One of the most common problems reported by adolescents is irregular, profuse menstruation. Rarely, a teenager with her first period might even show a decrease of 10 to 20 percentage points in her hematocrit. More often, a teenager has irregular menses after menarche. Another teen may have had several years of regular cycles but begins to have periods every 2 weeks or prolonged bleeding for 14 to 20 days after 2 to 3 months of amenorrhea. A young adolescent is prone to anovulatory periods with incomplete shedding of a proliferative endometrium; the older adolescent may develop anovulatory cycles with stress or illness. A study of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) patterns in perimenarchal girls with anovulatory bleeding suggests the prevalence of a maturation defect (1). The higher-than-normal levels of FSH in relation to LH may result in rapid follicular maturation, increased synthesis of estrogen, and absence of the midcycle surge of LH. Anovulatory vaginal bleeding, has often been called dysfunctional uterine bleeding (DUB) in the past, but the terms used more commonly now are “abnormal uterine bleeding” (AUB) or “heavy menstrual bleeding” (HMB). Although the etiology may appear to be simply a defect in positive feedback and the lack of establishment of ovulatory cycles, many adolescents in fact are anovulatory during the perimenarchal period and yet do not have abnormal bleeding patterns. The pathophysiology of AUB is not well understood. These adolescents appear to have delayed maturation of normal negative feedback cyclicity; rising levels of estrogen do not cause a fall in FSH and subsequent suppression of estrogen secretion, and thus the endometrium becomes excessively thickened. In contrast, normal adolescents have an intact negative feedback mechanism that allows for orderly growth of the endometrium and withdrawal flow before the endometrium is excessively thickened. In addition, the occasional ovulatory cycle stabilizes endometrial growth and allows more complete shedding. Adolescents with conditions that cause sustained anovulation may also be likely to present with AUB; such problems include eating disorders, weight changes, athletic competition, chronic illnesses, stress, drug abuse, endocrine disorders, and, most importantly, polycystic ovary syndrome (PCOS) (see Chapter 11). In deciding whether the pattern of the adolescent is normal or abnormal, the clinician needs to be cognizant of normal variations. The adult menstrual cycle is 21 to 35 days, and an adult tends to have the same interval on a month-to-month basis (2). Although adolescents have a slightly wider range of normal cycles of 21 to 45 days even in the first year, a given adolescent has more variability within this range than does the adult woman. A normal duration of flow is 3 to 7 days; a flow of 8 or more days is considered excessive. Normal blood loss is 30 to 40 mL per menstrual period, which usually translates into 10 to 15 soaked tampons or pads per cycle. Soaking through a pad or tampon within 1 hour, soaking through bedclothes, and clots >1 cm are suggestive of HMB. However, self-reported estimation of blood loss by adolescents (and adult women) may be inaccurate, unless the flow is very scant (3). Scales such as pictorial blood assessment charts have not been validated for use with adolescents (although helpful in adults), and even counting the number of tampons or pads changed in a day cannot always give the clinician an assessment of the likelihood of bleeding significant enough to result in anemia or low iron levels (4,5,6,7). Thus, the hematocrit/hemoglobin should be measured in the girl who reports possible abnormal bleeding to determine the extent of blood loss. Menorrhagia has classically been defined as >80 mL blood loss per menstrual cycle (8,9). Objective measurement of menstrual blood loss volume is impractical in the clinic setting and may not even be predictive of iron status, so the patient’s perception of heavy flow is important to elicit in the history, but laboratory studies must also be obtained (6). Although there are additional terms used to describe menstrual bleeding, an actual description of cyclicity and amount of bleeding is most helpful. The terms include: metrorrhagia, bleeding at irregular, frequent intervals; menometrorrhagia, prolonged bleeding occurring at irregular intervals; polymenorrhea, bleeding occurring at regular intervals of <21 days. Abnormal uterine bleeding in adolescents most frequently results from excessive, prolonged, unpatterned bleeding from the endometrium unrelated to structural or systemic disease, and thus other diagnoses must be excluded. In adults, 90% of cases of AUB are associated with anovulatory cycles, and 10% have a dysfunctional corpus luteum or atrophic endometrium. Whether or not the menstrual cycles appear to be clinically abnormal, it is vital to consider the patient’s subjective experience of her periods in the initial assessment. Menstrual irregularity and perceived heaviness of bleeding significantly impact teens’ quality of life and may result in school absence and lack of participation in social activities and sports (8,9,10,11). The patient’s preferences should shape the treatment plan, and the ultimate goal of the treatment plan should be to improve quality of life.

The list of diagnoses to be considered in approaching the problem of abnormal vaginal bleeding in the adolescent is long and necessitates the careful consideration and examination of each patient. The differential diagnosis is shown in Table 10-1. Importantly, disorders of pregnancy and the possibility of pelvic infection must be appraised early in the evaluation. Ectopic pregnancy should be a consideration, especially in the adolescent with a previous history of pelvic inflammatory disease (PID) or sexually transmitted infections (see Chapter 18). Adolescents with PID and endometritis caused by Neisseria gonorrhoeae or Chlamydia trachomatis frequently present with heavy or irregular bleeding. The possibility of these infections (especially C. trachomatis) needs to be considered in the adolescent taking oral contraceptives who develops new intermenstrual bleeding. Clinicians should have a low threshold for testing for these conditions in all patients with unexplained bleeding, regardless of reported sexual history.

Patients with bleeding disorders often have other signs of bleeding, such as petechiae, ecchymoses, or epistaxis; however, the teenager with von Willebrand disease may not have a prior
history of injuries or surgical procedures and thus may be diagnosed only because of profuse menstruation starting with her menarche (8,9,12). Acquired von Willebrand disease can occur in girls with systemic lupus erythematosus with the production of anti–von Willebrand factor antibody. Likewise, the teenager with chronic thrombocytopenic purpura, or the cardiac patient on warfarin, may have heavy menstrual bleeding. Patients with significant liver disease or those who have undergone liver transplantation may have coagulopathies.

Irregular, heavy menstruation may accompany endocrine disorders that are also associated with secondary amenorrhea and anovulation. Adrenal problems such as late-onset 21-hydroxylase deficiency, Cushing syndrome, and Addison disease can cause anovulation; Addison disease may be associated with primary ovarian insufficiency (POI) (see Chapter 9). Patients with hyperprolactinemia usually have amenorrhea but may have irregular bleeding from anovulation or a shortened luteal phase. Adolescents with hypothyroidism and hyperthyroidism may have amenorrhea but may also present with significant vaginal bleeding or irregular frequent menses. Similarly, patients with ovarian insufficiency from Turner syndrome, chemotherapy, or radiation therapy may have irregular bleeding before the onset of amenorrhea. The anovulation of PCOS is present early in adolescence; 20% to 30% of patients with PCOS experience AUB. This diagnosis needs to be considered in adolescents with persistent AUB and those who initially have evidence of androgen excess (hirsutism, acne) or acanthosis nigricans, because these girls are at increased risk of endometrial hyperplasia and the early development of endometrial carcinoma (rarely in the teenage years). Thus, long-term therapy with progestins, oral contraceptives, or other combined hormonal preparations needs to be prescribed in these girls.

Uterine structural abnormalities manifested by irregular bleeding are extremely rare in adolescents but can include submucous myomas, polyps, adenomyomas, and congenital anomalies. Irregular bleeding is not unusual in adolescents utilizing an intrauterine device (IUD) (see Chapter 24). Breakthrough or intermenstrual bleeding from hormonal methods (oral contraceptives, patches, rings, and injectables) is common, and patients using progestin-only methods frequently have irregular cycles. Congenital anomalies are sometimes detected by the presence of regular, red menstrual bleeding followed by brown or prune-colored spotting intermenstrually; the bloody fluid may have a foul odor if infected. The normal uterus empties in a cyclic pattern, and the obstructed uterus or vagina may empty through a fistula slowly over a longer period of time (see Chapter 12). The possibility of breakthrough bleeding in the adolescent taking hormonal contraceptives needs to be kept in mind, since the adolescent may have obtained the method confidentially from a clinic and yet be brought to another clinician by her mother for irregular menses. Unless the girl is seen alone and asked specifically about the use of hormonal methods, the diagnosis may not become apparent. An occasional patient may have slight vaginal bleeding for 1 or 2 days at midcycle because of a fall in estrogen levels at ovulation; we have seen this particularly in athletes who do significant running at midcycle. The bleeding may be more apparent to the adolescent who is exercising vigorously that day because of more rapid emptying of the menstrual blood from the vagina. A carefully kept menstrual calendar helps make the diagnosis.

Carcinomas or sarcomas of the vagina or uterus are rare among teenagers. Cervical problems may also cause bleeding, especially with trauma or postcoitally. Sexually transmitted infections such as those caused by Trichomonas and C. trachomatis can be associated with bleeding from a friable cervix. Young women with cystic fibrosis often have a large cervical ectropion with chronic inflammation; the cervix may bleed easily with coitus or when a speculum is inserted. Hemangiomas or other vascular anomalies rarely occur in the vagina or on the cervix, but cause bleeding especially with trauma or coitus. Cervical cancer is extraordinarily rare in adolescence. Endometriosis has been associated with irregular menses from anovulation and also with brown spotting in the premenstrual phase of the cycle (see Chapter 13). Ovarian abnormalities, including hormonally active tumors and cysts, may cause hypermenorrhea (see Chapter 21).

Systemic diseases (see Chapter 27) may interfere with normal cyclicity because of an impact on ovulation, an interference with normal coagulation, or a local endometrial infection such as tuberculosis (a common cause of bleeding in third-world countries but exceedingly rare in the United States). Patients undergoing renal dialysis frequently have either amenorrhea or excessive menstrual flow; the menorrhagia may increase
the transfusion requirement of the patient and thus frequently requires ongoing management with progestins, combined hormonal methods, or gonadotropin-releasing hormone (GnRH) agonists.

Trauma may occur because of acute falls, waterskiing injuries, foreign objects introduced for masturbation, or sexual assault (see Chapter 30). The most common foreign body is a retained tampon, sometimes left in the vagina for weeks to months. The young adolescent may have tried to use a tampon and not realized the need for removal, or she may have put two tampons in the vagina and forgotten to remove one. The bleeding from a retained tampon is usually accompanied by a foul-smelling discharge.

Medications such as anticoagulants and platelet inhibitors can be associated with excessive bleeding. Adolescent athletes taking anabolic steroids may develop masculinization and anovulatory cycles, with irregular bleeding or amenorrhea. Antipsychotic medications such as risperidone and anticonvulsants such as valproate (associated with PCOS) can also cause irregular menses.

Categorizing bleeding as cyclic or acyclic may help the clinician focus on the appropriate diagnosis. Adolescents with normal cyclic intervals but very heavy bleeding at the time of each cycle are usually normal but may have a bleeding disorder or a uterine problem (submucous myoma or IUD use). In adults with heavy cyclic bleeding (>80 mL/cycle), the plasma concentrations of LH, FSH, and estradiol and the salivary levels of progesterone are not different from those in women with normal blood loss (13).

An adolescent with normal cycles but superimposed abnormal bleeding at any time throughout the cycle may have a foreign body within the vagina, infection (such as C. trachomatis or N. gonorrhoeae), uterine polyp, vaginal, cervical, or uterine malignancy, congenital malformation of the uterus with obstruction, cervical polyp or other abnormality, or endometriosis. Adolescents with no cyclicity apparent, or cycles of <21 days or >40 to 45 days, usually have anovulatory bleeding with lack of normal negative feedback. Disorders associated with anovulation include psychosocial problems, eating disorders, athletic competition, PCOS, primary ovarian insufficiency, ovarian tumors, and endocrinopathies such as hypothyroidism.

Several case series have evaluated adolescents requiring hospitalization for treatment of menorrhagia. The conclusions have varied among studies. In a study of 59 patients hospitalized from 1971 to 1980, Claessens and Cowell (14,15) reported a primary coagulation disorder in 20% of girls: one-fourth of those with hemoglobin <10 g/dL, one-third of those requiring transfusion, and one-half of those presenting at menarche. The diagnoses included idiopathic thrombocytopenia (ITP) (four), von Willebrand disease (three), Glanzmann disease (two), thalassemia major (one), and Fanconi syndrome (one); seven patients had other conditions, and 34% were treated with dilatation and curettage (D&C). A study published in 1994 by Falcone and colleagues (16) reported 61 patients hospitalized between 1981 and 1991. Only 3% had newly diagnosed coagulation disorders: ITP (one) and acute promyelocytic leukemia (one). However, 28% had past histories of significant medical problems, including leukemia, ITP, Glanzmann disease, hypothyroidism, mental retardation, and rheumatoid arthritis; 50% had a history of irregular menses (defined as <25 or >35 days apart). The mean hemoglobin was 8.9 g/dL, and 41% required blood transfusions. In contrast to the earlier series, 93% responded to medical management, and only 8% underwent D&C. They reported no difference in the response of patients treated with intravenous conjugated estrogens (Premarin) versus oral estrogen/progestin combinations in the initial hemoglobin, percentage of patients transfused, or days in the hospital (the patients were not randomized). In a study of 71 patients 10 to 19 years old seen for inpatient or outpatient evaluation of menorrhagia at a children’s hospital from 1990 to 1998, Bevan and colleagues reported that 9 (13%) had thrombocytopenia (5 ITP, 2 secondary to chemotherapy) and 8 had hereditary coagulation disorders (2 with von Willebrand disease) (17). One-half had hemoglobin <12 g/dL, and 7 girls in their series had hemoglobin <5.0 g/dL.

Two recent studies of adolescents presenting for outpatient care for menorrhagia suggest that the prevalence of underlying bleeding disorders in this population is high, although arguably these studies suffer from selection bias. In a 2007 study of 61 consecutive adolescents with heavy vaginal bleeding referred to a pediatric hematology clinic, 25 (41%) had a hematologic disorder, of whom 22 (36%) had von Willebrand disease (VWD), and 4 (7%) had platelet aggregation abnormalities (18). In a 2005 study of 25 young women 13 to 19 years old presenting to a gynecology clinic with a physician diagnosis of menorrhagia, 12 (48%) ultimately had a bleeding disorder such as a platelet aggregation deficit (11, or 44%), VWD (1, or 4%), and/or a coagulation factor deficiency (1, or 4%) (7). In our experience at Children’s Hospital Boston, most adolescents with severe menorrhagia respond well to oral medical therapy, and surgical intervention (D&C) is very rarely needed. Importantly, those with known coagulopathies and scheduled procedures such as bone marrow transplantation should be managed expectantly with a hematologist (see Chapter 27).