Systematic Review and Meta-Analysis of the Etiology of Menorrhagia in 2,770 adolescent females

Abstract

Abstract Background: Adolescent menorrhagia, heavy menstrual bleeding, or abnormal uterine bleeding commonly occur in adolescent woman. 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 menorrhagia, heavy menstrual bleeding, or abnormal uterine bleeding Methods: A comprehensive literature search was conducted using PubMed, EMBASE, and SCOPUS databases. Case series describing adolescents from 10 to 21 years of age with menorrhagia, abnormal uterine bleeding (AUB), or heavy menstrual bleeding (HMB) were 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 menorrhagia, abnormal uterine bleeding, or heavy menstrual bleeding, and the country of origin was extracted from articles that met inclusion criteria. Cumulative rate estimates were determined by Bayesian probability modeling. Results: 17 full text articles were reviewed in detail; 2,770 patients were included. The most frequent causes of menorrhagia 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 menorrhagia in healthy adolescent females were varied. The sub-analysis identified distinct etiologies, suggesting that multiple factors must be considered in the evaluation of menorrhagia. 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 menorrhagia in females, this systematic review assigns probabilities to the etiologies of menorrhagia in adolescent females, providing physicians with a more focused and efficient pathway to diagnosis.