Dysfunctional Uterine Bleeding in Pediatrics Clinical Presentation

Patients present with unexpected and often heavy vaginal bleeding. Irregular menstrual periods are common during the first few years after menarche. Because dysfunctional uterine bleeding (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 assuming the history may be less than accurate is prudent. 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
• Bleeding associated with severe pain or cramping
• Bleeding associated with the passage of tissue

Coagulation defects

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
• Excessive bleeding associated with minor injuries (eg, small cuts, dental procedures), phlebotomy, or their first period
• Frequent or prolonged nose bleeds
• Easy bruising, purpura, or petechiae

Bleeding from an 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 intraabdominal or pelvic mass

Medication-related DUB

Obtain a complete history of recent medication use. Specific medications to look for include use of hormonal contraceptive methods, anticoagulants, aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs).

Polycystic ovarian syndrome (PCOS)

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 include the following:

• Irregular periods
• Male-pattern hair growth and/or acne
• Excessive body weight
• Infertility

Systemic disease

These disease states often cause abnormal bleeding through their impact on the HPO axis. Ask the patient about typical symptoms of endocrine disorders such as diabetes or thyroid disease (hypo- or hyperthyroidism). Additionally, questions aimed at discovering history suggestive of an eating disorder to help explain menstrual cycle dysfunction.

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

A complete examination is always important. Measure height and weight and calculate body mass index (BMI) with age percentile. Pay special attention to the following:

• Inadequate or excessive weight gain
• Physical signs of a bleeding dyscrasia (ie, petechiae or purpura)
• Physical signs of anemia (ie, pale conjunctiva, pale coloring to the skin and/or nail beds, tachycardia)
• Signs of androgen excess such as acne and/or hirsutism, male-pattern baldness
• Thyroid enlargement
• Tanner breast stage and evidence of nipple discharge such as galactorrhea (suggestive of hyperprolactinemia)
• A palpable abdominal mass, liver enlargement, and/or splenic enlargement

Pelvic examination

Perform 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 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.

• Tanner stage and 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), as 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 Chlamydiatrachomatis 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 compartment of the HPO axis. In the pediatric age group, the vast majority of cases can be attributed to an immature axis with acyclic hormonal stimulation of the endometrium. Although anovulatory bleeding can occur in any reproductive-aged female, 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)
• Morbidly obese women
• Adolescents under significant psychological stress
• Athletes under significant exercise stress^[8]