Sarah Gubara, PhD (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Sarah Gubara. And today, I'm joined by Dr. Lauren Amos, Program Director for Pediatric Hematology and Oncology Fellowship at Children's Mercy Kansas City, and Dr. Ashli Lawson, pediatric and adolescent gynecologist and Program Director of their Fellowship. Today, we're discussing heavy menstrual bleeding in adolescents. Thank you both for taking the time to join me this morning.

Ashli Lawson, MD, MS: Happy to be here.

Lauren Amos, MD, MS: Yep. Thank you so much for having us.

Host: Of course. So as we're discussing heavy menstrual bleeding, it's a common complaint in adolescents. Dr. Amos, what features should make providers think about whether or not there's an underlying bleeding disorder?

Lauren Amos, MD, MS: Yeah, thanks for that question. I always like to start and state up to 30% of adolescents with heavy menstrual bleeding will ultimately be diagnosed with a bleeding disorder. And so, increased awareness and referrals are really key to avoiding making that diagnosis later in life.

The things that are really important when sorting out, if this can be a bleeding disorder versus another source of heavy menstrual bleeding, start with certainly a family history. So really, seeing if there are others in the family who have had significant heavy menstrual bleeding requiring blood transfusions or early interventions in life, such as hysterectomies, evaluation for maternal postpartum hemorrhage or postoperative bleeding, and then also focusing in on your patient.

So, are there other bleeding signs such as nosebleeds or easier excessive bruising? But a lot of times, those features are absent. And so then, just focusing on, is the heavy menstrual bleeding even enough that's impacting the patient's quality of life? Are they missing school or work? Is it causing symptomatic anemia? And if any of those features are present, then the patient really should be referred for further workup.

Host: That makes a lot of sense. Going off of that, Dr. Lawson, how do you distinguish normal early adolescent menstrual irregularities from bleeding that warrants further evaluation or even a referral to Dr. Amos?

Ashli Lawson, MD, MS: I'm actually going to back up and just add on to some of Dr. Amos' last answer, because there is this really good mnemonic that I use with my trainees called 7-2-1. In fact, not to prop up other podcasts, but there's a whole podcast called 7-2-1 put out by the Foundation for Women and Girls with Bleeding Disorders. And these numbers can help you remember some quick, easy numbers for what bleeding is too much bleeding.

Seven stands for how many days they're bleeding. So if they're bleeding more than seven days in a row, that's concerning and should start triggering your mind to think about a workup for a bleeding disorder. Two stands for how long each product will last you. So if they're soaking a tampon or soaking a pad every two hours or more, that should be another trigger. And the one stands for one inch, which is about the size of a quarter if you have patients who don't know how big an inch is yet. So if they're having blood clots that are an inch or larger or bigger than a quarter, then that should trigger a workup for a bleeding disorder as well. And so, if you're ever unsure or on the fence, that 7-2-1 is a good place to start.

Host: That sounds like a fantastic mnemonic.

Ashli Lawson, MD, MS: Back to your question though of how do we distinguish abnormal bleeding early on from something that warrants a further workup though is a little bit trickier. Most people, or at least for most females, when you start talking about your first period, everyone remembers that first period that they had. There's some sort of story that goes along with it. Whether it was Christmas morning or your birthday or at Girl Scout camp, we all have these memories of it. But what we forget is that year that follows it that was super irregular and also unpredictable. I say that starting a period is kind of like learning to play a new sport or learning to play an instrument. It takes some time for your brain and ovaries and uterus to figure out this beautiful rhythm of ovulate and roughly two weeks later have a period, ovulate, two weeks later roughly have a period. And so, there can be lots of irregular patterns in that first year. And when your period isn't coming along with an ovulation, it can lead to it being heavier or more unpredictable. So within that first year, try to give these patients a little bit of grace, meaning they can skip up to a month or two. But if they're skipping more than three months, that might be a sign that something else is going on.

With regards to bleeding though, I fall back on that 7-2-1. If they are having bleeding that's lasting longer than seven days, at least begin the workup or begin the referral to getting someone else to take a look at this. I think it's also important to remember to trust women, to trust girls. If they're coming to you saying, "This is heavy bleeding. This is not normal," it's very likely that this has been going on longer than they're letting on. And if the bleeding's heavy enough to be impacting their quality of life, that's a sign that bleeding is heavier than average. Dr. Amos, do you have anything else to add?

Lauren Amos, MD, MS: Yeah. Dr. Lawson, I would completely echo that. I think, sometimes as girls start to have their periods, they're not keeping close track on all of the details that sometimes you need to check those boxes that this is heavy. But if they're really reporting things like they are missing sports practices or not being able to get to the bathroom from class in time, things like that, it's better just to go ahead and start that workup.

You don't want to delay these diagnoses. And we see that time and time again that, you know, men with bleeding get diagnosed much earlier in life than females do. And so, the earlier you can see that something is wrong and start the process of figuring out what it is, the better off those patients are going to be.

Host: I love the focus on quality of life. I think that's really, really important, as a psychologist because there's a lot of conversations we have about that as well. Now, you both mentioned some of the workups that would be needed for further evaluation. What initial laboratory workup should primary care providers consider before referring?

Lauren Amos, MD, MS: So certainly, from a hematology standpoint, anytime we're thinking about heavy menstrual bleeding, the first thing you're wanting to get is a complete blood count or a CBC, because you want to assess for the presence of anemia, and you want to catch that early before that anemia progresses to a degree that would require further intervention, like a blood transfusion or hospitalization.

You also want to assess iron stores because iron deficiency is incredibly prevalent among females with heavy menstrual bleeding. And I recommend getting a ferritin, which is the most reliable marker of your iron stores, to see if they're iron deficient, and acting on that. So, those are kind of my first-line things that a primary care provider can do and make sure that the patient isn't going to need immediate attention.

Following that, certainly, you can get other screening bleeding disorder labs. But really, I feel that those are best obtained in a hematologist's office where we can run those labs on-site and get the most accurate levels. There have been studies that have shown that if you run testing like von Willebrand panels or factor levels, and those are send out labs, that just due to the sensitive nature of those tests, there can be false positives or false negatives that also lead to the diagnosis delay.

So, I think if you start with that screening CBC and ferritin, see what those levels are, and then get them in touch with a hematologist and get them plugged in, we can take over the workup to look for bleeding disorders and do it in a very accurate way. I'll let Dr. Lawson weigh in more on the gynecology aspect of those things.

Ashli Lawson, MD, MS: Yeah, I usually throw in a TSH there as well if they're having irregular periods going along with heavy bleeding too, and if the TSH hasn't been done within the past twelve months. It's more rare for us to be catching a thyroid abnormality in these patients. But every now and then, we do find it, and that can help explain either the irregularity or the heaviness going along with it too.

Sometimes people will ask me about a pelvic sono and whether or not that's needed, and there aren't clear guidelines stating you do or you do not have to do this. And so, I tend to make that decision based on each individual patient. Ultrasounds are pretty low risk and low cost. We do them all transabdominal, meaning this is not going to be a probe into the vagina, but it helps get us a better look at the uterus and the ovaries. Both of those can help rule out that there's a structural problem, things like fibroids, which are pretty rare in teenagers, but it can help rule out a structural cause of uterine bleeding, or it can rule out an adnexal mass, something like a hormonally secreting tumor causing abnormal bleeding. That's also pretty rare in teens. Sometimes it does give the patients or the parents a little bit of reassurance.

And so, again, low risk, low cost intervention, but helps rule out things. Certainly, if they're having any bulk symptoms, things like chronic constipation or urinary urgency that might be signs of like a mass pushing there, then of course lean towards getting that ultrasound. Or if they're not responding to therapy, like something you've already started them on and they are still having bleeding through that, then I would certainly get an ultrasound then as you're referring to someone else to take a look at this patient.

Host: Wonderful. So as we're taking a look at patients, when should they be referred to either gynecology or hematology, or is there an opportunity to refer to both? How can you help us tease that out a little bit more?

Lauren Amos, MD, MS: I think from a hematology standpoint, anytime heavy menstrual bleeding is present and you've identified it, you should refer to hematology to evaluate for underlying bleeding disorders. Certainly, if that is affecting why the patient is having heavy menstrual bleeding, we can really add to the management and it's going to affect them lifelong in terms of planning for surgeries, injuries, accidents, and childbirth.

So, to me, if you think they have heavy menstrual bleeding, please send them on to us in hematology so that we can work them up for bleeding disorders.

Ashli Lawson, MD, MS: I feel very similarly. We are always here. We're always available. And this is something that we train extensively in, so we're happy to help with. I think many pediatricians feel comfortable either starting tranexamic acid or starting different types of hormones to help with things. And so, I think that's very appropriate, both from a scope of practice and from a patient safety standpoint, is to initiate treatment of this and begin the workup as you get a referral in. But if a patient is having heavy bleeding that's impacting their life, that's causing anemia or iron deficiency, then they should be sent on to see a specialist.

Lauren Amos, MD, MS: And I will piggyback off of Dr. Lawson on that. I think, you know, if they come to me for heavy menstrual bleeding, almost always I end up sending on the referral then to Dr. Lawson and her colleagues because it's that co-management of, first of all, making sure it's not just a hematologic issue, but also the management using, you know, specific hormonal methods.

And they just offer an advanced level of care for this unique patient population and do it in a way that's incredibly comfortable for these patients. And oftentimes, families and patients aren't even aware of the options for controlling heavy menstrual bleeding that extend beyond just, you know, a combination oral contraceptive.

So, I think if you send the referral to both of us simultaneously, you're providing excellent care for your patient and really going to address everything in a full scope manner.

Host: I love that teamwork. That sounds wonderful. In regards to collaborative care, I'm curious how you both help families manage some of the natural anxiety that comes with coping with heavy bleeding. I would love to hear from both of you about some strategies for that.

Ashli Lawson, MD, MS: I call myself a gyneciatrist, and that's probably not fair because I did not go through psychiatry residency and they have a whole different skill set. But almost every single day, we are dealing with, the stigmas going along with reproductive care or menstrual care, and the mom's or caregiver's story of what they have experienced. And I just hope each passing generation we're doing better and better for the care for women.

As far as how do we provide this comprehensive care, I think that we turn on our listening ears and we think about the patient as more than just numbers. So despite some of my patients with heavy menstrual bleeding, having normal hemoglobins or normal iron counts, and a normal thyroid check and no signs of a bleeding disorder, they're still telling me that their periods are heavy and they can't go to cheer practice because they never know when they're going to bleed. And when they do, they're going to flood the base that's holding them up.

And so, to provide that care, we have to listen to what their goals are. Are their goals to have just a monthly period that's lighter? Are their goals for their period to go away? Are their goals for them to just be reassured that their blood counts are normal and that they don't need a blood transfusion? And so, really individualizing what the patient needs from a medical standpoint and what they need from a social integration standpoint is helpful.

We also have a combined clinic, which I hope I'm not stealing Dr. Amos' thunder, but we have a combined clinic for our girls with bleeding disorders. It's called ABC, the Adolescent Bleeding Clinic, and that's where we can provide multidisciplinary care with our hematologists as well as gynecologists. We also have social workers there because we know this impacts their needs at school among other things. And so, that clinic really helps our most at-risk teens, navigate through their adolescence.

Lauren Amos, MD, MS: And I absolutely agree with everything that Dr. Lawson said. I reassure these patients and families that, you know, this is a conversation I have every single day, and that there are so many other girls and moms and families who have experienced the same thing of not being acknowledged or feeling that nobody is believing or listening to their concerns about heavy menstrual bleeding.

So, just normalizing it, you know, I talk about blood, I talk about bleeding, I talk about bleeding all the time in different ways. And this is just one aspect of that. And it's nothing that is something that should be embarrassing or concerning, and that our job is really to help and to make things better. And just providing that support and meeting the goals of the patient, just like Dr. Lawson said. It's not enough to say, "Oh, your hemoglobin is normal." I mean, there's a lot of dismissal over that. They're not anemic, you know. So, this can't really be that big of a deal, and that's just not the truth.

We want, you know, if you're a competitive swimmer or if you're on the soccer field or you have a job where you're not able to take breaks in time, you know, those things are extremely detrimental to our patients. And so, it's really just listening, acknowledging, understanding and, you know, letting these girls, and oftentimes their moms have stories just like Dr. Lawson said. And I end up referring them to our adult side of our bleeding disorder clinic, because they often have bleeding disorders too that have been not acknowledged and missed until, you know, their daughter came to medical care. And so, I think, you know, our responsibility is really to be advocates for this population and acknowledge and support them.

Host: Thank you for sharing so much about collaborative care and the thoughtfulness in validating the experience of some of these patients. What are some opportunities for earlier intervention that can improve outcomes and quality of life for these patients?

Ashli Lawson, MD, MS: I'm going to let Dr. Amos take this one with the, one of the newest AAP guidelines that came out that I think all of us were in the bleeding disorder world were very happy to hear.

Lauren Amos, MD, MS: Yeah, absolutely. So, the screening guidelines for evaluating for anemia and iron deficiency have been really focused on the toddler population for quite some time. And we recognize in the adolescent group that that's, you know, another very critical time where iron deficiency and anemia goes unnoticed. And in girls, the number one culprit is going to be heavy menstrual bleeding. So, those guidelines have just come out that for menstruating females with their first period, they should have a screening CBC and ferritin, and to continue that routinely with menstruation. And so, I think that's going to be a really ideal outcome because even if the girl doesn't recognize that her periods are too heavy or is in a family that unfortunately has had generations of heavy menstrual bleeding. So, they think something's normal, it's not. They're going to get those lab markers that are showing something's going on. So, that's going to be a first opportunity for intervention that we haven't had before with such a standardization across pediatric and adolescent care.

So, I'm incredibly excited about those guidelines. And not to plug something else, but at the Clinical Advances in Pediatric Symposium that Children's Mercy is hosting, I'll be giving a talk about those updated guidelines and iron deficiency and recognizing and treating it earlier. So, just supporting that that's a great opportunity for early intervention.

I think another way is just to make sure that you include a careful assessment of menstrual cycles in your well-child check or your adolescent physical. It should be almost like another vital sign. I had a mentor talk to me about that, and I truly agree. and it's really got to be a detailed question. It cannot just be, "Do you have heavy periods?" Or, "Do you think your periods are normal?" Or, "Are your periods bothering you?" I mean, these are sometimes incredibly hard for people. So if you just pull it out, ask those questions, that mnemonic that Dr. Lawson gave is incredible. That can really help you in actually identifying sooner. But instead of just kind of asking a question where you may just get a, "Yeah, I think they're fine," and move on and miss that opportunity. So, I think those are two great ways to really catch it and refer in a faster manner.

Ashli Lawson, MD, MS: I think an opportunity for early intervention outside of the hospital or clinic setting is reaching out to these kids where they are, and almost all of them are going to be in school. And so, making sure that in health education classes, that they're getting comprehensive reproductive health care that is inclusive of menstrual cycle normality and abnormality.

Teachers can't do it all themselves. They're experts in teaching the next generation, and I hope that they are equipped through their school with what to be teaching in these classes. But I hope that there are physicians out there who are also equally involved in advocacy and interested in doing outreach to these schools so that we can meet these kids in their health education classes and talk about it too, because unfortunately, not every child is getting routine care with their PCP and someone to check in with them on these things.

Host: Thank you both for helping us be so much more confident treating this patient population. I appreciate how much that you've shared with us about heavy menstrual bleeding and how to refer, and as well as some workups and considerations for quality of of life.

Ashli Lawson, MD, MS: Thank you for having us.

Lauren Amos, MD, MS: Yes, I really appreciate this opportunity. Dr. Lawson and I both feel really passionately about this topic, and I think if you can intervene at a critical point in an adolescent's life and manage heavy menstrual bleeding, it impacts so much more than just their anemia or their iron deficiency. It really can affect their school attendance, their mood, their activities, interactions with friends. It's just incredibly important. So, really welcome the, the chance to talk about this and hopefully continue to improve outcomes for these girls and women.

Host: And as a reminder to our audience, claim your CME credits after listening to this fascinating episode today. You can do so by visiting cmkc.link/cmepodcast and then click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Dr. Sarah Gubara, and this has been Pediatrics in Practice, a CME podcast.