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Heghine Khachatryan: Menarche as the First ‘Bleeding Challenge’

Heghine Khachatryan/LinkedIn, Abdul Mannan/LinkedIn

Jun 28, 2026, 10:34

Heghine Khachatryan: Menarche as the First ‘Bleeding Challenge’

Heghine Khachatryan, Editor-in-Chief of Hemostasis Today, Head of Hemophilia and Thrombosis Center at Yeolyan Hematology and Oncology Center, shared Abdul Mannan’s post on LinkedIn, adding:

“Menarche as the first ‘bleeding challenge’

Menarche is often the first major haemostatic challenge in a girl’s life. Severe menstrual bleeding at this stage should never be interpreted only as ‘heavy periods’ or pubertal immaturity.

Acute heavy menstrual bleeding at menarche may be the first clinical presentation of:

Von Willebrand disease
Platelet function disorders
Thrombocytopenia
Rare inherited coagulation factor deficiencies
Connective tissue–associated bleeding phenotypes

The diagnostic difficulty is that acute bleeding, stress, inflammation, anaemia, hormonal therapy, and transfusion may transiently modify haemostatic parameters.

Von Willebrand factor and factor VIII can rise during physiological stress; therefore, a ‘normal’ VWF result during an acute bleeding episode does not always exclude von Willebrand disease.

Management should be structured:

Stabilize the patient: assess haemodynamics, CBC, ferritin, coagulation profile, pregnancy test when appropriate.
Control bleeding: tranexamic acid, hormonal therapy, iron replacement, and transfusion only when clinically indicated.
Investigate haemostasis: VWF antigen/activity, FVIII, platelet count and morphology, platelet function testing, fibrinogen, PT/APTT, and selected factor assays.
Repeat testing after recovery if clinical suspicion remains high.
Take a detailed bleeding history: epistaxis, bruising, dental/surgical bleeding, postpartum bleeding in relatives, family history.
Ensure multidisciplinary follow-up: adolescent gynaecology, haematology, primary care, and family education.

A normal laboratory result during a haemostatic storm is not the same as a normal haemostatic system.

Menarche can reveal a hidden bleeding disorder. Recognition at this stage prevents years of anaemia, repeated emergency visits, unnecessary suffering, and delayed diagnosis.

Based on current guidance and recent discussion in The Lancet Haematology.”

Abdul Mannan, Consultant Haematologist at Betsi Cadwaladr University Health Board, shared a post on LinkedIn:

“Menarche Can Be the First Bleeding Challenge

A teenager with severe menstrual bleeding should never be waved away as “just heavy periods.”

Acute bleeding at menarche is a recognised first presentation of:

Von Willebrand disease
Platelet function disorders
Rare inherited bleeding disorders
Sometimes it is severe enough to need hospital admission or transfusion.

Here is the trap.

Von Willebrand factor rises under physiological stress. A girl tested in the middle of a heavy bleed can have factor levels that look reassuringly normal.

So if your suspicion is high: