14. In the premenarchal girls

Question 1

What does vaginal bleeding in early childhood indicate?

Answer 1

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

Question 2

What are the two main sources 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

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 are the key components of history-taking in a premenarchal girl with vaginal bleeding?

Answer 6

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

Question 7

What is the main indication for an examination under anesthesia (EUA) in a premenarchal girl?

Answer 7

Vaginal bleeding, to allow thorough inspection of the lower genital tract.

Question 8

Why is it important to check for secondary sexual characteristics in a premenarchal girl with vaginal bleeding?

Answer 8

If present → suspect precocious puberty.

If absent → Perform a genital examination to identify trauma or lesions.

Question 9

If no signs of secondary sexual characteristics are present, what should be examined next?

Answer 9

A thorough genital examination for:

• Trauma.
• Lesions (warts, polyps, urethral prolapse, skin lesions, lichen sclerosis, tumors).

Question 10

If there are no lesions or signs of trauma, what should be assessed next?

Answer 10

Determine if the bleeding is offensive in odor.

Question 11

What does offensive vaginal bleeding in a premenarchal girl suggest?

Answer 11

A foreign body should be suspected.

Question 12

What does non-offensive vaginal bleeding in a premenarchal girl suggest?

Answer 12

Vulvovaginitis or rarer tumors should be considered.

Question 13

Why is it important to suppress GnRH in idiopathic precocious puberty?

Answer 13

To prevent premature closure of long bones, which would stop further growth.

Question 14

What is the treatment for lichen sclerosis in premenarchal girls?

Answer 14

Potent steroid cream.

Question 15

What are the treatment options for warts in premenarchal girls?

Answer 15

Cautery, excision, or laser.

Question 16

How is urethral prolapse treated in premenarchal girls?

Answer 16

Estrogen cream (Premarin) or excision.

Question 17

What is the management of other vulval lesions in premenarchal girls?

Answer 17

Excision biopsy and/or additional biopsies.

Question 18

How is a foreign body managed in a premenarchal girl with vaginal bleeding?

Answer 18

Examination under anesthesia (EUA) and removal of the foreign body if present.

Question 19

What are the steps in treating vulvovaginitis in premenarchal girls?

Answer 19

1. Take pus swab for microscopy, culture, and sensitivity.
2. Use Premarin cream (to change vaginal pH) for 2 weeks.
3. Treat based on microscopy and sensitivity results.

Question 20

Why should sexual abuse always be considered in premenarchal girls with vaginal bleeding?

Answer 20

Because trauma from abuse is a possible cause and must be ruled out.

Question 21

Why is candidiasis rarely seen in premenarchal girls?

Answer 21

Because estrogen is necessary for Candida growth, and premenarchal girls have low estrogen levels

Question 22

How can parasitic infestations contribute to vaginal bleeding?

Answer 22

Worms can cause irritation and bleeding, so if suspected, empirical treatment for worms should be considered.

Question 23

What should be done if an abnormal mass or tumor is seen on EUA (examination under anesthesia) ?

Answer 23

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