Heavy menstrual bleeding and haemostasis disorders in adolescents

Background: Heavy menstrual bleeding (HMB) is a prevalent gynaecological concern among adolescents, significantly impacting their quality of life. In the early post-menarcheal years, anovulatory cycles, resulting from the immaturity of the hypothalamic-pituitary-ovarian axis, are the primary cause. However, secondary causes like bleeding disorders should be ruled out., As a first-line treatment, medical management incorporating hormonal and non-hormonal therapy is generally recommended. Objective: The aim of the study was to evaluate the prevalence of bleeding disorders and the contribute that a multidisciplinary approach could provide to the diagnosis and management of the patients. Moreover the aim is to identify clinical variables that could predict the presence of such disorders among adolescents. Methods: a retrospective study was conducted on female patients who have attended the paediatrics and adolescent gynaecological clinic of the Sant’Anna hospital and the haemophilia centre of the Regina Margherita children hospital in Turin between 2015 and 2021. Two cohorts have been studied: one included consecutive adolescent patients with HMB, the second included adolescent patients with a diagnosis of haematological disorders, namely leukaemia, thalassemia, and bleeding disorders. Results: Out of the 2158 patients who visited the clinics, 153 patients (7.08%) were included in the cohort with HMB and/or bleeding disorders. Anovulatory cycles were the cause of HMB in 49.7% of patients, followed by bleeding disorders (22.2%). Among patients with bleeding disorders, HMB was the first sign of disease in 22% of cases, 55.5% had episodes of epistaxis, 40% reported gum bleeding, 44.4% had anaemia, 76.5% had iron deficiency, and 32% had platelet deficiency. Epistaxis and positive family history were identified as statistically significant clinical predictors for bleeding disorders. Hormonal therapy with combined oral contraceptives or progestin-only pills was prescribed in 30% of patients with BD and 37.5% of patients without BD, with the preferred COC being oestrogen valerate/dienogest and the preferred POP being desogestrel. Tranexamic acid was prescribed to 66.7% of patients with BD and 50.8% of patients without. All patients with BD received hematological consultations compared to 27.3% without. At the follow-up stage, symptom resolution was observed in 50% of patients with BD and 58.5% of patients without BD. Among patients with BD who achieved symptom resolution, 42.9% were treated with a combination of hormonal therapy and antifibrinolytic therapy, 42.9% received antifibrinolytic therapy only, and 14.3% were managed with hormonal therapy alone. Conversely, among patients without BD who achieved symptom resolution, 50% were treated with hormonal therapy alone, 29.2% received combined therapy, and 16.7% received antifibrinolytic therapy only. Conclusion: This study highlighted the prevalence of HMB in the general population and the prevalence of bleeding disorders as a cause of HMB, emphasising the need of an appropriate evaluation of patients with heavy bleeding also in primary care and the importance of a multidisciplinary approach in management. Treatment involved hormonal and non-hormonal therapy with a joint hematological support. Follow-up consultations showed improvement in symptoms for the majority of patients, although the limitations of the study.