Adolescent girls frequently report experiencing heavy menstrual bleeding (HMB), and hematologists often become crucial partners to reduce the burden of this complication and determine if the clinical features of an adolescent with HMB are consistent with an underlying bleeding disorder.

A recent publication in Blood by Sarah O’Brien, MD, of Nationwide Children’s Hospital in Columbus, Ohio, provided key learning objectives for hematologists and related professionals who are not well acquainted with current best practices for managing HMB and signs of inherited bleeding disorders in adolescents.

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“In pediatrics, we do hematology and oncology training together. A lot of it is focused on inpatient time, whereas HMB is primarily a problem we see on the outpatient side of hematology,” explained Dr O’Brien. “During residency training, both in pediatrics and in internal medicine, trainees spend most of their time with us on the wards. So it’s a problem of exposure because patients [with HMB] typically present as outpatients, and they often present in our hemophilia treatment centers, which are quite specialized. So there may not be as many trainees in those settings.”

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Quantifying HMB

HMB is defined by the American College of Obstetricians and Gynecologists as bleeding lasting for longer than 7 days or the loss of more than 80 mL of blood per menstrual cycle. The International Federation of Gynecology and Obstetrics defines HMB more subjectively as excessive menstrual blood loss that interferes with a woman’s physical, emotional, social, and material quality of life.

“You can’t just ask a patient, ‘do you have heavy menstrual bleeding?’ It can’t be a yes-or-no question because patients and families often don’t know what is heavy [and what is] not. They only know what they experience. They don’t have anything to compare it to. Physicians have to get comfortable with asking specific questions about the duration and amount of flow and the amount of products patients are using,” said Dr O’Brien.

The pictorial blood assessment chart (PBAC) is the tool used most commonly to measure menstrual blood loss. Patients are asked to count the number of menstrual products they have used and to estimate the degree of soiling during the menstrual period. Different numbers and degrees are associated with numerical values, and a score over 100 indicates HMB. However, most studies using the PBAC have been conducted in adults; therefore, data on its sensitivity, specificity, and predictive values in adolescent girls are lacking. Additional indicators of HMB include soaking a pad or tampon within 1 hour, soaking bedclothes, a low ferritin level, or anemia.

“It is important for trainees to get familiar with taking a detailed menstrual history,” said Dr O’Brien. “Honestly, after someone does this several times, it becomes much more familiar and less awkward. I think that a lot of physicians feel a bit uncomfortable taking a detailed menstrual history, and so they’re not educating their trainees on that topic either.”

She continued, “Half the people in the world have a menstrual period for many years of their lives, and so it’s not something that we should be embarrassed to ask about or embarrassed to talk about, certainly in a medical setting.”