It's a new year, time for a new tweetorial!

This one is for all of the amazing #tweetiatricians taking care of adolescent girls.

14yo female presents to primary care with a complaint of fatigue. Labs are ordered and hemoglobin is 6.0. She describes periods as "fine" 1/n

But how can that be? You decide to delve a little deeper and ask some details.

Turns out her "fine" periods last 3-4 weeks, and she requires pad or tampon changes between every class.

*key point* many adolescent girls DO NOT KNOW what a normal period should be like. 2/n

So what is a normal period?
Bleeding for < or = 7 days
Cycles between 21-45 days
Should be able to go at least a few hours without changing products
Product use should be 3-6 regular/day 3/n

Heavy menstrual bleeding is common, occurring in up to 37% of adolescents.

Other red flags: large clots, "gushing sensation", accidents, needing to change overnight, and development of iron deficiency 4/n

As you sit in amazement wondering how she can consider those periods to be "fine", her mother pipes up that hers were the same way.

This is something I commonly see. Horrific periods are normalized when multiple family members are affected. 5/n

Often mom is the only one who knows how heavy an adolescent's periods are because she is the one buying the menstrual products, and washing out the menstrual stains.

So why are her periods so heavy? The differential diagnosis for HMB is broad and includes.. 6/n

Anovulatory cycles (by far the most common), coagulopathies (such as VWD), STIs, iatrogenic causes, pregnancy, and structural causes (very rare in adolescents).

So what next? 7/n

History should focus on bleeding (epistaxis, oral bleeding, abnormal bruising, surgeries, etc), medical hx, and family hx. Lack of a bleeding hx does not r/o a coagulopathy as HMB can be the 1st presentation.

Sadly, the 1st patient to be described with VWD died from HMB. 8/n

It has historically been taught that hypothyroidism can cause HMB. We published a retrospective review in J Peds last year ( https://www.jpeds.com/article/S0022-3476(19)30534-7/fulltext) of 427 adolescent females with HMB and actually found lower rates of hypothyroid than that seen in the general population! 9/n

Lab eval depends on hx, but all patients should have a CBC, ferritin, and pregnancy test. Hemostatic testing can be performed if the hx suggests but ideally under the guidance of a hematologist as testing can be affected by testing location, sample processing, etc. 10/n

Management of HMB depends on severity and complications. Iron deficiency can be treated with oral iron (if tolerated) which should be given once daily or every other day for better absorption (no more 3x a day as previously taught!) https://ashpublications.org/blood/article-lookup/doi/10.1182/blood-2015-05-642223 11/n

Iron deficiency is difficult to treat without managing the primary issue. HMB can be treated with hormonal options (combined oral contraceptives or progesterone only options), or hemostatic agents (antifibrinolytics such as lysteda or amicar, DDAVP or factor products). 12/n

Choice of treatment is based on patient preference, desire/need for contraception, and tolerance of side effects. Typically if the patient is severely anemic, complete suppression of their menses is required for some period to replenish iron stores and treat their anemia. 13/n

It is important to ask about contraindications to estrogen (migraine with aura, personal hx of VTE, or known thrombophilia.) Progesterone only has lower thrombotic risk and progesterone only pills are very effective at menstrual suppression if taken at the same time daily 14/n

The IUD is fantastic for menstrual suppression but often is not the first choice for adolescents, especially if they have not been sexually active. The nexplanon can be effective in some patients but often leads to irregular bleeding which is a nuisance. 15/n

Hemostatic agents are most helpful in patients who have regular heavy bleeding which is not too long in duration. Although there is a black box warning, we do use antifibrinolytics and OCPs together and there is data to show that this is safe. 16/n

Biggest take home pts
-Ask details about menstrual cycles as patients may not know what is "normal"
-Think about anemia and iron deficiency in adolescents with HMB
-Do not be timid in referring to hematology and/or gynecology as we love to help with these patients! 17/fin

And just to clarify, it is the teenagers I see that don’t want the IUD. Medically, it is a fantastic option! And once they do get it, adolescents love them. It is getting them comfortable with the idea that is the hurdle.