(109) Primary Care Referrals for Heavy Menstrual Bleeding in Adolescents: A Retrospective Chart Review

Background: Heavy menstrual bleeding (HMB) is excessive menstrual blood loss that interferes with physical, social, emotional, or material quality of life. Several organizations, including NASPAG, have algorithms to guide initial investigations and management. We aim to evaluate the extent to which primary care providers (PCP) initiate first-tier guideline investigations and management prior to specialist referral.

Methods: A retrospective review of adolescents referred to PAG for HMB over a 2-year period was conducted. Patient demographics, investigations and management initiated by the referring PCP were extracted. In addition, diagnosis, investigations, and management initiated by the PAG team at the first visit was captured. A modification of ‘first-tier’ investigations for HMB as per NASPAG Committee Opinion to reflect local practices was utilized, including CBC, ferritin, INR, PTT, and beta HCG for sexually active (SA) teens.

Results: This is a work in progress. 638 patients were identified for chart review. To date, 258 charts (40%) have been reviewed, 124 patients meet inclusion criteria.

Most patients are referred by Pediatricians (73%) or Family Physicians (19%). The average age at PAG consult is 13.8 years, and patients are an average of 2.3 years postmenarchal. Of first-tier recommendations, CBC (74%) and ferritin (56%) are most included. Coagulation testing (INR, PTT) is included in 17% referrals and beta HCG is included for 40% of SA teens. Inclusion of all first-tier investigations is uncommon (12%). Despite not being a recommendation, nearly one-third of referrals include a pelvic ultrasound. 27% of patients are referred with no completed investigations. Nearly two-thirds of patients are started on treatment by PCP prior to referral, most commonly iron supplementation (31%) and NSAIDs (31%).

PAG ordered investigations for 38% of patients at first consult. Management of HMB is offered to 68% of patients at their initial visit (83% had at least one first-tier investigation ordered by PCP and 17% had no testing included). The minority of patients (12%) had treatment deferred to future visits after investigations ordered by PAG could be reviewed; of this group, two-thirds had a first-tier test included with referral and one-third no testing included.

Conclusions: The study provides an understanding of how PCP are investigating, managing and referring adolescents with HMB, and the potential impact on decision making at first PAG consultation. This serves to inform collaborative efforts between PCP and PAG providers, with the goal of promoting judicious use of healthcare resources and timely care.