Menstrual disorders in adolescents — formative SAQs

SAQ 1 — Heavy menstrual bleeding in a 14-year-old (10 marks)

A 14-year-old presents 18 months after menarche with menses lasting 9 to 10 days, flooding, clots, and fatigue. She has missed several days of school each cycle. Her mother reports heavy periods "run in the family." Examination shows pallor; haemoglobin is 78 g/L. [5] [1]

Questions

1. Give the normal adolescent menstrual cycle thresholds and classify this bleeding using FIGO terms. (3 marks) [1] [4]
2. Outline the focused investigation panel and justify screening for a bleeding disorder. (4 marks) [5] [6]
3. Describe the stepwise, mechanism-based management. (3 marks) [5]

Model answer

Normal thresholds and classification (3). Normal cycle: 21 to 45 days, fewer than 8 days of flow (often quoted as 7 days), regular within 3 years of menarche, menarche by age 15. This adolescent has heavy, prolonged bleeding (duration over 7 to 10 days, flooding, clots) complicated by symptomatic anaemia. Use FIGO objective terms (heavy, prolonged) rather than menorrhagia. [1] [4]

Investigation panel (4). Pregnancy test, full blood count and ferritin (anaemia and iron deficiency), TSH, prolactin and free testosterone (endocrine gates), and a coagulation screen with a von Willebrand panel (von Willebrand factor antigen, activity/ristocetin cofactor, factor VIII). Screen for a bleeding disorder because about one in five adolescents referred for heavy menstrual bleeding has an underlying bleeding disorder, with von Willebrand disease dominant; heavy bleeding from menarche plus family history raises this further. Pelvic ultrasound only if a structural cause is suspected. [5] [6]

Stepwise management (3). Treat the anaemia and iron deficiency with oral iron and recheck at about 3 months. For cycle control use combined hormonal contraception as first-line (suppresses ovulation, regularises withdrawal bleeds, reduces volume), or the 52 mg levonorgestrel intrauterine system; add tranexamic acid during menses when hormonal therapy is declined or contraindicated; cyclic oral progestin protects the endometrium when combined hormonal contraception is contraindicated. Run the visit through confidential adolescent care, address school attendance, and arrange follow-up. [5]

SAQ 2 — Secondary amenorrhoea and refractory dysmenorrhoea (10 marks)

A. A 16-year-old competitive runner has not menstruated for six months; she is fatigued and her BMI is 17. B. Separately, a 15-year-old has dysmenorrhoea that has not responded to an adequate NSAID trial or combined hormonal contraception and causes her to miss school each cycle. [8] [2]

Questions

1. Give the differential for the runner's secondary amenorrhoea and outline the first-line management principle. (5 marks) [1]
2. Outline the evaluation and referral pathway for the adolescent with refractory dysmenorrhoea. (5 marks) [2] [7]

Model answer

Secondary amenorrhoea (5). Exclude pregnancy first with a confidential test. Differential: functional hypothalamic amenorrhoea from energy deficit (leading here, given low BMI and over-exercise), PCOS, thyroid or prolactin disturbance, premature ovarian insufficiency, and (less commonly) structural cause. First-line management of functional hypothalamic amenorrhoea is restoration of energy balance — nutrition, reduced training, weight restoration — with the eating-disorder team involved and bone density monitored; hormone replacement is adjunctive for bone protection once the energy deficit is addressed, not a substitute for it. [1] [8]

Refractory dysmenorrhoea (5). Dysmenorrhoea refractory to an adequate NSAID trial plus combined hormonal contraception is a secondary cause until proven otherwise. Take a focused pain history (non-cyclic pain, deep dyspareunia, mass) and examine, including external genitalia, to look for outflow obstruction. The main secondary cause in this age group is endometriosis; outflow obstruction (imperforate hymen, vaginal septum) and pelvic infection are also considered. Refer to adolescent gynaecology for specialist evaluation and laparoscopic diagnosis or excision as indicated; continue symptom control and school support in the meantime. [2] [7]