Evaluation of Heavy Menstrual Bleeding in Adolescents within the Primary Care Setting

Introduction: Heavy menstrual bleeding (HMB) is a prevalent issue in adolescents, with significant adverse impacts on physical, mental, and social health. While the differential diagnosis for HMB is broad, studies estimate that up to 62% of adolescents may have an underlying bleeding disorder. Sequelae of HMB including severe anemia and iron deficiency often necessitate additional healthcare utilization and further affect quality of life. Primary care providers (PCPs) are frequently the first to evaluate adolescents' HMB concerns. Thus, it is essential to understand current primary care practices for assessing HMB to improve early recognition, evaluation, and management. Our study aimed to describe the patterns of primary care evaluation, treatment, and management during initial assessment of HMB.

Methods: We conducted a retrospective analysis of menstruating adolescents between 9 and 16 years of age who presented to a pediatrician or family medicine provider for initial evaluation for HMB at an academic institution between January 2017 and June 2019. Patients were identified by ICD-10 codes and confirmed through chart review. We excluded patients who had been previously evaluated for HMB and those with iatrogenic causes of HMB. Primary outcomes included hematologic workup, hormonal therapy discussion and treatment, and referrals placed. Secondary outcomes included quantification of HMB, assessment of family history, and evaluation of hematologic symptoms. Subgroup analyses were also conducted to understand if primary outcomes differed by race and insurance status. These analyses were performed with Chi-squared tests.

Results: In total, 359 patients met the inclusion criteria for this study. 41.2% of adolescents had a hematologic workup conducted including complete blood count (41.2%), iron studies (14.2%), and von Willebrand testing (10.6%). 74.7% of patients discussed hormonal therapies and 47.1% were prescribed hormonal therapies. Referral rates to hematology and gynecology were low at 3.3% and 10.6%, respectively. 74.7% of providers quantified heavy menstrual bleeding severity with 63.2% inquiring about duration, 34% about frequency of menstrual product changes, and 18.7% about number of menstrual products used daily. The majority were not queried about a family history of bleeding symptoms (79.7%) or bleeding disorders (80.5%). Additionally, most were not asked about the presence of large clots (84.4%), nosebleeds (93.0%), abnormal bruising (89.7%), oral bleeding (92.8%), or fatigue (83.3%). In a subgroup analysis, Black patients were less likely to receive counseling (p <0.01) and hormonal therapy (p=0.03) compared to their white counterparts. Adolescents with Medicaid insurance were also less likely to receive hormonal treatment (p=0.02) compared to those with private insurance. Interestingly, Black adolescents (p=0.03) and those with Medicaid insurance (p=0.045) were more likely to undergo hematologic testing than their White or privately-insured peers, respectively.

Conclusion: Our study revealed several gaps in the initial evaluation and management of adolescents with HMB. Hematologic workups were conducted at a minority of visits, and referrals to hematology and gynecology were notably low. Providers frequently assessed the severity of HMB, but often neglected to inquire about additional aspects that could guide the decision to order a hematologic workup such as family history and concurrent hematologic symptoms. Given the prevalence of iron deficiency and underlying bleeding disorders in this population, lack of evaluation likely results in delays in diagnosis and appropriate care. These findings underscore the need for more comprehensive and standardized evaluation protocols to ensure effective management of HMB in adolescents.