Abnormal (Dysfunctional) Uterine Bleeding in Pediatrics Clinical Presentation

Patients who have abnormal uterine bleeding (AUB; also referred to as 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 AUB is largely a diagnosis of exclusion, exploring the more common and serious possible alternatives (see Differential Diagnosis) is prudent.

Bleeding associated with complications of pregnancy

Any patient of reproductive age should be considered pregnant until proved otherwise (with a negative pregnancy test result). Frequently, adolescents do not report sexual behavior, and it is wise to assume that their histories may be less than accurate. The patient should be asked 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

Coagulation defects

In adolescents with acute menorrhagia, there is the potential risk of a coagulation disorder; von Willebrand disease (vWD), ^[19] idiopathic thrombocytopenic purpura (ITP), and leukemia are the more common etiologies. ^[20] The incidence of coagulopathy in this setting could be as high as 20-30%. Questioning should focus on the following:

• Family history of bleeding disorders - Information about female family members and their menstrual and childbirth history should be sought; concern arises with a history of recurrent, heavy prolonged periods or of prolonged bleeding after childbirth
• Poor clotting response time as seen with excessive bleeding associated with minor injuries (eg, small cuts, dental procedures), phlebotomy, or 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. Important questions to consider in quickly surveying this organ system include the following:

• Has there been recent traumatic intercourse?
• Is there a history of sexually transmitted infections, abnormal discharge, or pelvic pain?
• Has there been a change in abdominal girth that raises concerns about a possible intra-abdominal or pelvic mass?

Medication-related abnormal uterine bleeding

A complete history of recent medication use should be obtained. Specific medications to look for include the following:

• Hormonal contraceptive agents
• Anticoagulants
• Aspirin
• 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 of AUB. ^[21] Physical manifestations of this syndrome (usually due to elevated androgen levels) can be prevented if appropriate treatment is begun at an early stage. Symptoms of PCOS include the following:

• Irregular periods
• Male-pattern hair growth, acne, or both
• Excessive body weight
• Infertility

Systemic disease

Systemic disease states often cause abnormal bleeding through their impact on the hypothalamic-pituitary-ovarian (HPO) axis. The patient should be asked about typical symptoms of endocrine disorders, such as diabetes or thyroid disease (hypo- or hyperthyroidism). Additional questions should be aimed at investigating the possibility that an eating disorder (eg, anorexia nervosa or bulimia) may help explain menstrual cycle irregularity or secondary amenorrhea as being due to weight fluctuations or low body mass index (BMI).

The physical examination should focus on uncovering signs of the more common or serious diagnoses cited in the Differential Diagnosis list.

General physical examination

Initial steps should include the following:

• Measurement of height and weight
• Calculation of BMI with age percentile
• Inquiry into the patient's pregnancy history and menstrual history, including the date of the last menstrual period, the characteristics of prior menses (if the patient has had vaginal bleeding in the past), the length of the cycle, the number of days of bleeding, the number of sanitary pads changed per day, the use of tampons, the contraceptive method used (if any), and the age at menarche in female family members

In addition, special attention should be paid to the following clinical signs:

• Excessive weight gain or weight loss, addressing rapid fluctuations in weight without a clear etiology
• 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 or nail beds, tachycardia)
• Signs of androgen excess (eg, acne or hirsutism, thinning hair, male-pattern baldness)
• Thyroid enlargement (eg, concern for hypo- or hyperthyroidism)
• Tanner breast stage and presence or history of nipple discharge, such as galactorrhea (suggestive of hyperprolactinemia)
• A palpable abdominal mass, liver enlargement, or splenic enlargement

Pelvic examination

A pelvic examination should be performed, with careful consideration of the patient's age, sexual history, and use of tampons. Every effort should be made to ensure that this portion of the examination is as comfortable and atraumatic as possible. Considerable psychological harm can result from an examination that is performed in a rushed and an insensitive manner. The following considerations should be taken into account:

• The best setting for the pelvic examination is often in the office of the primary care clinician who has established rapport, trust, and a level of comfort with the patient
• Potential concerns of the patient are fear of discovering abnormalities, pain, embarrassment, and uneasiness with the examiner.
• A history of sexual abuse may affect the patient's comfort level
• Important aspects of preparing the patient include explaining the examination, instructing the patient to stop the examination if needed, explaining relaxation techniques, and asking the patient to empty her bladder prior to the examination
• Chaperones are recommended with the patient's permission, even if the clinician and the patient are of the same sex
• In regard to the speculum examination, the 7/8-in.-wide Pederson speculum is typically used in sexually active young women, and the 1/2-in.-wide Huffman speculum is used in virginal young women
• The bimanual examination (insertion of one or two fingers into the vagina with a water-based lubricant on the gloved hand) can assess cervical consistency and motion tenderness, uterus size and tenderness, and adnexal pain or masses ^[22]

Salient aspects of the pelvic examination are the following:

• Tanner stage (or sexual maturity rating [SMR]), with the distribution of pubic hair noted
• Discharge and excoriations suggesting chronic vaginal candidiasis
• Old or acute vulvar and vaginal lacerations and the condition of the hymenal 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 the sexual history
• Evidence of cervical lesions, cervical motion tenderness, or an open cervical os
• Uterine size and any pelvic masses or tenderness

The main complication of AUB is anemia. ^[23] For female adolescents, anemia is indicated when the hemoglobin level is lower than 12 g/dL (normal range, 12.1-15.1 g/dL). Acute blood loss can occasionally lead to a profound anemia. Blood product transfusion (with the attendant risks and complications) is occasionally required. Blood loss in the healthy female adolescent is rarely fatal. 

Chronic or recurrent AUB can cause in an iron-deficient state.