Systematic review and meta-analysis of the etiology of heavy menstrual bleeding in 2,770 adolescent females

Erin M Hall; Ana E Ravelo; Stephen C Aronoff; Michael T Del Vecchio

doi:10.1186/s12905-024-02921-7

Menstrual Cycle · Cycle Disorders

Systematic review and meta-analysis of the etiology of heavy menstrual bleeding in 2,770 adolescent females

Hall EM, Ravelo AE, Aronoff SC, Del Vecchio MT

Published February 20, 2024 BMC women's health, 24(1), 136

DOI 10.1186/s12905-024-02921-7 PMID 38378571 PMC PMC10880246

RRM Academy Synopsis

Almost half of adolescents with heavy periods had no clear cause

About 46 out of 100 adolescents with heavy periods had no identifiable cause, a review of 17 studies found. It covered 2,770 patients aged 10 to 19. Ovarian uterine disorders were the most common identified group.

Key Findings

Seventeen studies published between 1998–2020 met the inclusion criteria, covering 2,770 patients aged 10–19. The largest study contributed 24% of the patient sample.
No identifiable cause was found in 45.9% of cases (95% CredI 43.8-47.9).
Ovarian uterine disorders were the leading identified group at 23.7% (95% CredI 22-25.5). Coagulation disorders followed at 19.4% (95% CredI 17.8-21.1), then platelet disorders at 6.23% (95% CredI 5.27-7.27).
Within ovarian uterine disorders, bleeding without ovulation made up 98.7% (95% CredI 97.6-99.5). Endometriosis and polycystic ovary syndrome (PCOS, now called PMOS) were each 0.564% (95% CredI 0.117-1.35).
Within coagulation disorders, von Willebrand disease made up 88.1% (95% CredI 84.9-90.9).

Interpretation

The authors pooled 17 case series, some prospective and some retrospective, using Bayesian modeling. The shares describe the patients in those studies. Each study's causes were taken as it reported them, and testing resources, criteria and thoroughness varied between institutions. The authors attribute the large group with no identified cause to that variation. Studies limited to one subgroup, such as PCOS only, were excluded. The authors suggest future studies split results by region and hospital type. The authors call their list a reasonable starting point when a risk-based approach is wanted.

RRM Context

Restorative reproductive medicine treats a heavy period as a reason to investigate. The authors tie the large group with no identified cause to uneven testing between institutions. Undiagnosed is the right word for those cases. Nearly all identified ovarian uterine cases involved bleeding without ovulation. Ovulation shapes a cycle's bleeding pattern, so cycle charting can show whether it happens.

Our editorial summary of this paper, not the article's abstract.

Abstract

Background

Adolescent heavy menstrual bleeding(HMB), menorrhagia or abnormal uterine bleeding commonly occur in adolescent women. The differential diagnosis can be challenging. The pneumonic: PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified), is commonly used but it does not stratify as to the likelihood of a disorder. We have sought to develop a probability-based differential diagnosis for Adolescent HMB, menorrhagia or abnormal uterine bleeding.

Methods

A comprehensive literature search was conducted using PubMed, EMBASE, and SCOPUS databases. Case series describing adolescents from 10-19 years of age with HMB, menorrhagia or abnormal uterine bleeding was acceptable if: more than 10 patients were included; editorials, case reports, and secondary sources such as review articles, or book chapters were excluded. No language filter was used, but an English abstract was required. The etiology of HMB, menorrhagia or abnormal uterine bleeding, and the country of origin was extracted from articles that met inclusion criteria. Cumulative rate estimates were determined by Bayesian probability modeling.

Results

Seventeen full text articles were reviewed in detail; 2,770 patients were included. The most frequent causes of HMB were Ovarian Uterine Disorders (23.7%; 95% CredI 22-25.5%), Coagulation Disorders (19.4%; 95% CredI 17.8-21.1%), and Platelet Disorders (6.23%; 95% CredI 5.27-7.27%) with 45.9% (95% CredI 43.8-47.%9) of the cases of indeterminate origin.

Conclusions

The leading causes of HMB in healthy adolescent females were varied. The sub-analysis identified distinct etiologies, suggesting that multiple factors must be considered in the evaluation of HMB. While PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) provides us with a comprehensive picture of the possible causes of HMB in females, this systematic review assigns probabilities to the etiologies of HMB in adolescent females, providing physicians with a more focused and efficient pathway to diagnosis.

Topics

Menstrual Cycle › Cycle Disorders › Abnormal Uterine Bleeding · Research Methods › Evidence Synthesis › Meta-Analysis

Erin M Hall, Ana E Ravelo, Stephen C Aronoff, Michael T Del Vecchio

E Hall, A Ravelo, Steve Aronoff, S Aronoff, Mike Vecchio, M Vecchio

PMID 38378571 38378571 DOI 10.1186/s12905-024-02921-7 10.1186/s12905-024-02921-7 Hall et al. 2024, Hall 2024

Keywords

Abnormal uterine bleeding, Adolescents, Heavy menstrual bleeding, Menorrhagia, PALM-COEIN, Systematic review

Systematic review and meta-analysis of the etiology of heavy menstrual bleeding in 2,770 adolescent females

Almost half of adolescents with heavy periods had no clear cause

Key Findings

Interpretation

RRM Context

Abstract

Topics

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Keywords