Abnormal Vaginal Bleeding

Age of the patient is important when considering the differential diagnosis of abnormal vaginal bleeding. Pregnancy should always be ruled out despite a negative history of sexual activity. Bleeding that occurs before pubertal development of normal menarche should raise suspicion of nonendocrine causes.

Differential Diagnosis

• Dysfunctional uterine bleeding (DUB)
  –Physiologic anovulation is normal for up to 2 years after menarche
  –Androgen excess
  –Functional ovarian hyperandrogenism, or polycystic ovary syndrome, is common in adolescence
  –Estrogen excess
  –Hyperprolactinemia
  –Hypothyroidism
  –Early premature ovarian failure

• Luteal phase defects
• Pregnancy disorders
  –Spontaneous abortion (threatened, missed, incomplete)
  –Molar pregnancy
  –Ectopic pregnancy
• True vaginal bleeding
  –Trauma (including sexual abuse)
  –Vaginal sarcoma (sarcoma botyroides)
  –Foreign body (more common in the younger child)
• Menorrhagia
  –Idiopathic: Most common cause of menorrhagia in adolescents
  –Coagulopathy/bleeding disorder (e.g., thrombocytopenia, von Willebrand disease, factor IX deficiency)
  –Uterine polyp or neoplasm
  • Hematuria mistaken for vaginal bleeding
    –Urethral prolapse
    –Urinary tract infection
  • Excoriations due to pruritus
  • Vulvovaginitis
    –Trichomonas
    –Chlamydia
    –Gonorrhea
    –Pinworms (rare)
  • Cervical lesions
    –Cervical polyp
    –Hemangioma
    –Cervical friability

  Workup and Diagnosis

  • History
    –Age at onset of bleeding
    –Quantity, duration, and frequency of bleeding
    –Associated pain or discomfort
    –Age at onset of puberty
    –First day of last menstrual period
    –Other symptoms: Dysuria, symptoms of hypothyroidism (fatigue, cold intolerance, constipation), symptoms of hyperprolactinemia (headaches, nipple discharge/galactorrhea)
    –Sexual abuse; sexual activity
    –Family history of irregular periods/infertility
  • Physical exam
    –Inspection of external genitalia (anatomy, evidence of trauma, source of bleeding)
    –Evidence of puberty (breast development, estrogenization of vaginal mucosa)
    –Signs of virilization (hirsutism)
    –Nipple discharge
    –Signs of hypothyroidism (bradycardia, dry skin, coarse hair, short stature, delayed reflexes)
  • Labs
    –LH, FSH, estradiol (E2), hCG
    –T4, TSH, prolactin
    –Platelet count, PT, PTT, bleeding time, vWF
    –Urine analysis
  • Pelvic US to detect ovarian and uterine abnormalities
  • MRI of pituitary to detect abnormalities of the gland

  Treatment

  • Physiologic anovulation does not usually need to be treated unless it persists beyond 2 years past menarche
  • Polycystic ovary syndrome treat with: Oral contraceptives, androgen inhibitors (spironolactone) as adjunct, insulin sensitizing medications (metformin)
  • Hyperprolactinemia: Treat with bromocriptine
  • Hypothyroidism: Treat with L-thyroxine replacement
  • Coagulopathy: Referral to hematologist for management
  • Gynecologic tumor or foreign body: Surgical exploration and resection
  • Intracranial mass (pituitary tumor): Referral to oncologist, endocrinologist
  • Menorrhagia
    –Oral estrogen is required to stop an acute episode
    –Patient with very heavy bleeding may require
  hospitalization for IV fluid/blood products (correction of hypovolemia) and IV Premarin
  –OCPs or progestins are useful to prevent recurrences

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Vaginal symptoms

Read excerpts from these other book chapters related to Vaginal symptoms:

Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Vaginal symptoms

• Back to symptom: Vaginal symptoms: Introduction (review 153 causes)
• Next Book Extract About Vaginal symptoms: DYSMENORRHEA (Differential Diagnosis in Primary Care)
• All Book Extracts: All Online Book Extracts for Vaginal symptoms

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: DYSMENORRHEA (Differential Diagnosis in Primary Care)

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• Dysmenorrhea (Handbook of Signs & Symptoms (Third Edition))

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