Referral Practices in Management of Heavy Menstrual Bleeding in Adolescents

Background: Due to the prevalence of mild bleeding disorders (MBDs) among adolescent females with heavy menstrual bleeding (HMB), the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) recommend screening select adolescent patients with HMB for mild bleeding disorders (MBDs) under the guidance of a hematologist, as coagulation labs can be difficult to interpret. The goal of this study was to describe referral patterns for adolescents with HMB and compare evaluation and management practices among different pediatric specialties using Medicaid claims data.

Methods: Our patient population comprised 10-17 year old females enrolled in Medicaid in central and southeastern Ohio with at least 2 separate diagnoses of HMB and at least 12 months of continuous enrollment prior to their first HMB diagnosis. While there is no standard definition of “severe” HMB, for this study, patients with iron deficiency anemia, an inpatient hospital stay for HMB, or an outpatient blood transfusion were defined as having severe HMB. Medicaid claims data and electronic medical records from Nationwide Children’s Hospital, the region’s only children’s hospital, were linked to collect study data.

Results: We identified 509 patients with HMB. Referral to a pediatric specialist occurred in 17.9% of patients; 39.5% of those with severe HMB and 13.8% of those with non-severe HMB were referred. 10.8% of patients were referred to adolescent med, 6.7% were referred to hematology, and 0.4% were referred to endocrinology. Of the patients seen by a specialist at a children’s hospital, 69% were screened for a MBD. When stratified by specialty, 100.0% of patients seen by hematology were screened for a MBD while 51.0% of patients seen by adolescent medicine were screened for a MBD. Approximately one-third (35.7%) of referred patients were diagnosed with a MBD, most commonly platelet function defects and von Willebrand disease (VWD). 48.3% of patients with severe HMB were diagnosed with a MBD, while 29.1% of patients with non-severe HMB were diagnosed with a MBD. Both hematologists (100.0%) and adolescent medicine doctors (97.0%) almost uniformly prescribed treatment for HMB, most commonly hormonal contraception (95.2%). Patients had significantly higher odds of referral to a pediatric specialist if they had severe HMB [2.3, 95% CI (1.42-3.71)]. Patients had significantly lower odds of referral if they lived farther away from the region’s children’s hospital [0.16, 95% CI: (0.09-0.29)]. There was no significant difference in frequency of referral between patients initially diagnosed by family practitioners, pediatricians, or gynecologists.

Conclusions: Despite ACOG and AAP recommendations, we found that only a small percentage of adolescents with HMB are referred to a pediatric specialist. Efforts should be made to increase education regarding which patients are at higher risk of an underlying MBD, and increasing the number of these adolescents who are referred to hematology so that coagulation lab studies can be ordered and interpreted appropriately. Such efforts should be targeted at patients in rural areas, since this population was particularly unlikely to receive care from a hematologist.