Menstrual disorders in adolescents — formative SAQs

SAQ 1 — Heavy menstrual bleeding in a 14-year-old (10 marks)

A 14-year-old presents 18 months after menarche with menses lasting 9 to 10 days, flooding, clots, and fatigue. She has missed several days of school each cycle. Her mother reports heavy periods "run in the family." Examination shows pallor; haemoglobin is 78 g/L. ^{[5] [1]}

Questions

1. Give the normal adolescent menstrual cycle thresholds and classify this bleeding using FIGO terms. (3 marks) ^{[1] [4]}
2. Outline the focused investigation panel and justify screening for a bleeding disorder. (4 marks) ^{[5] [6]}
3. Describe the stepwise, mechanism-based management. (3 marks) ^[5]

Model answer

Normal thresholds and classification (3). Normal cycle: 21 to 45 days, fewer than 8 days of flow (often quoted as 7 days), regular within 3 years of menarche, menarche by age 15. This adolescent has heavy, prolonged bleeding (duration over 7 to 10 days, flooding, clots) complicated by symptomatic anaemia. Use FIGO objective terms (heavy, prolonged) rather than menorrhagia. ^{[1] [4]}

Investigation panel (4). Pregnancy test, full blood count and ferritin (anaemia and iron deficiency), TSH, prolactin and free testosterone (endocrine gates), and a coagulation screen with a von Willebrand panel (von Willebrand factor antigen, activity/ristocetin cofactor, factor VIII). Screen for a bleeding disorder because about one in five adolescents referred for heavy menstrual bleeding has an underlying bleeding disorder, with von Willebrand disease dominant; heavy bleeding from menarche plus family history raises this further. Pelvic ultrasound only if a structural cause is suspected. ^{[5] [6]}

Stepwise management (3). Treat the anaemia and iron deficiency with oral iron and recheck at about 3 months. For cycle control use combined hormonal contraception as first-line (suppresses ovulation, regularises withdrawal bleeds, reduces volume), or the 52 mg levonorgestrel intrauterine system; add tranexamic acid during menses when hormonal therapy is declined or contraindicated; cyclic oral progestin protects the endometrium when combined hormonal contraception is contraindicated. Run the visit through confidential adolescent care, address school attendance, and arrange follow-up. ^[5]