14. Approach to abnormal bleeding in premenarchal girls

Question 1

What does vaginal bleeding in early childhood always indicate?

Answer 1

Vaginal bleeding in early childhood, regardless of its duration or quantity, always indicates pathology.

Question 2

What are the two potential origins of abnormal vaginal bleeding in premenarchal girls?

Answer 2

1. Local vulvar, vaginal, or cervical lesions.
2. Endometrial shedding as a manifestation of precocious puberty.

Question 3

How is precocious puberty defined?

Answer 3

Precocious puberty is defined as:

1. The appearance of secondary sexual characteristics before 8 years of age.
2. Onset of menarche before 9 years of age.

Question 4

What are the local causes of vaginal bleeding in premenarchal girls?

Answer 4

• Vulvovaginitis / infection (bacterial, parasite)
• Foreign body
• Trauma (including sexual abuse)
• Urethral prolapse
• Hymenal tags
• Vulval skin disorders (lichen sclerosis, warts, haemangioma)
• Sarcoma Botryoides
• Other rare malignancies of the genital tract

Question 5

What are the causes of endometrial shedding in premenarchal girls?

Answer 5

• Physiological (neonatal withdrawal bleeding due to the circulating oestrogen left over from the mother’s circulation)
• Premature menarche
• Exogenous oestrogens (pills, food)
• Endogenous oestrogen (functional cyst, an oestrogen-producing tumour)
• Precocious puberty (a) idiopathic (b) central nervous system lesion

Question 6

What is neonatal withdrawal bleeding, and why does it occur?

Answer 6

Neonatal withdrawal bleeding is physiological bleeding caused by circulating estrogen left over from the mother’s circulation.

Question 7

What are two types of causes of precocious puberty?

Answer 7

Idiopathic.

Due to a central nervous system lesion.

Question 8

What two main steps should be taken when managing a premenarchal girl presenting with vaginal bleeding?

Answer 8

1. A detailed history should be taken.
2. A careful inspection should be performed, including possible examination under anaesthesia to inspect the lower genital tract thoroughly.

Question 9

What aspects should be covered in the detailed history of a premenarchal girl with vaginal bleeding?

Answer 9

• Medical and surgical history, especially CNS problems
• Associated trauma (including sexual abuse)
• Duration
• Offensive or not
• Other relevant systemic symtoms: weight loss etc

Question 10

What is one of the main indications for an examination under anaesthesia in a premenarchal girl?

Answer 10

Vaginal bleeding is one of the main indications for an examination under anaesthesia to thoroughly inspect the lower genital tract.

Question 11

What should you suspect if there are signs of secondary sexual characteristics?

Answer 11

Suspect precocious puberty.

Question 12

What should you do if there are no signs of secondary sexual characteristics?

Answer 12

Perform a genital examination and look for:

• Signs of trauma.
• Lesions such as warts, polyps, urethral prolapse, skin lesions, lichen sclerosis, or tumours.

Question 13

What should you suspect if no trauma or lesions are found but the bleeding is offensive?

Answer 13

Suspect a foreign body.

Question 14

What should you suspect if no trauma or lesions are found and the bleeding is not offensive?

Answer 14

Suspect vulvovaginitis or rarer tumours.

Question 15

What is the treatment for idiopathic precocious puberty, and why is it important?

Answer 15

Suppress GnRH to prevent the premature closure of long bones, which would stop the girl from growing further.

Question 16

How is lichen sclerosis treated in premenarchal girls?

Answer 16

Lichen sclerosis is treated with potent steroid cream.

Question 17

What are the treatment options for warts in premenarchal girls?

Answer 17

Warts can be treated by cautery, excision, or laser.

Question 18

How is urethral prolapse managed?

Answer 18

Urethral prolapse is treated with estrogen cream (e.g., Premarin) or excision.

Question 19

What is the approach to other vulval lesions?

Answer 19

Perform excision biopsy and/or biopsies as needed.

Question 20

What is the treatment for a foreign body causing vaginal bleeding?

Answer 20

Perform an examination under anaesthesia (EUA) and remove the foreign body if present.

Question 21

How is vulvovaginitis managed?

Answer 21

1. Take a pus swab for microscopy, sensitivity, and culture.
2. Use Premarin cream for 2 weeks to change the vaginal pH.
3. Treat according to microscopy and sensitivity results.

Question 22

Why should you always consider sexual abuse in premenarchal girls with vaginal bleeding?

Answer 22

Sexual abuse is a potential cause and should always be ruled out in such cases.

Question 23

Why is candidiasis seldom seen in premenarchal girls?

Answer 23

Candidiasis is rare because the presence of estrogen is necessary for the growth of this organism.

Question 24

What should you consider if parasitic infestations are suspected in a premenarchal girl with vaginal bleeding?

Answer 24

Treat for worms if parasitic infestations are suspected.

Question 25

What should be done if a mass or tumour is seen during an examination under anaesthesia?

Answer 25

A biopsy should be taken. If a malignancy is confirmed, refer the girl to the appropriate referral center.