Abnormal Uterine Bleeding in Adolescents

Elisabeth H. Quint, MD, Yolanda R. Smith, MD

Disclosures

J Midwifery Womens Health. 2003;48(3) 

In This Article

Evaluation

The initial goal in the approach to evaluation of an adolescent with abnormal bleeding is to determine hemodynamic stability, locate the origin of bleeding, identify any organic causes and classify whether the bleeding is ovulatory or anovulatory.

An accurate and complete menstrual history is critical. The history should include age at menarche, frequency, amount, and duration of menses, pain with menses, and last menstrual period. A menstrual calendar can accurately and prospectively keep track of the cycles, especially because adolescents often have difficulty remembering exactly the dates of their cycles. To an adolescent, monthly may mean once every calendar month, so that a period on day 1 and day 27 of the same month, while normal, may strike her as having periods twice a month. Age at menarche, month and year, is important to calculate gynecologic age because it may take at least 2 years to become ovulatory. Menstrual flow needs to be assessed in detail, including number of pads, the saturation of these pads, the passage of clots and the soaking of clothes and bedding. Some have advocated a pictorial chart, but more recent research has found that to be unreliable.[22] In addition, family history should be obtained to rule out any familial diseases including bleeding disorders.

Special attention should also be paid to a careful sexual history because pregnancy and sexually transmitted infections (STIs) can also present with abnormal bleeding. Medications should also be carefully recorded. A thorough review of systems should be obtained, with particular emphasis on symptoms of bleeding abnormalities (easy bruisability, epistaxis, and gingival bleeding), endocrine disorders, and eating disorders, exercise and sport participation. Because many questions address sensitive areas that may require confidentiality between the adolescent and her health care provider, the young woman should also always be interviewed without her parents in the room.

A thorough physical examination should include height and weight and evaluation of overall health. Generally, pubertal development is assessed by Tanner staging.[23] Bruises should be noted in search of a bleeding abnormality. Any signs of hyperandrogenism, such as acne or hirsutism, should be noted. The thyroid gland should be assessed for enlargement and the neck for acanthosis nigricans. This is a gray-brown velvety, sometimes verrucous, discoloration of the skin, usually at the neck, groin, axilla, or under the breasts, which is a marker for insulin resistance, as sometimes found in PCOS. The breasts should be examined, not only for pubertal staging but also for nipple discharge (galactorrhea) to screen for hyperprolactinemia. The abdomen should be assessed for masses and hirsutism. The decision to perform a pelvic examination primarily depends on the sexual history. If the client denies sexual activity, it may not be possible or necessary to perform a pelvic examination. She should have an evaluation of the external genitalia, looking for signs of clitoromegaly or hirsutism. If indicated, a rectoabdominal examination can be done. This is usually well tolerated and can be very helpful in girls with severe dysmenorrhea, to rule out an obstruction in the genital tract, endometriosis in the cul-de-sac, or a pelvic mass. All sexually active girls should have an internal examination with a narrow speculum, screening for sexually transmitted diseases, a Papanicolaou smear (if not done in the last 12 months), and a bimanual examination to assess for masses. If there is any evidence of coagulopathy, an endocrine abnormality, such as severe hirsutism, acanthosis nigricans, an enlarged thyroid, galactorrhea, or physical evidence of thyroid abnormalities, the patient should be referred to a physician for further evaluation. A pelvic ultrasound can be obtained if there is a high level of suspicion for an anatomic abnormality or if it impossible to perform a pelvic examination in a patient with severe dysmenorrhea that does not respond to initial treatment.

Initial laboratory studies should include a complete blood count (CBC) with platelets and a thyroid-stimulating hormone (TSH) or prolactin, if indicated. A pregnancy test should also be obtained, even if the patient denies sexual activity. A coagulation profile, including prothombin time, partial thromboplastin time, and a bleeding time, is recommended if the patient is having acute hemorrhage or has hemoglobin of less than 10 g/dL. Experts recommend a von Willebrand panel, including von Willebrand factor antigen and ristocetin cofactor activity if a bleeding disorder is highly suspected. A referral at that time is indicated.

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