“Someone’s menstrual period should not be impairing them from leading a normal life, because we have really good treatments for pain and for heavy bleeding,” an expert says.
By Perri Klass
Adolescents with heavy menstrual periods may find it impossible to get through the school day without getting blood on their clothes, or wake at night to find blood on the sheets. Beyond the inconveniences, those with heavy or prolonged menstrual periods can lose a lot of blood, month by month.
In a review published in the journal JAMA Pediatrics at the end of December, Dr. Claudia Borzutzky, an adolescent medicine specialist at Children’s Hospital Los Angeles and Dr. Julie Jaffray, a pediatric hematologist at the same institution, reviewed the issue of heavy menstrual bleeding in adolescents. Both of them are faculty members at Keck School of Medicine at the University of Southern California.
“We have a lot of patients who are missing school, who leave school to be home-schooled, who are leaving sports activities, because of their really crazy heavy periods,” Dr. Borzutzky said. “Someone’s menstrual period should not be impairing them from leading a normal life, because we have really good treatments for pain and for heavy bleeding.”
Rather than defining a heavy period in terms of milliliters of blood, the doctors said it is important to take it seriously if it impairs a teenager’s functioning.
And although some teenagers may find this a difficult topic to address head-on with parents, parents will often be aware, Dr. Jaffray said, not only that their daughters may be missing school, but that they are having to wash bedsheets, or that they are going through sanitary products much faster than expected.
In the first year or two after menarche, the most common reason for heavy or prolonged periods is what is called anovulatory bleeding, reflecting a cycle in which no ovulation has actually occurred, but hormones cause continued bleeding. Over time, cycles should become more regularly ovulatory, and the bleeding should decrease, but in the meantime, the heavy periods can be treated, Dr. Borzutzy said.
Most people who have heavy periods will not actually have bleeding disorders, but about 20 percent of them will, and since some of these disorders are inherited, it is not uncommon to start by diagnosing the problem in the adolescent and move on to finding the same problem in a parent or other family member. “A mother may not recognize her daughter’s heavy menstrual bleeding because it’s just like hers,” Dr. Jaffray said. “Many times we diagnose a young girl and have to go back and encourage the mother or the father to be tested.”
These mothers may have given birth and had difficulties with blood loss, may even have had hysterectomies for their own heavy menstrual bleeding, all without finding out the underlying diagnosis, she said. The Foundation for Women and Girls with Blood Disorders works to raise awareness of these issues and increase the likelihood that medical providers make these diagnoses and treat them appropriately.
In a study published in November in the Journal of Pediatric and Adolescent Gynecology, researchers looked at 258 adolescents who came into the emergency room for heavy menstrual bleeding. Forty-four (17 percent) were admitted to the hospital, and almost a third of those had a bleeding disorder. The mean age of the girls who were hospitalized was 15, and most of them received blood transfusions or other blood products, like platelets or plasma.
Dr. Monica Woll Rosen, an assistant professor of obstetrics and gynecology at the University of Michigan Medical School who was the lead author on the study, said that in addition to the signs of heavy or prolonged menstruation, parents should watch for symptoms of anemia, such as fatigue and dizziness.
Even young women who don’t have bleeding disorders can lose enough blood through heavy menstrual periods to become significantly — and sometimes dangerously — anemic. “It’s very important especially in teenagers to have normal iron levels, to help them with growth and development, energy, intellectual function,” Dr. Jaffray said.
If a girl is passing large clots — anything from the size of a quarter on up — that’s concerning. Parents should pay attention if a daughter can’t make it through a class at school without going to the bathroom to change her pad or her tampon, if she’s taking changes of clothing to school because of accidents, if she’s regularly doubling up pads and tampons, or having periods that last longer than seven days.
The most common bleeding disorder among these young women is Von Willebrand disease, a genetic clotting defect, which can occur in more or less severe forms. These girls may also bruise easily and may have nosebleeds, or bleed from their gums when they brush their teeth. Von Willebrand disease may be inherited from either parent.
Various platelet disorders can also result in heavy menstruation, including immune thrombocytopenia, or ITP, a platelet deficiency that can occur after a viral infection. And there may be some subtle bleeding disorders that we cannot yet detect.
The American College of Obstetricians and Gynecologists recommends thinking of the menstrual period as a vital sign. Dr. Borzutzky said: “Just as important as your blood pressure and your heart rate is your menstrual period and the pattern of it.”
But because doctors were not necessarily trained to think this way, they don’t always assess this particular vital sign, and some patients may find that doctors dismiss their concerns, telling them that early on, the menstrual cycle can be irregular in various ways. “Irregular periods, be they absent or frequent or heavy, are common, but that doesn’t mean normal,” Dr. Borzutzky said. “It warrants evaluation if it’s affecting the patient’s life.”
Doctors may prescribe oral contraceptives to regularize periods without looking for bleeding disorders or other problems, Dr. Jaffray said. “I would love to say to the parents, to the patients, to really advocate for yourself if you really think you’re bleeding more than your peers.” A full evaluation is important, especially if there’s any family history to consider.
The primary treatments for heavy menstrual periods are hormones — that is to say, the medications we think of as contraceptives. “Birth control pills for hormonal benefits, a patch, a ring, a shot, an implant or an I.U.D. are all options we give these girls,” Dr. Rosen said. “Our cycles are regulated by hormones, namely estrogen and progesterone, and to decrease the amount of menstrual bleeding someone has, you can use hormones, albeit synthetic hormones, to regulate the hormones your own body is making.”
Some parents have strong objections to their daughters taking hormones, Dr. Borzutzky said, for a broad range of reasons, many connected to historical experiences with hormone therapy. Some have had bad experiences themselves, others worry about possible future effects on their daughters’ fertility or other complications, and some may be concerned that giving young women contraceptive medications will increase the chances of early sexual activity, though there is no evidence that this is true.
“There are very few patients in whom we cannot find a safe hormonal medication,” Dr. Borzutzky said. “We have to take each method one by one and talk about the safety, the benefits, the risks of each one and really go through what science we have — it’s not perfect, but we have quite a bit of safety evidence.” In addition, girls with bleeding disorders may need hematologic medications, and anyone who is anemic will need iron.
So parents should discuss this with adolescents, Dr. Borzutzky said, “when they start their menstrual life,” and make sure that their periods are not causing them a lot of discomfort. Ask if there’s anything they’ve stopped doing because of their periods, she suggested. “We say this all the time, try to just normalize discussion, give context, use humor — say, I know it feels funny to talk about this sometimes,” but emphasize that it’s a completely normal part of life, and keep on checking in.
“Say that the pediatrician has asked me to check in two or three times a year about periods,” Dr. Rosen suggested. “Say, because this is your health, I need to ask you a few questions about what’s going on with your period.”