🩸 Chapter 22: Menstrual Problems and Vaginal Bleeding

Nelson's Pediatric Symptom-Based Diagnosis | Prepubertal Bleeding · Abnormal Uterine Bleeding (AUB) · HPO Axis · Coagulopathy · PALM-COEIN · Amenorrhea

🔍 Menstrual Problems & Vaginal Bleeding in Children/Adolescents

👶 Prepubertal Bleeding
Common causes: estrogen withdrawal (first days), foreign body (toilet paper, malodorous), vulvovaginitis (GAS, Shigella), urethral prolapse, lichen sclerosus, trauma (straddle injury), precocious puberty.
📊 Abnormal Uterine Bleeding (AUB)
PALM-COEIN classification. In adolescents: ovulatory dysfunction (HPO immaturity, PCOS), coagulopathy (von Willebrand, platelet disorders), pregnancy, STI, structural rare (polyps, fibroids).
🩸 Heavy Menstrual Bleeding
Menorrhagia: >80 mL blood loss, soaking >1 pad/hour, duration >7 days, anemia. Screen for bleeding disorders if heavy since menarche or family history.
⏰ Amenorrhea Workup
Primary: no menarche by age 15 (or by 13 if no secondary sex characteristics). Causes: Turner (45,X), Müllerian agenesis (MRKH), androgen insensitivity (46,XY), hypothalamic, outflow obstruction.
💊 Treatment of AUB
Hormonal: combined OCPs, progestins (norethindrone, medroxyprogesterone). Tranexamic acid. For acute severe bleeding: IV conjugated estrogens or high-dose OCPs.
🚩 Red Flags
Bleeding disorder (easy bruising, epistaxis). Pregnancy (ectopic risk). Pelvic inflammatory disease (fever, discharge, cervical motion tenderness). Malignancy (sarcoma botryoides).

💡 Key Takeaway: Most adolescent irregular bleeding is due to anovulation (HPO immaturity). However, always rule out pregnancy, STI, and coagulopathy. Prepubertal bleeding requires careful exam to exclude foreign body, trauma, or precocious puberty.

🩺 Clinical Approach to Vaginal Bleeding by Age

🔹 Step 1: Prepubertal (birth to 9 years)
• Neonatal (days 1-7): estrogen withdrawal → self-limited, no workup.
• Foreign body: malodorous, brown discharge → vaginoscopy for removal.
• Vulvovaginitis: group A strep, Shigella (bloody), poor hygiene, irritants.
• Urethral prolapse: "doughnut" red mass at meatus → topical estrogen.
• Trauma: straddle injury → exam under anesthesia if needed.
• Precocious puberty: breast development + bone age advance → GnRH testing.
🔹 Step 2: Adolescent - Assess bleeding pattern
• Cycle interval: normal 21-45 days (first few years up to 90 days).
• Duration: 3-7 days normal. Heavy bleeding: >7 days, changing pads <2 hours.
• Ask: easy bruising, epistaxis, family bleeding history → coagulopathy screen (PT/PTT, vWF panel).
• Always test for pregnancy (urine β-hCG).
• Assess for STI risk → NAAT for chlamydia/gonorrhea.
🔹 Step 3: Causes of abnormal uterine bleeding (PALM-COEIN)
• COEIN most common in adolescents: Coagulopathy, Ovulatory dysfunction (HPO immaturity, PCOS, thyroid), Endometrial, Iatrogenic (hormonal contraceptives), Not yet classified.
• PALM (structural) rare: Polyp, Adenomyosis, Leiomyoma, Malignancy.
• PCOS: hyperandrogenism (acne/hirsutism) + oligomenorrhea + polycystic ovaries.
🔹 Step 4: Amenorrhea evaluation
• Primary: no menarche by 15 (or 13 without breast development).
• Labs: β-hCG, TSH, prolactin, FSH, LH.
• Exam: breast development (estrogen effect), presence of vagina (MRKH), imperforate hymen.
• Elevated FSH → gonadal dysgenesis (Turner, XY gonadal dysgenesis).
• Normal FSH, low estradiol → hypothalamic amenorrhea (stress, athletes, eating disorder).
🔹 Step 5: Treatment of acute heavy bleeding
• Hemodynamically stable: high-dose OCPs (ethinyl estradiol 30-50mcg + progestin) or oral norethindrone 5-10mg BID-TID.
• Unstable: IV conjugated estrogens 25mg q4-6h + IV fluids, consider transfusion.
• Long-term: cyclic OCPs or progestin-only (IUD or oral). Tranexamic acid for bleeding disorders.