Dysmenorrhoea and heavy menstrual bleeding — structured clinical encounter

Station brief (candidate)

You are the general paediatric registrar in adolescent clinic. A 13-year-old is brought by her mother with heavy periods since her first menstrual period at menarche eight months ago. She soaks a pad every 1 to 2 hours on heavy days, passes clots, and tires easily. Her mother mentions the young person bruises easily and bled after a recent dental extraction, and that she herself had a hysterectomy for menorrhagia. The team asks you to assess the problem, decide on investigations, and outline the management plan. You have 12 minutes with the young person and her mother and 5 minutes for examiner discussion. [4]

Information available on request

• 13-year-old, menarche eight months ago; heavy bleeding from the first period; soaks a pad every 1 to 2 hours on heavy days; clots larger than a 50-cent coin; bleeding up to 8 days. [2]
• Fatigue and pallor; haemoglobin 95 g/L, ferritin 8 micrograms/L (iron-deficiency anaemia). Easy bruising; prolonged bleeding after a dental extraction. Mother had a hysterectomy for menorrhagia. [4]
• Not sexually active; no dyspareunia, no pelvic pain between periods, no pregnancy concern. Well systemically, no haemodynamic compromise. [1]

Tasks

1. Quantify the heavy menstrual bleeding from the history, and explain why this presentation warrants a bleeding-disease screen rather than reassurance alone. [2] [4]
2. Apply the FIGO PALM-COEIN classification to the causes of adolescent heavy menstrual bleeding, and identify the most likely cause in this young person. [3]
3. State the bleeding-disease screen you would order, what it includes, and the timing caveat for interpretation. [4]
4. Outline the stepwise medical management ladder, the iron-repletion plan, and the safety-netting and follow-up. [4] [8]

Marking anchors

Must-hit

• Quantifies the bleeding: soaking a pad every 1 to 2 hours, clots, bleeding beyond 7 days, iron-deficiency anaemia; recognises that bleeding from menarche with easy bruising, dental bleeding and a family history of menorrhagia warrants a bleeding-disease screen, because heavy menstrual bleeding from menarche is the most common presentation of a bleeding disorder such as von Willebrand disease in females. [2] [4]
• Reproduces the FIGO PALM-COEIN classification; identifies the COEIN arm as dominant in adolescents and coagulopathy (von Willebrand disease) as the most likely cause here, given the bleeding history and family history. [3]
• Orders the bleeding-disease screen: von Willebrand factor antigen and activity (ristocetin cofactor), factor VIII, with blood-group-aware interpretation, and a platelet count and platelet function screen. States the timing caveat that von Willebrand factor levels fall during active bleeding, so a level drawn during heavy bleeding is interpreted in context and repeated when stable. [4]
• Outlines the ladder: an NSAID or tranexamic acid 1 g three times daily for 2 to 4 days of bleeding; add or switch to the combined oral contraceptive or an oral progestogen; the levonorgestrel intrauterine system as the most effective long-term option (more effective than oral therapies, per Bofill Rodriguez 2020, Cochrane), with a warning about irregular spotting in the first 3 to 6 months. Treats the iron-deficiency anaemia at the first visit (oral iron repletion; intravenous iron if severe symptomatic), provides an explicit safety-net, and arranges follow-up at three cycles with haematology liaison. [4] [8]

Merit

• Frames confidentiality and sees the young person alone, integrating the menstrual assessment into the HEEADSSS framework; treats the menstrual cycle as a vital sign. [2]
• Notes that, because anovulatory cycles are the expected background in the first 1 to 2 years after menarche, the bleeding-disease screen and the family history are what move this presentation out of the reassure-and-calendar lane. [4]

Fail

• Reassures the family that the bleeding is "just puberty" and defers investigation, missing the bleeding disorder and allowing the iron deficiency to progress. [4]
• Orders a bleeding-disease screen during active heavy bleeding and over-interprets a low von Willebrand factor level without planning to repeat it when stable. [4]
• Reaches for endometrial biopsy or hysteroscopy as a first step, which are rarely indicated in the adolescent. [4]