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.)
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- 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