Heavy menstrual bleeding

There are a very specific set of labs that should be done for adolescents presenting with HMB since menarche: complete blood count, thyroid-stimulating hormone, INR, PT, PTT, and a Von Willebrand panel which includes Factor 8, Ristocetin cofactor activity, and Von Willebrand factor antigen. If blood products are necessary, it is imperative to draw these labs before transfusion is started. The American College of Obstetricians and Gynecologists (ACOG) supports testing adolescents with HMB since menarche for Von Willebrand disease. This is because of the prevalence as well as positive impact of early diagnosis.[18] HMB in adolescents can be due to bleedings disorders other than Von Willebrand disease such as platelet dysfunction and factor deficiencies. If there is a high index of suspicion referral to a hematologist should be made for additional testing.[14]

Vulvovaginitis

Prepubescent patients that present with nonspecific vulvovaginal symptoms and have an exam that is consistent with poor hygiene do not need any labs. Counseling on proper hygiene is usually sufficient.[5] If the symptoms are severe or persistent, it is useful to do a bacterial swab. There is limited data on how to best attain a sample in this population. A small saline moistened swab can be inserted directly into the vagina if the patient tolerates it. Alternatively, sterile water can be introduced via a feeding tube or small catheter, with valsalva the water will come out and the sample can be taken from there. The sample can be sent for culture, gram stain, or used to perform a wet mount. If abuse is suspected, N. gonorrhea and Chlamydia trachamotis must be considered. Cultures can be sent and the cervical probe for nucleic acid amplification tests can be used vaginally. In cases of suspected abuse a specialist in assault should be involved as there are often specific protocols for how cultures and tests need to be collected and performed. Pediatric patients may have vulvovaginal infections from a wider variety of organisms than adult patients; organisms such a Beta Streptococcus and Shigella are known pathogens for pediatric vulvovaginitis. It is frequently necessary to notify the laboratory that testing for respiratory and enteric pathogens is also required in addition to the usual vaginal pathogens.

Delayed puberty

Several laboratory tests may aid in the evaluation of delayed puberty. Some, all, or none of these may be necessary based on the history and physical exam findings. Labs that could provide additional information include a CBC, BUN, creatinine, glucose, electrolytes, and liver function tests. Labs more specifically related to delayed puberty are follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, prolactin, thyroid-stimulating hormone (TSH) and free T4. An x-ray of the hand and wrist for bone age can also provide very valuable information and often dictates the next step in the workup. If diagnosis is made a chromosome analysis and florescent in situ hybridization (FISH) for sex androgen determining region Y (SRY) should be performed, at which point a pediatric endocrinologist or gynecologist should be involved.

Since delayed puberty can be attributed to a variety of causes, imaging of the pelvis may be important to rule out any anatomic abnormalities of the vagina, cervix, or uterus. If these structures are intact, then uterine size and ovarian volume should be evaluated. These values provide information regarding whether or not these structures have undergone estrogen stimulation.

Precocious puberty

When precocious puberty is suspected, based on history and examination findings, the initial laboratory workup is similar to that listed earlier including FSH, LH, estradiol, TSH, and prolactin. Androgens (testosterone, androstenedione, DHEAS, and 17 OHP) should be measured if the patient has isosexual development.

If LH levels are markedly elevated at baseline, then GDPP can be diagnosed without additional testing. If not, a gonadotropin-releasing hormone (GnRH) stimulation test will clarify a diagnosis. When needed, a GnRH stimulation test can distinguish patients with GDPP, GIPP, and normal pubertal variants. Levels of LH are measured at baseline and then after GnRH administration.[19]

Based on the results of the stimulation test, additional laboratory or radiologic evaluation may be indicated. If a diagnosis of GDPP is made, imaging of the brain will be necessary to rule out a central nervous system (CNS) lesion. Serum testosterone and estradiol levels will be helpful to establish the degree of pubertal advancement and can also be followed if therapy is initiated.

Abdominal and pelvic ultrasound should be obtained to identify any ovarian mass and if there is evidence of post-pubertal uterine and ovarian development.[9] A radiographic bone age should be determined, as this will help to guide therapy.

Heavy menstrual bleeding

In the outpatient clinical setting there are multiple very effective options to control bleeding. Hormonal therapy has long been used and proven effective time and time again.[20] For the patient that is actively bleeding and has been bleeding excessively an oral contraceptive pill (OCP) taper is a good place to start. Most tapers are based on anecdotal experience or reports from experts. One commonly used taper is any 35 mcg combination OCP three times a day for a week, twice a day for a week, then one pill daily. The addition of an anti-emetic is often helpful if dosing more than one pill a day. Contraceptive rings and patches can be used with similar efficacy to oral pills for maintenance. For patients who have undesired side effects from combination contraception or a contraindication to estrogen, several progesterone only options exist. The most commonly used progesterone methods for adolescents with HMB are depo medroxyprogesterone acetate and levonorgestrel intrauterine devices. In patients with severe bleeding disorders, 104 mg of depo medroxyprogesterone acetate can be given subcutaneously to avoid risk of hematoma; side effects are similar to that of intramuscular administration.[21] The levonorgestrel intrauterine device has proven to be very effective in controlling HMB in the adolescents, particularly those that have failed other medical management.[22]

Antifibrinolytics have recently become more commonly used for patients with heavy bleeding. Aminocaproic acid and tranexamic acid are the two that are available in the United States, both in IV and PO form. They are typically taken multiple times a day for three to seven days during active bleeding. It can be used in conjunction with or independent of hormonal methods.[23]

Vulvovaginitis

The treatment for vulvovaginitis is entirely dependent on the etiology. Nonspecific vulvovaginitis can be addressed with hygiene counseling such as using scent free, dye free soaps and detergents, wearing white cotton underwear, voiding with legs wide open, and wiping from front to back. In the initial period sitz baths followed by a barrier cream or low dose steroid such as A+D ointment, or hydrocortisone ointment can be recommended to keep the area clean and dry. Hand washing and loose-fitting clothing should also be encouraged.[4, 6]

In the case of a positive culture, antibiotics should only be used if the cultured organism is not normal flora of the vagina. The most common pathogenic agents to cause vulvovaginitis are S. pyogenes, H. influenza, and E. vermicularis; these should be treated with PO penicillin, amoxicillin, and mebendazole, respectively.[4] Candida albicans and C. glabrata are also causative agents of infectious vulvovaginitis. The first-line treatment is a topical antifungal for C. albicans, whereas C. glabrata often necessitates a long course of 1% boric acid cream. Rarely, abnormal vulvar or vaginal discharge and itching can be due to condylomata acuminate or genital herpes. Genitals warts can be treated with either liquid nitrogen or carbon-dioxide laser therapy; however, if they are asymptomatic they can be followed up for 60 days as they may spontaneously resolve.[4] Genital herpes is treated with acyclovir or an equivalent. Although neither genital warts nor herpes is diagnostic of sexual abuse, possible abuse should certainly be investigated in a pediatric patient presenting with either finding.

Labial adhesions and lichen sclerosis are not infections, but the hypoestrogenic state of prepubescent females puts them at risk for both conditions. Labial adhesions may, however, increase the risk of vulvovaginal infections that may manifest as irritation, discharge, or itching. The first-line treatment for labial adhesions is estrogen cream, however recent studies have shown that betamethasone cream is equally effective.[24] The labial adhesions should not be separated forcefully in the office. Manual separation is required only if urinary outflow is disrupted and when rarely needed should be performed in a setting with anesthesia.

Lichen sclerosis often presents as itching in the vulvar area; the exam is usually consistent with hypopigmented vulvar skin and loss of architecture. This condition has been diagnosed in the prepubertal population more frequently than previously. Treatment is a topical high dose steroid such as clobetasol twice daily.[25]

Finally if trauma or foreign body is suspected as a cause of a vulvovaginal complaint, surgical intervention may be required. An exam under anesthesia with a vaginoscopy can be both diagnostic and therapeutic. If a foreign body is identified it can be removed and the vagina well cleaned. Vaginoscopy is performed in the operating room with use of a small diameter cystoscope. The pressure from the distending medium (usually sterile water) and clasping the labia together will allow the vaginal mucosa to distend for a survey of the cavity.[6]