All locations

See a listing of all our Children’s Hospital Colorado locations including inpatient, outpatient, therapy, surgery facilities and more.

Locations near you

See all locations

Acute Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB), including heavy menstrual bleeding (HMB) is common, with up to 40% of adolescents reporting their bleeding as abnormally heavy and accounts for nearly one-third of outpatient visits to gynecology. In adolescents, the majority of abnormal bleeding is due to anovulatory cycles.

In the normal menstrual cycle, the endometrium is stimulated to proliferate by endogenous estrogen, which is produced by the ovary at the onset of puberty. Menarche will typically occur 2 to 3 years after the onset of breast growth, which usually corresponds with Tanner IV breast development. Menstrual cycles usually occur every 21-45 days and are less than 7 days, but irregularity due to anovulatory cycles from an immature hypothalamic-pituitary-ovarian (HPO) axis is common, especially in the first several years following menarche.⁵ Numerous studies have shown that 50-80% of menstrual cycles in the first two years after menarche are anovulatory, creating dysfunctional endometrial shedding.^6.7 Anovulatory cycles create an environment of unopposed estrogen stimulation and endometrial proliferation, without progestin-induced stabilization. The end result is disorderly shedding of the endometrial lining without prostaglandin-mediated vasoconstriction and platelet-plugging of arterioles.⁸ This may ultimately lead to episodes of heavy uterine bleeding, prompting an emergency room visit.

In addition to anovulation from an immature HPO axis, polycystic ovary syndrome frequently causes heavy and irregular menstrual cycles from irregular ovulation and is increasingly being recognized as the primary cause of heavy menstrual bleeding in young teens. Other less common causes of heavy menstrual bleeding from irregular ovulation includes thyroid disease and prolactin-producing tumors.

Notably, it has also been recognized that up to 30% of adolescents presenting acutely with heavy menstrual bleeding may have an underlying bleeding disorder. Several studies, including one from the Centers for Disease Control have shown that females with inherited bleeding disorders are often not diagnosed until adulthood although they have had bleeding symptoms since adolescence. Barriers to timely diagnosis including stigma around discussing menstrual bleeding and normalization of heavy menstrual bleeding by patients, family members and healthcare providers.

Studies have further demonstrated that adolescents and young adults with heavy menstrual bleeding can experience bleeding complications resulting in severe anemia, hypovolemic shock, inpatient hospitalization and coagulopathy.

The objective of this clinical pathway was to help guide practitioners in the initial evaluation, stabilization and early management of adolescents and young adults presenting acutely with heavy menstrual bleeding.