Pediatric emergency medicine trisk 1548 1548
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The American College of Obstetrics and Gynecology has recommended replacing
the phrase dysfunctional uterine bleeding (DUB) with the phrase abnormal
uterine bleeding (AUB) when describing an adolescent with prolonged vaginal
bleeding. Abnormal bleeding may be characterized as menorrhagia, defined as
bleeding that occurs at regular intervals but lasts more than 7 consecutive days or
in excess of 80 mL. Metrorrhagia is defined as bleeding that occurs at irregular
intervals. Menometrorrhagia denotes heavy and irregular bleeding.
Evaluation and Decision in the Nonpregnant Adolescent
A comprehensive history and physical examination, along with minimal ancillary
testing, usually points to an etiology to guide management (see Fig. 79.3 ). The
detailed history includes a review of the patient’s menstrual history including age
at menarche, usual cycle duration, a relative estimate of usual blood loss, and how
the current symptoms may differ from baseline. Heavy bleeding from the first
period may indicate an underlying bleeding disorder, most commonly von
Willebrand disease. Abdominal cramping may occur at the time of ovulation due
to progesterone secreted in the luteal phase. Prostaglandins released from the
endometrium at the time of menstruation may contribute to uterine cramping,
nausea, vomiting, or diarrhea, which are all common features of dysmenorrhea.
NSAIDs may alleviate the discomfort of dysmenorrhea by inhibiting
prostaglandin release. The presence of dysmenorrhea is not usually a feature of
anovulatory bleeding. Other pertinent historical details include the presence or
absence of trauma, fainting, dizziness, fever, easy bruising, and excessive
bleeding at other sites. Postural dizziness and other signs of anemia can be
elicited. Questions regarding sexual activity, the possibility of pregnancy, sexual
abuse, and/or sexually transmitted infection should be asked with the teen alone.
An opportunity for private conversation between a teen and her physician without
parent(s) is a routine and necessary part of the adolescent medical evaluation
regardless of chief complaint.
The physical examination helps the clinician determine the severity of blood
loss in order to narrow the differential diagnosis. The ED physician begins with
an assessment of vital signs and the patient’s hemodynamic status. Tachycardia,
hypotension, orthostatic changes, and/or signs of anemia may indicate more
significant blood loss. The mucous membranes, conjunctiva, and palms of the
hands/feet should be assessed for pallor. The skin should be examined for signs of
androgen excess such as acne, hirsutism, or acanthosis nigricans as well as
purpura or petechiae to suggest an underlying bleeding disorder. The thyroid
should be palpated for nodules or enlargement. Presence of a soft systolic flow
murmur may be noted during the cardiac examination in the setting of anemia.
