It is common for adolescent girls to experience some disruption in their menstrual cycles in the first few years after menarche (their first menstruation). Their body is adjusting to the hormonal rhythm under the influence of the hypothalamic-pituitary-ovarian (HPO) axis, which often leads to an ovulatory cycles and sporadic bleeding. But if there is consistently heavy, prolonged bleeding, or if it's a problem in daily living, this may be a sign of a medical problem that should be investigated.


Excessive or heavy menstrual bleeding is a medical term known as menorrhagia . In teenagers, it is often missed or mistakenly thought to be part of development. However, continuous heavy bleeding should not be dismissed—particularly if it results in fatigue, interferes with school or after-school activities, or produces signs of anemia like pale color of the skin, dizziness, shortness of breath, or unexplained fatigue.


Among the most frequent causes of menorrhagia in adolescents is hormonal imbalance, especially during the initial years when ovulation is infrequent or doesn't occur at all. Without ovulation, there is no production of progesterone, which can lead to excessive growth and shedding of uterine lining, resulting in heavy bleeding.


Outside of hormonal reasons, there are various medical issues that can also cause heavy periods. One issue to rule out is a bleeding disorder, the most common inherited form of which is von Willebrand disease. It affects blood clotting, which may first show symptoms of heavy menstrual bleeding, frequent nosebleeds, or easy bruising. Other disorders affecting the blood may also be present.


Thyroid disorders, particularly an underactive thyroid (hypothyroidism), also cause irregular periods and more bleeding. Though less frequent in teenagers, structural abnormalities such as uterine polyps or fibroids may be the culprit. Some medications, in particular those that work on blood clotting or hormones cause heavier periods.


Heavy bleeding is concerning when periods last longer than 7 days, when they are changed every one to two hours and pads or tampons, there are heavy blood clots, and anemia. If a teenager needs to wear several sanitary products simultaneously or miss school because of her period, this is also not normal and should be evaluated by a physician.


Diagnosis typically starts with an extensive medical history and physical examination, and then laboratory tests to evaluate blood counts, clotting status, thyroid hormones, and, in certain instances, reproductive hormone balance. Pelvic ultrasound can be employed to evaluate for anatomical defects. If a bleeding disorder is suspected, referral to a hematologist would be indicated. In instances in which hormonal problems are probable, referral to an endocrinologist could be made.


Early treatment and diagnosis have a significant impact on the quality of life of a teenager, allowing them to remain active in school, sports, and society, and avoiding complications such as iron deficiency anemia, which has long-term consequences when left untreated.

In short, although certain menstrual irregularity is to be expected in early adolescence, persistent heavy bleeding is not an innocuous part of puberty. Parents and guardians need to pay attention to these symptoms and insist on medical evaluation, not waiting for the problem to run its course.

(Dr Asha Dalal , Director - Obstetrics & Gynaecology, Sir H.N. Reliance Foundation Hospital, Mumbai)