Clinical Protocols in Pediatric and Adolescent Gynecology

S. Paige Hertweck, Maggie L. Dwiggins, S. Paige Hertweck, Maggie L. Dwiggins

• Publisher: CRC Press
• Year: 2022
• eBook ISBN: 9781000550863
• Edition: 2
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Published in association with NASPAG, this updated second edition gives quick access to the essential information. The authors combine their clinical experience with a complete review of the literature, placing it in an easy to consult format with photographs, figures, and algorithms.

1Abnormal Uterine Bleeding (AUB)

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S. Paige Hertweck and Maggie L. Dwiggins

DOI: 10.1201/9781003039235-1

Key Points

• In the adolescent, abnormal uterine bleeding (AUB) is usually due to anovulatory cycles (nonstructural etiologies)
• Important to consider the possibility of pregnancy, sexual trauma, and infection regardless of the sexual history that the patient provides
• Must rule out pelvic inflammatory disease and ectopic pregnancy before considering the PALM-COEIN differential (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified)

Normal Menstrual Cycles in Adolescent Girls

• Normal menarche: Age 12–13
• Normal cycle interval/length:21–45 days
• Normal flow length:2–7 days
• Normal menstrual product use:3–6 pads/tampons per day

Differential Diagnosis

• PALM-COEIN (structural-nonstructural)
• PALM (rare in adolescents only 1.3% of population have these)
  • Polyps
  • Adenomyosis
  • Leiomyomas
  • Malignancies
    • Rhabdomyosarcoma, hormonally active tumors (i.e. granulosa cell tumor of ovary)
• COEIN (more prevalent in adolescents)
  • Coagulopathies
    • 20% of adolescents with heavy bleeding have underlying bleeding disorder
    • Von Willebrand disease is most common of bleeding disorders
    • Platelet aggregation disorder
  • Ovulatory disorder
    • Anovulation due to
      • Immature hypothalamic-pituitary-ovarian axis (present in 95% of adolescents)
      • Polycystic ovarian syndrome (PCOS)
      • Hypothalamic issue (i.e. stress, chronic medical illness, eating disorder)
  • Endometrial disorders
  • Iatrogenic
    • Includes medications such as anticoagulants, hormonal medications like oral contraceptives, or medications that interfere with ovulation like antipsychotics
  • Not yet classified

Diagnosis

History

• Menstrual history
  • Date/age of menarche
  • Frequency of menstrual cycles
  • Date/length of most recent menses
  • Number of pads/tampons per day used
• Evaluate for coagulation defects (If “Yes” to several of the below)
  • Menses longer than 7 days
  • Changing pad or tampon every 1–2 hours
  • Passing blood clots larger than a quarter size
  • History of soiling clothes due to heavy menstrual bleeding
  • History of anemia
  • History of epistaxis, gingival bleeding
  • History of bleeding after hemostatic challenge (i.e. tooth extraction, surgery)
  • Family history of bleeding disorders
  • Family history of need for blood transfusion
• Medications
  • Hormonal contraceptive use
  • Antipsychotic medications
  • Anti-epileptic medications
• Confidential sexual history
  • Chlamydia can cause AUB
• Related health changes that may affect ovulation
  • Weight change
  • Nutrition history
  • Exercise history
  • Weight concerns
  • Chronic medical problems

Physical Examination

• Vital signs
  • Pulse, blood pressure check (signs of anemia, orthostatic)
  • Height, weight, body mass index (extremes of weight associated with anovulation)
• General
  • Look for signs of androgen excess (acne, hirsutism, acanthosis nigricans)
• Thyroid
  • Palpate for enlargement
• Breast exam
  • Assess sexual maturity rating
• Abdomen
  • Assess for tenderness or mass
• Pelvic exam (consider use of thinnest bladed speculum)
  • Assess for anatomic/traumatic cause of bleeding
    • Rule out vaginal foreign body
    • Rule out reproductive tract laceration
  • Assess cervix
    • Rule out inflammation, lesion
    • Test for gonorrhea, chlamydia
  • Assess uterine/adnexal size
    • Rule out pregnancy, ovarian mass
  • Pelvic ultrasound
    • If unsure of adequacy of pelvic exam
    • Or
    • Concern of adnexal mass on exam
    • Or
    • If bleeding persistent despite medical management (rule out ...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Contents
• Preface
• Contributors
• 1. Abnormal Uterine Bleeding (AUB)
• 2. Adolescent Pregnancy
• 3. Ambiguous Genitalia and Differences of Sexual Development (DSD)
• 4. Amenorrhea
• 5. Androgen Insensitivity Syndrome (AIS)
• 6. Anesthetics in Pediatric Adolescent Populations: EMLA®
• 7. Anorectal Malformations (ARM)
• 8. Bartholin's Abscess
• 9. Breast Disorders
• 10. Cervical Mass
• 11. Condyloma Acuminatum and Human Papillomavirus (HPV)
• 12. Contraception
• 13. Depression
• 14. Dysmenorrhea
• 15. Eating Disorders (EDs)
• 16. Endometriosis
• 17. Female Genital Mutilation (FGM)
• 18. Fertility Preservation
• 19. Genital Trauma
• 20. Gynecologic Examination
• 21. High-Risk Behaviors (HRB): How to Assess for and Help Patients Become Resilient and Not Engage in HRB
• 22. Hirsutism
• 23. Human Immunodeficiency Virus (HIV): Prevention and Management in Adolescents and Young Adults
• 24. Hymenal Anatomy (Normal and Abnormal)
• 25. Labial Disorders
• 26. Menstrual Suppression in Special Populations
• 27. Menstruation
• 28. Molluscum Contagiosum
• 29. Obesity
• 30. Oncology Care and Gynecologic Concerns
• 31. Operative Care
• 32. Operative Care: Enhanced Recovery after Surgery (ERAS)
• 33. Osteoporosis
• 34. Ovarian Cysts
• 35. Ovarian Masses
• 36. Ovarian/Adnexal Torsion
• 37. Pelvic Inflammatory Disease (PID)
• 38. Pelvic Pain
• 39. Polycystic Ovary Syndrome (PCOS)
• 40. Premature/Primary Ovarian Insufficiency (POI)
• 41. Premenstrual Dysphoric Disorder (PMDD)
• 42. Premenstrual Syndrome (PMS)
• 43. Prolactin Disorders
• 44. Puberty
• 45. Radiologic Imaging for Gynecologic Conditions
• 46. Sexual Abuse, Sex Trafficking, and Rape
• 47. Sexual Activity
• 48. Sexually Transmitted Infections (STIs)
• 49. Substance Abuse
• 50. Toxic Shock Syndrome (TSS)
• 51. Transgender and Gender Diverse Care
• 52. Tubal Mass
• 53. Turner Syndrome (TS)
• 54. Urinary Tract Infection (UTI)
• 55. Uterine Anomalies and Masses
• 56. Uterovaginal/Müllerian Agenesis (Mayer-Rokitansky-Küster-Hauser Syndrome)
• 57. Vaginal Bleeding in the Prepubertal Patient
• 58. Vaginal Tract Anomalies
• 59. Vulvar Disorders: Atopic Dermatitis, Burns, Crohn's Disease (Vulvar Manifestations), Hidradenitis Suppurativa, Lichen Sclerosus, Nevi of Vulva, Psoriasis, Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN), Ulcers of the Vulva, and Vascular Anomalies of the Vulva
• 60. Vulvovaginitis
• Index