Call to action: identifying an underlying bleeding disorder in adolescents with heavy menstrual bleeding

Heavy menstrual bleeding (HMB) is prevalent, with consequences impacting quality of life from adolescence through adulthood. Several clinical tools have been developed to aid in HMB diagnosis, which must be coupled with a detailed menstrual history. The diagnosis of HMB should be accompanied by evaluation of coexisting iron deficiency or iron deficiency anemia with appropriate treatment, and importantly, an in-depth evaluation for an underlying etiology. HMB is a significant hallmark of a bleeding disorder (BD) in adolescents; BDs are not often investigated and are underdiagnosed due to knowledge gaps, inconsistent referral practices, and lack of coordinated management by primary care providers, hematologists, and gynecology providers. Due to several missed opportunities, there is a substantial diagnostic delay of an underlying BD resulting in significant morbidity, risk of bleeding with future hemostatic challenges, and subsequent impact on undiagnosed family members. This review highlights issues related to HMB, associated iron deficiency/iron deficiency anemia, and the diagnostic journey for adolescents with BDs, emphasizing the roles of providers, community members, and other stakeholders to mitigate obstacles and create solutions to develop improved pathways to access best care for this population.