Chapter 28 Vaginal Bleeding/Discharge
3 List the causes of abnormal vaginal bleeding in the adolescent female
Although anovulation is the most common cause of dysfunctional vaginal bleeding in the adolescent, it remains a diagnosis of exclusion. The diseases listed in Table 28-1 must be considered when excessive vaginal bleeding is present.
Life-threatening: Ectopic pregnancy, vaginal/cervical laceration | ||
Common: Anovulation, sexually transmitted infections, pregnancy/complications of pregnancy, hormonal contraception | ||
Complete Differential Diagnosis by Category | ||
Pregnancy-related | Systemic Disease | Genital Tract |
Pregnancy | Coagulation abnormalities | Sexually transmitted diseases |
Ectopic pregnancy | Von Willebrand’s disease | Trauma |
Threatened abortion | Idiopathic thrombocytopenic purpura | Tumor |
Spontaneous abortion | Renal failure | Foreign body |
Hydatidiform mole | Liver failure | Malignancy |
Endocrine | Systemic lupus erythematosus | Endometriosis |
Anovulation | Malignancies | Myoma, polyp |
Polycystic ovary syndrome | Drugs | |
Hypothyroidism/hyperthyroidism | Hormonal contraceptives | |
Cushing’s disease | Anticonvulsants | |
Addison’s disease | Anticoagulants | |
Premature ovarian failure | Chemotherapeutic agents | |
Ovarian tumor |
5 What are the recommended therapies for dysfunctional uterine bleeding?
A combination of estrogen and progesterone is needed in patients with active bleeding. Any pill combining 35 or 50 μg of ethinyl estradiol or mestranol and a progestin can be used. Progestin only may be used in patients who are not actively bleeding (Table 28-2).
Severity | Hemoglobin Level (g/dL) | Therapy |
---|---|---|
Mild | >12 | Menstrual calendar Iron therapy Follow-up 3–6 months |
Moderate | 10–12, not bleeding | Low-dose OCP or progestin only Iron therapy Follow-up 3–6 months |
<10, not bleeding | Low-dose OCP or progestin only Iron therapy Follow-up 3–6 months |
|
<10, bleeding | High-dose OCP 1 pill four times daily for 4 days 1 pill three times daily for 3 days 1 pill twice daily for 2 weeks |
|
Severe | <7, hemodynamic symptoms | IV conjugated estrogen and/or high-dose OCP Iron therapy Follow-up 3–6 months |
OCP = oral contraceptive pill (combination of estrogen, progesterone, and suggested minimum of 30 μg ethinyl estradiol). Antiemetics are usually needed when higher dose of estrogen is given.
Slap BG: Menstrual disorders in adolescence. Best Prac Res Clin Obstet Gynaecol 17:75–92, 2003.
8 How common is dysmenorrhea?
Banikarim C, Middleman AB: Primary dysmenorrhea in adolescents. UpToDate, version 13.3, 2005. www.utdol.com.
9 What is the treatment for primary dysmenorrhea?
Banikarim C, Middleman AB: Primary dysmenorrhea in adolescents. UpToDate, version 13.3, 2005. Available at www.utdol.com.
10 What are the causes of secondary dysmenorrhea?
Other Gynecologic Disorders | Nongynecologic Disorders |
---|---|
Endometriosis | Inflammatory bowel disease |
Pelvic inflammatory disease | Irritable bowel syndrome |
Pelvic adhesions | Ureteropelvic junction obstruction |
Ovarian cysts, mass | Renal stone |
Polyps, fibroids | Cystitis |