Treatment with mefenamic acid and other nonsteroidal anti-inﬂammatory agents (NSAIDs) results in decreased menstrual bleeding when compared with placebo (93). Tranexamic acid, an antifibrinolytic agent, is more effective in decreasing heavy menstrual bleeding, and was approved by the U.S. Food and Drug Administration (FDA) for this indication in late 2009 (93a). After specific diagnoses are ruled out by appropriate laboratory testing, this condition can be managed either expectantly or with hormone therapy, depending on the clinical presentation and other factors, such as the need for contraception.
Anovulation: Mild Bleeding
Adolescents who have mildly abnormal bleeding, as defined by adequate hemoglobin levels and minimal disruption of daily activities, are best managed with prospective menstrual charting, frequent reassurance, close follow-up, and supplemental iron. If the patient is bleeding heavily or for a prolonged interval, an apparent decrease in the bleeding does not necessarily mean that therapy is not required. Intermittent bleeding characterizes anovulatory bleeding and is likely to continue in the absence of therapy.
A patient who is mildly anemic will benefit from hormone therapy. If the patient is not bleeding at the time of evaluation and has no contraindications to the use of estrogen, a combination low-dose oral contraceptive can be prescribed for use in the manner in which it is used for contraception. If the patient is not sexually active, she should be reevaluated after three to six cycles to determine whether she desires to continue this regimen. Parents may sometimes object to the use of oral contraceptives if their daughter is not sexually active (or if they believe her not to be or even if they would like her not to be). These objections are frequently based on misconceptions about the potential risks of the pill and can be overcome by careful explanation of the pill’s role as medical therapy. Objections may be based on concerns that hormonal therapy for medical indications is likely to hasten the onset of coitarche or sexual debut, although no data support this fear. If the medication is discontinued when the young woman is not sexually active and she subsequently becomes sexually active and requires contraception, it may be difficult to explain the reinstitution of oral contraceptives to the parents. If there is no significant medical or family history that would preclude their use, combination oral contraceptives are especially appropriate for the management of abnormal bleeding in adolescents for a number of reasons: 1.
Approximately 50% of high schools juniors in the United States are sexually experienced (63).
2.
Adolescents typically wait many months after initiating sexual activity to seek medical contraception.
3.
At least 80% of adolescent pregnancies are unintended (94).
4.
Approximately one-quarter of adolescent pregnancies end in abortion (95).
5.
Approximately one in three young women will experience a pregnancy before age 20 (96).
Thus, consideration should certainly be given to continuing the oral contraception use, and parents should be reassured that the medical risks are small in otherwise healthy adolescents and that there are no significant risks associated with prolonged use. Individuals may choose to continue oral contraceptives for contraception or their noncontraceptive benefits (improvement of acne, decreased dysmenorrhea, and lighter, more regular menstrual ﬂow, protective effect for endometrial and ovarian cancer).