Heavy menstrual bleeding (HMB) in adolescents is a significant clinical concern, often underdiagnosed and undertreated, despite its substantial impact on health and quality of life. Defined as menstrual blood loss exceeding 80 mL per cycle or bleeding lasting more than seven days, HMB can be the presenting symptom of various underlying conditions, including hematological disorders, hormonal imbalances, and structural anomalies [1]. Adolescents, particularly those in early post-menarcheal years, may experience cycles that are anovulatory, resulting in irregular and often excessive menstrual flow due to unopposed estrogen stimulation [2].

The global prevalence of HMB in adolescent girls ranges from 10% to 37%, with considerable variation due to differing diagnostic thresholds and self-reporting methods [3]. In many cases, what is considered “heavy” is based on subjective perceptions of inconvenience or disruption to daily life, rather than quantitative measures. The adolescent population is uniquely vulnerable, as menstrual issues are often normalized or dismissed, leading to diagnostic delays and increased risk of anemia, absenteeism from school, social withdrawal, and reduced physical activity [4].

The etiology of HMB in teenagers is multifactorial. While anovulatory cycles are common in the first 2–3 years post-menarche, inherited bleeding disorders such as von Willebrand disease account for a significant proportion of cases when bleeding is excessive and persistent [5]. Endocrine disorders like hypothyroidism and polycystic ovary syndrome (PCOS) may also contribute to abnormal uterine bleeding. Additionally, lifestyle factors such as stress, obesity, and extreme exercise routines can influence menstrual patterns, compounding the risk of HMB [6].

A comprehensive diagnostic work-up is essential in adolescents presenting with HMB. Clinical evaluation should include a detailed menstrual history, assessment of bleeding severity using pictorial blood assessment charts (PBAC), and screening for underlying coagulation disorders, particularly in those with a family history of bleeding tendencies [7]. Hormonal profiles, pelvic ultrasonography, and in rare cases, hysteroscopy may be warranted based on clinical suspicion. Despite advancements in diagnostic tools, access and awareness remain limited in many low-resource settings, affecting early detection and timely intervention [8].

Management strategies for HMB in teenagers are individualized and depend on the underlying etiology, severity of symptoms, and patient preference. First-line treatments often include hormonal therapies such as combined oral contraceptives and progesterone-only pills, which help regulate cycles and reduce endometrial proliferation. Non-hormonal options like tranexamic acid and non-steroidal anti-inflammatory drugs (NSAIDs) are also commonly prescribed for symptom control [9]. In cases related to bleeding disorders, desmopressin and factor replacement therapies may be indicated. Counseling and education play a critical role in addressing psychological distress and improving adherence to treatment plans [10].

Given the wide-ranging implications of HMB on adolescent health and development, there is a pressing need for increased awareness, early diagnosis, and standardized care pathways. This study aims to evaluate the incidence and prevalence of HMB among teenage girls, explore the spectrum of etiological factors, assess diagnostic accuracy, and analyze treatment outcomes in a representative population. Findings from this research may contribute to improved clinical guidelines and policy frameworks for adolescent menstrual health.

Study Design and Setting

This was a cross-sectional observational study conducted over a period of 12 months in the Department of Obstetrics and Gynecology, in collaboration with the Department of Pediatrics at a tertiary care hospital. The study was approved by the Institutional Ethics Committee prior to initiation.

Study Population

Adolescent females aged 10 to 19 years who presented with complaints of excessive menstrual bleeding were considered eligible for inclusion. Heavy menstrual bleeding (HMB) was defined as bleeding lasting more than seven days and/or requiring frequent pad changes (>6 pads/day) or passage of clots large enough to interfere with normal daily activity.

Inclusion Criteria

• Female adolescents aged 10–19 years
• History of HMB for at least two consecutive menstrual cycles
• Willingness to provide informed consent (and assent where applicable)

Exclusion Criteria

• Pregnancy-related bleeding
• Known structural uterine anomalies (fibroids, polyps) confirmed prior to menarche
• Current use of anticoagulants or hormonal therapy for other indications
• Chronic illnesses unrelated to HMB that may confound symptoms (e.g., renal failure, liver disease)

Sample Size and Sampling

A minimum sample size of 120 participants was calculated using a prevalence estimate of 20% for HMB in adolescents, with a 95% confidence level and 7% margin of error. Participants were selected using consecutive sampling among those attending the outpatient and emergency gynecology services.

Data Collection

After obtaining written informed consent from guardians and assent from the adolescents, participants were interviewed using a structured proforma. Data collected included:

• Demographics (age, BMI, age at menarche)
• Menstrual history (cycle length, duration of bleeding, number of pads used per day, clot passage)
• Family and personal history of bleeding disorders
• Medical history, including thyroid disorders or any systemic illness

A Pictorial Blood Loss Assessment Chart (PBAC) was used to quantify menstrual blood loss. A PBAC score of >100 was considered diagnostic of HMB.

Investigations

All participants underwent:

• Complete Blood Count (CBC)
• Prothrombin Time (PT), Activated Partial Thromboplastin Time (aPTT)
• Thyroid Function Tests (T3, T4, TSH)
• Pelvic ultrasonography (transabdominal in all cases)

Additional tests such as von Willebrand factor assay, serum ferritin, and hormonal profiles were done in selected patients based on clinical suspicion.

Treatment and Follow-up

Participants were managed based on underlying cause and severity. First-line interventions included NSAIDs (mefenamic acid), tranexamic acid, oral contraceptive pills, or progesterone therapy. Patients diagnosed with bleeding disorders received desmopressin or hematology referral. Follow-up was conducted at 1 and 3 months to assess treatment response using symptom diary and PBAC reassessment.

Statistical Analysis

Data were compiled in Microsoft Excel and analyzed using SPSS version 25. Descriptive statistics (mean, standard deviation, frequency, and percentage) were used for baseline data. Chi-square test was applied for categorical variables, and independent t-test for continuous variables. A p-value <0.05 was considered statistically significant.

Table 1: Demographic and Menstrual Characteristics

A total of 120 adolescent girls were included in the study. The mean age was 15.2 ± 2.1 years. The majority (42.5%) were between 15–17 years. The mean age at menarche was 12.8 ± 1.3 years, and most girls (60.8%) had attained menarche by 13 years. Approximately 66.7% of the participants reported bleeding duration exceeding 7 days, and 54.2% reported changing more than 6 pads per day. Clot passage was noted in 40.8% of participants. PBAC score >100 was observed in 78.3% of the sample.

Table 1: Demographic and Menstrual Characteristics of Participants (n=120)

Table 2: Clinical and Laboratory Findings

Anemia (Hb <12 g/dL) was observed in 70.8% of girls, with 30% classified as moderate-to-severe. Thyroid abnormalities (mostly subclinical hypothyroidism) were found in 15.8%. Coagulation abnormalities (prolonged aPTT or low von Willebrand factor levels) were identified in 12.5%. Pelvic ultrasound was normal in 82.5%, while 10% had ovarian cysts.

Table 2: Clinical and Laboratory Investigations (n=120)

Table 3: Treatment Modalities Used

The majority (41.7%) were treated with NSAIDs alone. Tranexamic acid was prescribed to 30.8%. Hormonal therapy (COCs or progesterone) was used in 27.5%. Hematology referral and desmopressin were required in 10% of cases.

Table 3: Treatment Modalities Administered (n=120)

Table 4: Response to Treatment at Follow-Up

At 1-month follow-up, 65% reported significant reduction in bleeding. By 3 months, 82.5% had symptom improvement (PBAC <100). Non-responders (PBAC still >100 at 3 months) were mostly among those with underlying hematological or endocrine disorders.

Table 4: Clinical Response at Follow-Up

Heavy menstrual bleeding (HMB) during adolescence is a frequent yet under-recognized gynecological problem that poses significant challenges to physical, psychological, and social well-being. The present study found that nearly two-thirds of teenage girls experienced bleeding longer than seven days and more than half reported excessive pad usage and clot passage, indicating a high prevalence of HMB among adolescents in this region. These findings are consistent with global estimates, where 10% to 30% of adolescents experience clinically significant heavy bleeding [6].

Menstrual bleeding patterns in adolescents are influenced by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, particularly in the first few years following menarche. Anovulatory cycles are common in this phase and may contribute to irregular and heavy bleeding due to unopposed estrogen action [7]. Our study supports this observation, with the majority of girls reporting menarche at or before 13 years and presenting with symptoms within 1–3 years post-menarche, a period commonly associated with HPO axis immaturity.

Anemia was a prominent clinical finding, affecting more than 70% of the participants, with moderate to severe anemia present in nearly 30%. These figures are alarming and suggest a significant public health burden, especially in developing countries where nutritional deficiencies and delayed health-seeking behavior are common. Previous studies have linked HMB with reduced academic performance, chronic fatigue, and missed school days due to untreated anemia [8]. The use of the PBAC scoring system allowed for an objective assessment of menstrual loss, with over 75% of girls scoring above the diagnostic threshold of 100. PBAC has been validated in adolescents as a reliable method to quantify bleeding severity, helping distinguish pathological cases from normal variation [9].

The etiology of HMB in adolescents is multifactorial. Coagulation disorders such as von Willebrand disease have been identified as the most common systemic causes. In our study, coagulation abnormalities were found in 12.5% of participants, aligning with international literature that suggests 10% to 20% of adolescents with HMB may have an underlying bleeding disorder [10]. These findings highlight the importance of integrating basic hemostatic screening into the diagnostic work-up for adolescent HMB, especially in those with a family history or prolonged bleeding post-injury.

Thyroid dysfunction was present in nearly 16% of the study group, with subclinical hypothyroidism being the predominant abnormality. The impact of thyroid hormone imbalances on menstrual regularity is well documented, affecting both endometrial receptivity and ovulatory function [11]. Our results reinforce the inclusion of thyroid function tests in the routine evaluation of adolescents presenting with HMB, particularly in the absence of structural uterine pathology.

Ultrasound imaging revealed abnormalities in 17.5% of cases, with ovarian cysts and endometrial thickening being the most common findings. Although structural causes are relatively uncommon in adolescents compared to adults, the use of pelvic ultrasound remains essential in ruling out anatomical abnormalities, especially in refractory cases [12].

Management strategies must be tailored to the underlying etiology and severity of the bleeding. In our cohort, NSAIDs were the most frequently used first-line agents due to their accessibility, tolerability, and dual action in reducing prostaglandin-mediated endometrial shedding and menstrual pain. Tranexamic acid was prescribed to nearly one-third of participants, showing excellent response rates by the first follow-up [13]. Hormonal therapies, including combined oral contraceptives and progestins, were used effectively in nearly 28% of the participants, especially in those with ovulatory dysfunction or where non-hormonal options failed. These findings support the international consensus that combined pharmacologic strategies offer superior outcomes compared to monotherapy in adolescent HMB [14].

By the three-month follow-up, more than 80% of girls had shown a marked reduction in bleeding severity, reflected by a decline in PBAC scores below the diagnostic cutoff. However, 17.5% remained symptomatic, with most belonging to the group with either coagulation or endocrine abnormalities. This underlines the need for long-term follow-up and multidisciplinary collaboration, including pediatric hematologists and endocrinologists, to optimize care in complex cases [15].

This study underscores the necessity of timely identification, appropriate evaluation, and evidence-based treatment of HMB in teenagers. Standardizing protocols for screening adolescents for anemia, thyroid disease, and bleeding disorders can significantly reduce long-term complications. Moreover, education and counseling for adolescent girls and their families should be an integral part of care to remove stigma, encourage early consultation, and improve compliance.

Heavy menstrual bleeding is a prevalent yet frequently neglected issue among adolescent girls. This study emphasizes the high burden of anemia, the underdiagnosis of bleeding and endocrine disorders, and the varied therapeutic responses in teenagers with HMB. Early identification through tools like PBAC and a structured diagnostic algorithm including hematologic and thyroid screening are crucial. Tailored, multi-modal treatment including NSAIDs, antifibrinolytics, and hormonal therapy was found effective in most cases. Establishing standardized care pathways and increasing awareness among adolescents and healthcare providers can significantly improve outcomes and quality of life.

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