Heavy menstrual bleeding in teenagers

When a period isn’t ‘just’ a period … When to seek help

JAIME CHASE

Jaime Chase is Haematology Clinical Nurse Specialist, Children’s Cancer & Haematology Service, John Hunter Children’s Hospital, Newcastle, NSW

Meet Marlie

Marlie is 14 years old, identifies as female (she/her) and has von Willebrand disease (VWD). She loves horse riding, ballet and swimming. She has lots of friends and could be described as an outgoing social teen.

Marlie started her period 6 months ago and describes it as tricky and heavy. Her menstrual cycle is erratic and lasts longer than what her friends experience. She has flooding at school and at night – soaking through her menstrual products and clothing. On occasions she has leaked onto her seat at school. She has issues accessing the toilet during class time – needing a pass from the teacher, which causes her anxiety.

She starts to not want to wear jodhpurs anymore and doesn’t compete in as many horse riding competitions. She no longer attends dance classes and is refusing to swim due to the fact she can’t trust wearing swimmers or leotards anymore. Her social circle is decreasing, and she is spending large amounts of time at home and in her room. Marlie also starts to refuse to attend to school when she has her period as she is so anxious.

Her parents are becoming increasingly concerned about her behaviours and periods and decide to book an appointment with Marlie’s Haemophilia Treatment Centre (HTC).

Women with bleeding disorders often begin to experience bleeding concerns at puberty, which can potentially impair their activities as an adolescent. If a person with a bleeding disorder menstruates, bleeding problems can be a very regular occurrence from their adolescence and into adulthood. Heavy menstrual bleeding (HMB), also known as menorrhagia, can significantly impact a person’s physical, social, or emotional quality of life. These effects can include physical and emotional effects and influence daily life such as work, school, and overall wellbeing.

It is well documented that children and adolescents with a bleeding disorder will already experience reduced quality of life due to the impact of their health condition. The negative psychological impacts of bleeding disorders escalate with the physical and hormonal changes of menstruation, and symptoms that indicate psychological distress can increase and become apparent over time.

There has been a lack of research into and education regarding bleeding disorders in females, which can lead to inappropriate clinical treatment and a healthcare experience that is fragmented. Research suggests that unsuitable treatment, or lack of treatment, may be avoided by increased disease awareness, accurate diagnosis, and a multidisciplinary approach to patient care. (1-3)

How do you know that you have heavy menstrual bleeding?

Signs of excessive menstrual bleeding include:

• Losing more than 5– 6 tablespoons of blood (80mls)
• Bleeding through clothing
• On heavy days
  • Changing sanitary pads or tampons or other sanitary products every hour
  • Having to get up at night to change sanitary pads/tampons/products
• Passing blood clots larger than a 50 cent piece
• Prolonged bleeding – longer than 8 days.

Heavy menstrual bleeding – RANZCOG definition (4)

HTC Appointment

Marlie attends her appointment at her HTC. The team there talk to her about her periods and how it feels to her when her periods are heavy. Marlie completes some diagnostic questionnaires with her HTC team – a bleed score and a menstrual bleeding assessment – and after discussing her answers, the team decide with Marlie and her parents that a referral to an adolescent gynaecologist is appropriate.

Marlie’s HTC starts oral medication to help control her periods until her appointment with adolescent gynaecology. A blood test has shown that Marlie has anaemia as her iron stores are low due to her excessive bleeding, so she is also prescribed oral iron medication.

The HTC Nurse Coordinator contacts Marlie’s school to discuss support for Marlie and access to the toilet during class times. Marlie is also referred to her social worker and psychology team to help with her feelings about her heavy menstrual bleeding that have influenced her quality of life.

THE PHYSICAL IMPACT OF HEAVY MENSTRUAL BLEEDING

The impact of heavy menstrual bleeding on a person can sometimes be hard to quantify.

People can experience one or more of the issues below:

• Fatigue and weakness – Significant menstrual bleeding resulting in excessive blood loss may lead to anaemia (decrease in red blood cells) which can make a person feel excessive tiredness, experience constant headaches and in severe cases, dizziness, and they may lose consciousness.
• Pain – Severe cramping and discomfort are very common which can be debilitating.
• Sleep disturbance – needing to change sanitary products frequently overnight can lead to a disruption in sleep patterns.

THE PSYCHOSOCIAL IMPACT OF HEAVY MENSTRUAL BLEEDING

Emotional and Psychological Impact

Stress and anxiety about heavy menstrual bleeding can play a large part in the life of a person with a bleeding disorder. The constant worry of needing to change protection regularly or the ability to access a toilet can create significant feelings of anxiety. This is especially apparent in school aged teenagers who may be denied access to toilets during class time.

Feelings of frustration, helplessness or isolation may arise if the person feels that their health concerns are not being taken seriously. If their heavy menstrual bleeding is not managed appropriately some people may feel depressed, which will increase the impact on their quality of life.

As they socialise less with others, there can also be a negative effect on their body image and self-esteem.

Social and professional impact

People with heavy menstrual bleeding may struggle attending school or work on their heavier days. This can be due to tiredness, anxiety, or the inability to access adequate protection or access to toilets. This can heavily impact the person’s professional life due to missed and workdays as well as heavily impact schooling due to days missed.

MANAGEMENT AND TREATMENT

• Medication – medication is normally prescribed by your GP, HTC or gynaecologist. These can range in nature from medications to help clotting to oral medications to regulate hormones.

• Surgical options/IUD (intrauterine device) – many people with a bleeding disorder and heavy menstrual bleeding find having an IUD placed in their uterus is very successful in controlling their symptoms. Other options for people who have finished their family or for other reasons may include endometrial ablation (removing the lining of the uterus) and hysterectomy.

• Psychological support – if you have heavy menstrual bleeding and a bleeding disorder that is impacting your day-to-day functioning and socialising with others you may find it helpful to talk to a psychologist or counsellor about your experiences. It is very normal to be anxious about returning to activities that have caused you problems in past and a psychologist can help with these feelings.

So where is Marlie now?

Marlie is back at school full-time, has just started back at swimming and is loving the preparation for her end of year ballet concert. Her horse-riding competitions have restarted, and she is no longer scared to wear her white jodhpurs for competitions.

By working with her HTC she has been able to choose a treatment plan that suited her for her heavy menstrual bleeding.

Marlie chose to have an IUD placed in her uterus and had oral medication to deal with any spotting after the IUD was placed.

She keeps in touch with her psychologist, social worker and the rest of her HTC team.

REFERENCES

1. James AH, Ragni MV, Picozzi VJ. Bleeding disorders in premenopausal women: (another) public health crisis for hematology? Hematology. ASH Education Program 2006;1:474-85.

2. O’Brien B, Mason J, Kimble R. Bleeding disorders in adolescents with heavy menstrual bleeding: The Queensland Statewide Paediatric and Adolescent Gynaecology Service. Journal of Pediatric & Adolescent Gynecology. 2019 Apr;32(2):122-127.

3. Pawar A, Krishnan R, Davis K et al. Perceptions about quality of life in a school-based population of adolescents with menorrhagia: impacts for adolescents with bleeding disorders. Haemophilia 2008;14(3):579-583.

4. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Heavy menstrual bleeding. RANZCOG: Melbourne, 2018.