Dysfunctional Uterine Bleeding in Pediatrics Clinical Presentation
- Author: Germaine L Defendi, MD, MS, FAAP; Chief Editor: Andrea L Zuckerman, MD more...
Patients with dysfunctional uterine bleeding (DUB) present with unexpected and often heavy vaginal bleeding. Irregular menstrual periods are common during the first few years after menarche. Because DUB is largely a diagnosis of exclusion, exploring the more common and serious conditions on the Differential diagnosis list is prudent.
Bleeding associated with complications of pregnancy
Consider any woman of reproductive age pregnant until proven otherwise (with a negative pregnancy test result). Frequently, adolescents do not report sexual behavior, and it is wise to assume that the history may be less than accurate. Nevertheless, ask the patient about risk factors for pregnancy and about symptoms of pregnancy, including the following:
Symptoms of breast tenderness, nausea, urinary frequency, and fatigue
Vaginal bleeding associated with severe pain or cramping
Vaginal bleeding associated with the passage of tissue
Depending on the population studied, adolescents with acute menorrhagia could have a 20-30% incidence of a coagulation disorder; von Willebrand disease (vWD), idiopathic thrombocytopenic purpura (ITP), and leukemia are the more common etiologies. Focus questioning on the following:
Family history of bleeding disorders (eg, female family members with recurrent, heavy prolonged periods or prolonged bleeding after childbirth)
Poor clotting response time as seen with excessive bleeding associated with minor injuries (eg, small cuts, dental procedures), phlebotomy, or their first menses
Frequent or prolonged nose bleeds
Easy bruising, purpura, or petechiae
Bleeding from anatomic cause
Anatomic causes of abnormal bleeding can occur anywhere along the female genital tract. Survey the entire organ system with a systematic series of questions, including the following:
Recent traumatic intercourse
History of sexually transmitted infections, abnormal discharge, or pelvic pain
Change in abdominal girth as concern for an intra-abdominal or pelvic mass
Medication-related dysfunctional uterine bleeding
Obtain a complete history of recent medication use. Specific medications to look for include hormonal contraceptive agents, anticoagulants, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs).
Polycystic ovarian syndrome
Polycystic ovarian syndrome (PCOS), an endocrine disorder of hyperandrogenism, is a common cause of anovulation and oligomenorrhea and should always be considered in the differential diagnosis. Some of the physical manifestations of this syndrome (usually due to elevated androgen levels) can be avoided if the diagnosis is made and treatment is begun at an early stage. Common symptoms of PCOS include the following:
Male-pattern hair growth and/or acne
Excessive body weight
Systemic disease states often cause abnormal bleeding through their impact on the hypothalamic-pituitary-ovarian (HPO) axis. Ask the patient about typical symptoms of endocrine disorders such as diabetes or thyroid disease (hypo- or hyperthyroidism). Additionally, ask questions aimed at discovering history suggestive of an eating disorder (eg, anorexia nervosa, bulimia) to help explain menstrual cycle irregularity or secondary amenorrhea.
As in the history, focus the physical examination on uncovering signs of the more common or serious items on the Differential diagnosis list.
General physical examination
Measure height and weight. Calculate body mass index (BMI) with age percentile. Inquire about pregnancy history and menstrual history. Include date of last menstrual period, characteristics of prior menses (if patient has had vaginal bleeding in the past), length of cycle, number of days of bleeding, number of pads changed per day, use of tampons, contraceptive method (if used), and age onset of menses in female family members. Also, pay special attention to the following physical signs:
Excessive weight gain or weight loss, addressing rapid fluctuations in weight without a clear reason
Physical signs of a bleeding dyscrasia (eg, petechiae or purpura, excessive gum bleeding after brushing teeth)
Physical signs of anemia (eg, pale conjunctiva, pale coloring to the skin and/or nail beds, tachycardia)
Signs of androgen excess (eg, acne and/or hirsutism, thinning hair, male-pattern baldness)
Tanner breast stage and presence or history of nipple discharge, such as galactorrhea (suggestive of hyperprolactinemia)
A palpable abdominal mass, liver enlargement, and/or splenic enlargement
Perform a pelvic examination with careful consideration of the patient's age, sexual history, and use of tampons. Make every effort to make this portion of the examination as comfortable and atraumatic as possible. Considerable psychological damage can result from an examination that is performed in a rushed and an insensitive manner.
If the practitioner is inexperienced in adolescent pelvic examinations, a review of the proper techniques is in order. If the patient is not sexually active, the bimanual examination may be more comfortable when performed using a single, well-lubricated finger in the rectum rather than in the vagina. Most significant pelvic pathology can be felt in this manner.
Salient aspects of the pelvic examination are the following:
Tanner stage (or sexual maturity rating [SMR]) noting distribution of pubic hair
Discharge and excoriations suggesting chronic vaginal candidiasis
Old or acute vulvar and vaginal lacerations and condition of hymnal ring
Retained foreign bodies (eg, toilet tissue, tampons, or tampon fragments); these occasionally cause a chronic blood-tinged vaginal discharge
Microscopic examination of the vaginal discharge, cervical cultures or amplified DNA probe on urine samples for Neisseria gonorrhoeae and Chlamydia trachomatis infection, and Papanicolaou test (Pap smear), if indicated by sexual history
Evidence of cervical lesions, cervical motion tenderness, or an open cervical os
Uterine size and any pelvic masses or tenderness
Anovulation can result from dysfunction in any path of the HPO axis. In the pediatric age group, the vast majority of cases can attributed to an immature axis with acyclic hormonal stimulation of the endometrium. Although anovulatory bleeding can occur in any female of reproductive age, the following patients may be at greater risk for DUB:
Adolescents during the first 3-5 years after menarche
Patients with eating disorders (eg, anorexia nervosa, bulimia)
Adolescents with a BMI higher than 30 (>95% for age/obese)
Adolescents under significant psychological stress
Athletes under significant exercise stress 
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