Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis
- Nirupama K De Silva, MD
Nirupama K De Silva, MD
- Clinical Associate Professor
- University of Oklahoma-Tulsa
- Section Editors
- Amy B Middleman, MD, MPH, MS Ed
Amy B Middleman, MD, MPH, MS Ed
- Section Editor — Adolescent Medicine
- Professor of Pediatrics, Chief of Adolescent Medicine
- University of Oklahoma Health Sciences Center
- Mitchell E Geffner, MD
Mitchell E Geffner, MD
- Section Editor — Pediatric Endocrinology
- Professor of Pediatrics
- Keck School of Medicine, University of Southern California
Abnormal uterine bleeding (AUB) refers to uterine bleeding that is excessive or occurs outside of normal cyclic menstruation .
The evaluation of common causes of AUB in adolescents will be discussed here. The management of AUB in adolescents and a more comprehensive discussion of the evaluation of AUB in older reproductive-age women are presented separately. (See "Abnormal uterine bleeding in adolescents: Management" and "Approach to abnormal uterine bleeding in nonpregnant reproductive-age women".)
NORMAL MENSTRUAL CYCLE IN ADOLESCENTS
The normal menstrual cycle results from a complex feedback system involving the hypothalamus, pituitary, ovary, and uterus (figure 1).
●Timing and flow – Although menstrual cycles vary considerably during the first five to seven years after menarche, the majority of cycles last 21 to 45 days with two to seven days of menstrual bleeding [2-6]. By the third postmenarchal year, 95 percent of cycles fall into this range (figure 2) . The average adult menstrual cycle lasts 28 days to 35 days with four to six days of menstrual bleeding. The median blood loss during each menstrual period is 30 mL; the upper limit of normal is 80 mL. (See "Physiology of the normal menstrual cycle".)
●Establishing ovulatory cycles – In the first postmenarchal year, approximately 50 percent of cycles are anovulatory. The duration of time that it takes to establish regular ovulatory cycles increases with increasing age at the time of menarche [8,9]. One-half of cycles are ovulatory by one year in girls with menarche at <12 years, by three years in girls with menarche between 12 and 13 years, and by 4.5 years in girls with menarche at ≥13 years . (See 'Anovulatory uterine bleeding' below.)
- APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecology and Obstetrics, 2006.
- World Health Organization multicenter study on menstrual and ovulatory patterns in adolescent girls. II. Longitudinal study of menstrual patterns in the early postmenarcheal period, duration of bleeding episodes and menstrual cycles. World Health Organization Task Force on Adolescent Reproductive Health. J Adolesc Health Care 1986; 7:236.
- Flug D, Largo RH, Prader A. Menstrual patterns in adolescent Swiss girls: a longitudinal study. Ann Hum Biol 1984; 11:495.
- Widholm O, Kantero RL. A statistical analysis of the menstrual patterns of 8,000 Finnish girls and their mothers. Acta Obstet Gynecol Scand Suppl 1971; 14:Suppl 14:1.
- Adams Hillard PJ. Menstruation in young girls: a clinical perspective. Obstet Gynecol 2002; 99:655.
- ACOG Committee Opinion No. 651: Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Obstet Gynecol 2015; 126:e143.
- Treloar AE, Boynton RE, Behn BG, Brown BW. Variation of the human menstrual cycle through reproductive life. Int J Fertil 1967; 12:77.
- Apter D, Vihko R. Early menarche, a risk factor for breast cancer, indicates early onset of ovulatory cycles. J Clin Endocrinol Metab 1983; 57:82.
- Vihko R, Apter D. Endocrine characteristics of adolescent menstrual cycles: impact of early menarche. J Steroid Biochem 1984; 20:231.
- Lavin C. Dysfunctional uterine bleeding in adolescents. Curr Opin Pediatr 1996; 8:328.
- Mitan LA, Slap GB. Adolescent menstrual disorders. Update. Med Clin North Am 2000; 84:851.
- Gray SH, Emans SJ. Abnormal vaginal bleeding in the adolescent. In: Emans, Laufer, Goldstein's Pediatric & Adolescent Gynecology, 6th ed, Emans SJ, Laufer MR (Eds), Lippincott Williams & Wilkins, Philadelphia 2012. p.159.
- Aksel S, Jones GS. Etiology and treatment of dysfunctional uterine bleeding. Obstet Gynecol 1974; 44:1.
- Bravender T, Emans SJ. Menstrual disorders. Dysfunctional uterine bleeding. Pediatr Clin North Am 1999; 46:545.
- Elford KJ, Spence JE. The forgotten female: Pediatric and adolescent gynecological concerns and their reproductive consequences. J Pediatr Adolesc Gynecol 2002; 15:65.
- Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3.
- American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol 2013; 121:891.
- Hartmann KE, Jerome RN, Lindegren ML, et al. Primary care management of Abnormal Uterine Bleeding. Comparative Effectiveness Review No. 96. Agency for Healthcare Research and Quality, Rockville, MD, 2013. www.ncbi.nlm.nih.gov/books/NBK132510 (Accessed on September 01, 2015).
- Lemarchand-Béraud T, Zufferey MM, Reymond M, Rey I. Maturation of the hypothalamo-pituitary-ovarian axis in adolescent girls. J Clin Endocrinol Metab 1982; 54:241.
- Rimsza ME. Dysfunctional uterine bleeding. Pediatr Rev 2002; 23:227.
- Hallberg L, Högdahl AM, Nilsson L, Rybo G. Menstrual blood loss--a population study. Variation at different ages and attempts to define normality. Acta Obstet Gynecol Scand 1966; 45:320.
- Fraser IS, McCarron G, Markham R. A preliminary study of factors influencing perception of menstrual blood loss volume. Am J Obstet Gynecol 1984; 149:788.
- Strickland JL, Wall JW. Abnormal uterine bleeding in adolescents. Obstet Gynecol Clin North Am 2003; 30:321.
- Janssen CA, Scholten PC, Heintz AP. A simple visual assessment technique to discriminate between menorrhagia and normal menstrual blood loss. Obstet Gynecol 1995; 85:977.
- Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA 1993; 269:1823.
- Adams Hillard PJ, Deitch HR. Menstrual disorders in the college age female. Pediatr Clin North Am 2005; 52:179.
- Warner PE, Critchley HO, Lumsden MA, et al. Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. Am J Obstet Gynecol 2004; 190:1216.
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
- Gray SH. Menstrual disorders. Pediatr Rev 2013; 34:6.
- Kouides PA, Conard J, Peyvandi F, et al. Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding. Fertil Steril 2005; 84:1345.
- Jayasinghe Y, Moore P, Donath S, et al. Bleeding disorders in teenagers presenting with menorrhagia. Aust N Z J Obstet Gynaecol 2005; 45:439.
- Pinola P, Lashen H, Bloigu A, et al. Menstrual disorders in adolescence: a marker for hyperandrogenaemia and increased metabolic risks in later life? Finnish general population-based birth cohort study. Hum Reprod 2012; 27:3279.
- Minjarez DA. Abnormal bleeding in adolescents. Semin Reprod Med 2003; 21:363.
- Fraser IS, Critchley HO, Munro MG, et al. A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding. Fertil Steril 2007; 87:466.
- Fraser IS, Critchley HO, Munro MG, Broder M. Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding? Hum Reprod 2007; 22:635.
- Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Semin Reprod Med 2011; 29:383.
- Claessens EA, Cowell CA. Acute adolescent menorrhagia. Am J Obstet Gynecol 1981; 139:277.
- Bevan JA, Maloney KW, Hillery CA, et al. Bleeding disorders: A common cause of menorrhagia in adolescents. J Pediatr 2001; 138:856.
- Smith YR, Quint EH, Hertzberg RB. Menorrhagia in adolescents requiring hospitalization. J Pediatr Adolesc Gynecol 1998; 11:13.
- Kanbur NO, Derman O, Kutluk T, Gürgey A. Coagulation disorders as the cause of menorrhagia in adolescents. Int J Adolesc Med Health 2004; 16:183.
- Oral E, Cağdaş A, Gezer A, et al. Hematological abnormalities in adolescent menorrhagia. Arch Gynecol Obstet 2002; 266:72.
- Díaz R, Dietrich JE, Mahoney D Jr, et al. Hemostatic abnormalities in young females with heavy menstrual bleeding. J Pediatr Adolesc Gynecol 2014; 27:324.
- Falcone T, Desjardins C, Bourque J, et al. Dysfunctional uterine bleeding in adolescents. J Reprod Med 1994; 39:761.
- Shankar M, Lee CA, Sabin CA, et al. von Willebrand disease in women with menorrhagia: a systematic review. BJOG 2004; 111:734.
- Demers C, Derzko C, David M, et al. Gynaecological and obstetric management of women with inherited bleeding disorders. Int J Gynaecol Obstet 2006; 95:75.
- Mannucci PM. Treatment of von Willebrand's Disease. N Engl J Med 2004; 351:683.
- Sokkary NA, Venkateswaran L, Dietrich JE, Teruya J. Platelet function disorders and menorrhagia in adolescents: a review of laboratory diagnosis. J Pediatr Adolesc Gynecol 2012; 25:233.
- Committee on Adolescent Health Care, Committee on Gynecologic Practice. Committee Opinion No.580: von Willebrand disease in women. Obstet Gynecol 2013; 122:1368.
- Toth M, Patton DL, Esquenazi B, et al. Association between Chlamydia trachomatis and abnormal uterine bleeding. Am J Reprod Immunol 2007; 57:361.
- NORMAL MENSTRUAL CYCLE IN ADOLESCENTS
- CAUSES OF VAGINAL BLEEDING IN ADOLESCENTS
- INITIAL EVALUATION
- Physical examination
- Pelvic ultrasonography
- Laboratory evaluation
- APPROACH TO DIAGNOSIS
- Irregular bleeding
- - Anovulatory uterine bleeding
- - Polycystic ovary syndrome
- - Other causes
- Excessive menstrual bleeding
- - Bleeding disorders
- - Other causes
- Intermenstrual bleeding
- - Hormonal contraception and IUDs
- - Infection
- - Other causes
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS