Unusual Adolescent Bleeding

For teenagers, skipping periods, heavy bleeding, continuous bleeding and other abnormalities are very common. The reason for this is that the cyclical regulation of the ovarian hormones by the pituitary is not well established, and ovulation is not regular. So the lining of the uterus can build up so that it is too thick or disordered. Often the cause is a temporary excess of estrogen effect on the uterus without enough progesterone.

In the case of this young girl, the first thing is to determine the amount of bleeding – whether the bleeding is very heavy, involving clots, several soaked pads a day, etc. going on for a month, and anemia. Very mild cases of abnormal bleeding can just be observed without treatment or treated with just one course of hormones. Severe bleeding would require much closer watching and higher doses of hormones than prolonged, lighter, merely annoying bleeding.

For lighter spotting and bleeding, I would use oral natural micronized progesterone given for ten to twelve days out the cycle, for one or two months at the most. For very heavy bleeding, it might be necessary to use estrogen and progesterone at the same time. Some insurance companies may not cover natural progesterone, which is sold in most pharmacies under the brand name, Prometrium. Natural micronized progesterone can also be obtained from compounding pharmacies. If necessary for financial reasons or because of more severe, heavy bleeding, Provera (an artificial progesterone-like hormone) could be used in addition to estrogen.

If this girl were a bit older, I would definitely recommend learning NFP charting from a certified instructor to help the hormonal therapy. Not only would she learn to appreciate her cycles, but it would also aid in her treatment and help determine when and if the cycles became ovulatory. Cooperative progesterone therapy, given at the proper time in the cycle, is more specific therapy than giving the hormones by the calendar. But in the case of an 11-year old, I would let the mother determine whether the girl were sufficiently mature to learn to chart NFP cycles. Charting would definitely be superior to therapy by the calendar if the bleeding problem were persistent, rather than a one-time event.

About the recommendation for birth control pills: In our training as ob/gyn’s, many of us were taught for both mild and severe bleeding to use high-dose birth control pills (two or three a day for one week), and then for the young women to go off the pills to have an artificial period. We then were instructed to keep the young woman on birth control pills for at least a few cycles. I now think that it would be preferable to just use estrogen and progesterone/Provera in severe bleeding situations formulated as two separate pills. Although birth control pills combine estrogen and progesterone conveniently, there is a lot of baggage associated with their use that can be avoided by using different formulations of similar drugs. Most importantly, even if higher dose hormones are necessary over the short term to deal with a more severe bleeding problem, I absolutely would not KEEP a young woman on birth control pills. If she does not establish regular, normal periods soon and has recurrent abnormal bleeding, she can be given natural progesterone at intervals (minimum every three months) to prevent hemorrhage. For more severe, recurrent bleeding the young woman should be checked for clotting problems and thyroid disorders.

Dr. Mary Davenport