Vaginal Bleeding/Discharge

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Chapter 28 Vaginal Bleeding/Discharge

1 What is the average age at menarche? Describe the normal menstrual cycle

The average age at menarche is 12.7 years, with a normal range of 11–14 years. Typically, it occurs approximately 2 years after thelarche and 1 year after peak height velocity.

One menstrual cycle is the time between the onset of one menses to the onset of another. Normal cycle length varies (21–45 days in teens), lasts from 2–8 days, and results in an average blood loss of 30–40 mL. Clinically, the menstrual cycle is usually defined by the ovarian cycle, which includes the follicular, ovulatory, and luteal phases.

During the follicular phase (7–22 days), low levels of estradiol and progesterone result in elevated gonadotropin-releasing hormone levels and, thus, rises in both follicle-stimulating hormone (FSH) and luteinizing hormone (LH). FSH stimulates the maturation of one follicle, while LH stimulates the theca cells to produce androgens, which are converted to estrogens that stimulate proliferation of the endothelium. As estradiol levels rise, FSH levels begin to fall. During the ovulatory phase, a preovulatory estradiol surge causes an LH surge, resulting in release of the ovum. During the luteal phase, the corpus luteum produces large amounts of progesterone and estrogen, resulting in development of the secretory endometrium. If fertilization does not occur, involution of the corpus luteum occurs, and there is loss of estrogen and progesterone. Sloughing of the endometrium follows, and increased levels of FSH lead to a new cycle.

Adams Hillard PJ, Dietch HR: Menstrual disorders in the college age female. Pediatr Clin North Am 52:179–198, 2005.

Gordon CM, Neinstein LS: Normal menstrual physiology. In Neinstein LS (ed). Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, 2002, pp 947–952.

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.

Table 28-1 Causes of Abnormal Bleeding in the Adolescent Female

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?

Patients with DUB present with a wide spectrum of severity of illness. Therapy is aimed at stopping the bleeding by converting the endometrium to the secretory state so that sloughing can occur under controlled conditions, correcting the anemia, restoring normal cyclic bleeding, and preventing recurrence and long-term sequelae of anovulation.

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).

Table 28-2 Therapies for Dysfunctional Uterine Bleeding

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.

In patients with severe bleeding, attention to the ABCs is necessary with IV access and fluid/blood resuscitation. All patients with active bleeding, low hemoglobin, and change in vital signs require admission for treatment. Evaluation should include coagulation studies. Bleeding usually stops after 24 hours of treatment. Combination pills with a higher dose of estrogen (50 μg of ethinyl estradiol) are the first-line therapy. IV estrogen is reserved for use in unstable patients; pulmonary embolism is associated with this therapy. In patients for whom estrogen is contraindicated, progesterone regimens can be tried. If this fails, other therapies include aminocaproic acid, desmopressin, or surgical curettage.

Mitan LA, Slap GB: Dysfunctional uterine bleeding. In Neinstein LS (ed). Adolescent Health Care: A Practical Guide, 4th ed. Baltimore, Williams & Wilkins, 2002, pp 966–972.

Slap BG: Menstrual disorders in adolescence. Best Prac Res Clin Obstet Gynaecol 17:75–92, 2003.

Strickland JL, Wall JW: Abnormal uterine bleeding in adolescents. Obstet Gynecol Clin North Am 30:321–335, 2003.

10 What are the causes of secondary dysmenorrhea?

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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