolescent's life
• 20:14
  and manage heavy menstrual bleeding, it impacts so much more than just
• 20:19
  their anemia or their iron deficiency.
• 20:22
  It really can affect their school attendance, their mood, their
• 20:26
  activities, interactions with friends.
• 20:28
  It's just incredibly important.
• 20:30
  So, really welcome the, the chance to talk about this and
• 20:33
  hopefully continue to improve outcomes for these girls and women.
• 20:37
  Host: And as a reminder to our audience, claim your CME credits after listening
• 20:42
  to this fascinating episode today.
• 20:44
  You can do so by visiting cmkc.link/cmepodcast
• 20:50
  and then click the Claim CME button.
• 20:53
  If you enjoyed this podcast, please share it on your social channels
• 20:56
  and check out the entire podcast library for topics of interest to you.
• 21:01
  I'm Dr.
• 21:01
  Sarah Gubara, and this has been Pediatrics in Practice, a CME podcast.