Pediatric emergency medicine trisk 1550 1550
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tampon use are typically inaccurate. Given the prevalence of sexually transmitted
infection in this age group, screening for Chlamydia trachomatis and N.
gonorrhoeae via nucleic acid amplification testing of the urine or vaginal swab is
recommended. Further evaluation for bleeding disorders and/or endocrine causes
is indicated based on clinical suspicion. Coagulation studies such as prothrombin
time (PT)/thromboplastin time (PTT), fibrinogen, von Willebrand assay (includes
von Willebrand factor antigen, ristocetin cofactor assay, and factor VIII), and
bleeding time may be helpful in patients with heavy cyclical bleeding from
menarche and those with more severe degree of anemia (hemoglobin less than 10
mg/dL). Von Willebrand studies, however, may be misleadingly normal during
acute bleeding or in the presence of estrogen. Endocrine studies may be
considered including TSH, prolactin, dehydroepiandrosterone sulfate (DHEAS),
testosterone profile, androstenedione, and 17-hydroxyprogesterone. Consultation
with adolescent, hematology, and endocrine specialists can be considered as
clinically indicated.
Causes of Uterine Bleeding in the Adolescent Patient
The differential diagnosis of abnormal genital bleeding is broad, and one must
consider all the diagnostic possibilities during the evaluation. For the vast
majority of adolescents evaluated in the ED for excessive bleeding, the most
common causes are anovulation, usually related to immaturity of the
hypothalamic–pituitary–gonadal axis or polycystic ovarian syndrome, and
sexually transmitted infection. It is crucial to evaluate for pregnancy-related
conditions early in all postpubertal girls with bleeding, even if sexual activity is
denied. Vaginal bleeding may be the result of accidental injury or trauma from
either a consensual or abusive relationship. A foreign body such as a retained
tampon or an intrauterine device may cause abnormal bleeding. Rare causes
include hematologic disorders, thyroid or adrenal disease, prolactinomas, or
another central nervous system neoplasm. Structural abnormalities of the
reproductive tract such as uterine fibroids or polyps are highly unusual causes in
the adolescent age group (see Table 79.2 ).
