PREMENARCHAL VAGINAL BLEEDING
An 8-year-old girl is brought by her mother to the gynecologist’s office because of vaginal bleeding for 2 weeks. The girl states that she has not taken any medication and gives no history suggestive of sexual abuse. She does not complain of headache or visual disturbance and has been doing well in school. On physical examination she is normal for her age without pubertal changes, and pelvic examination under sedation reveals a vaginal foreign body.
Definition. Premenarchal bleeding is bleeding that occurs before menarche. The average age atmenarche is 12 years old.
Differential Diagnosis and Etiology. Possible causes include ingestion of estrogen medication,a foreign body that irritates the vaginal lining, a cancer of the vagina or of the cervix (sarcoma botryoides), a tumor of the pituitary or adrenal gland, an ovarian tumor, sexual abuse, or idio-pathic precocious puberty. The most common cause of premenarchal bleeding is a foreign body.
Diagnosis and Management
• Pelvic examination. The patient who complains of premenarchal bleeding shouldhave a pelvic examination under sedation. In this examination, evidence of a foreign body, sexual abuse, or tumor are looked for. Sarcoma botryoides typically looks like grapes arising from the vaginal lining or from the cervix.
• Imaging study. CT scan or MRI scan of the pituitary, abdomen, and pelvis should
be done. The scans are looking for evidence of a pituitary, ovarian, or adrenal tumor, which may cause early estrogen production.
ABNORMAL VAGINAL BLEEDING
A 31-year-old woman complains of 6 months of menometrorrhagia. The patient states that she started having menstruation at age 13 and that she has had regular menses until the past 6 months. The pelvic examination including a Pap smear is normal. She has no other significant personal or family history.
Pregnancy
In a patient who has abnormal bleeding during the reproductive age group, pregnancy or a complication must first be considered.
Mechanism. Complications of early pregnancy that are associated with bleeding includeincomplete abortion, threatened abortion, ectopic pregnancy, and hydatidiform mole.
Diagnosis. Urine or serumb-hCG test is required to confirm pregnancy. If pregnancy is identi-fied vaginal ultrasound will help sort out which pregnancy complication is operative.
Management. Treatment will vary with the individual diagnosis identified.
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Chapter 11 l Menstrual Abnormalities
Anatomic Lesion
If the pregnancy test is negative, then an anatomic cause of vaginal bleeding should be con-sidered. The classic history is that of unpredictable bleeding (without cramping) occurring between normal, predictable menstrual periods (with cramping).
Mechanism. A variety of lower and upper reproductive tract factors can cause bleeding:
• Vaginal lesions: lacerations, varicosities or tumors
• Cervical lesions: polyps, cervicitis or tumors
• Endometrial lesions: submucous leiomyomas, polyps, hyperplasia or cancer
• Myometrial lesions: adenomyosis
Diagnosis. A number of tests can be used to for anatomic diagnosis.
• Lower genital tract: pelvic and speculum exam
• Upper genital tract: saline sonogram , endometrial biopsy, hysteroscopy
Management. Treatment will vary according to the individual diagnosis identified.
Inherited Coagulopathy
Up to 15% of patients with abnormal vaginal bleeding, especially in the adolescent age group, have coagulopathies. Review of systems may be positive for other bleeding symptoms including epistaxis, gingival bleeding and ecchyoses. Von Willebrand disease is the most common hereditary coagulation abnormality. The 3 types can vary in severity.
Mechanism. Coagulopathies can be due to vessel wall disorders, platelet disorders, coagulationdisorders and fibrinolytic disorders. Von Willebrand disease arises from a deficiency of von Willebrand factor (vWF), a protein required for platelet adhesion.
Diagnosis. Positive family history and review of systems are helpful for screening. Initiallaboratory tests include CBC with platelet count, PT and PTT. The best screening test for Von Willebrand disease if a vWF antigen.
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Management. Consultation with hematology specialists is recommended in managing patientswith inherited coagulopathies.
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