Practice Guidelines

Heavy Menstrual Bleeding in Adolescents: ACOG Management Recommendations


Am Fam Physician. 2020 May 15;101(10):633-635.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• One in five adolescents with heavy menstrual bleeding has an underlying bleeding disorder.

• In hemodynamically stable adolescents with heavy menstrual bleeding, most bleeding can be stopped with high-dose estrogen oral contraceptives taken every six to eight hours, tranexamic acid, or high-dose progesterone.

• Bleeding that is unresponsive to initial therapy may signal a retained clot, which can be identified by ultrasonography; an intrauterine Foley catheter can provide tamponade with hormonal or antifibrinolytic therapies

• Long-term management of heavy menstrual bleeding is best achieved with continuous hormonal contraceptive therapies.

From the AFP Editors

The American College of Obstetricians and Gynecologists (ACOG) has new recommendations and conclusions about menstrual bleeding disorders in adolescents.

A typical menstrual cycle occurs every 21 to 45 days and lasts no more than seven days; however, cycles in adolescents are often irregular because immaturity of the hypothalamic-pituitary-ovary axis leads to anovulation. Excessive menstrual blood loss that interferes with a woman's physical, social, emotional, or material quality of life is considered heavy menstrual bleeding. Common causes of heavy menstrual bleeding should be classified by the PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified) system.

Bleeding Disorders in Heavy Menstrual Bleeding

Anovulation is the most common cause of heavy menstrual bleeding in adolescents; an underlying bleeding disorder is the second most common cause. Approximately 20% of all adolescent girls with heavy menstrual bleeding and 33% of adolescent girls hospitalized for heavy menstrual bleeding have an underlying bleeding disorder. The most common bleeding disorders are von Willebrand disease, platelet function defects, thrombocytopenia, and clotting factor deficiencies.

Symptoms and Signs

Although many adolescent girls experience heavy menstrual bleeding only when their cycles become ovulatory, approximately one-half of adolescent girls who have bleeding disorders present with heavy menstrual bleeding at menarche. When adolescents with a bleeding disorder also experience anovulation, prolonged and irregular menses are common. Passing of clots and bleeding through clothing and sheets are reported by 70% of adolescents with a bleeding disorder.

Headaches and fatigue are common when heavy menstrual bleeding leads to iron deficiency anemia. Even in the absence of anemia, iron depletion from heavy menstrual bleeding can cause fatigue and decreased cognition, especially in verbal learning and memory.

Evaluation and Diagnosis

The most important elements of the patient history are quantifying bleeding and recognizing signs of bleeding disorders. Table 1 is a screening tool with a sensitivity of 89% for identifying a bleeding disorder. When asking adolescents about menstrual bleeding, it is important to quantify the frequency of pad or tampon use and whether bleeding through products onto clothing and sheets occurs. Discussion with a parent may be necessary because adolescents are not always able to describe their bleeding accurately.

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Screening Tool to Identify Adolescents with Heavy Menstrual Bleeding

1. How many days does your period usually last, from the time bleeding begins until it completely stops?  □ Less than seven days  □ Seven days or more  □ Don't know 2. How often do you experience a sensation of flooding or gushing during your period?  □ Never, rarely, or sometimes  □ All or most of the time  □ Don't know 3. During your period, have you ever bled through a tampon or pad in two hours or less?  □ Never, rarely, or sometimes  □ All or most of the time  □ Don't know 4. Have you ever been treated for anemia?  □ No  □ Yes  □ Don't know 5. Has anyone in your family ever been diagnosed with a bleeding disorder?  □ No  □ Yes  □ Don't know 6. Have you ever had a tooth extracted or had dental surgery?  □ No (if no, go to question 7)  □ Yes  □ Don't know

6a. Did you have a problem with bleeding after tooth extraction or dental surgery?  □ No  □ Yes  □ Don't know 7. Have you ever had surgery other than dental surgery?  □ No (if no, go to question 8)  □ Yes  □ Don't know 7a. Did you have bleeding problems after surgery?  □ No  □ Yes  □ Don't know 8. Have you ever been pregnant?  □ No (if no, stop)  □ Yes  □ Don't know 8a. Have you ever had a bleeding problem following delivery or after a miscarriage?  □ No  □ Yes  □ Don't know

How to use the screening tool If one of the following four criteria are met, adolescents should undergo la

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, editor-in-chief.

A collection of Practice Guidelines published in AFP is available at



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