Disorders of Menstruation E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 474

Veröffentlichungsjahr: 2011

Beschreibung

Learn how to interpret menstrual cycle events as vital signs for women.

Irregularities in the pattern and amount of vaginal bleeding of uterine origin are often signs of pathology or an aberration in the function of the hypothalamic, pituitary, and ovarian system. The type of menstrual disorder when coupled to the women's age can give important signals as to the likely problem.

Disorders of Menstruation follows the reproductive lifetime of women, from prepubertal abnormalities through the years of potential child bearing to menopause and beyond. The authors provide a conceptual framework to understand the mechanisms responsible for abnormal menstrual bleeding or early pregnancy failure.

This clinically focused book is written for any practicing clinician who provides healthcare for girls and women. Disorders of Menstruation highlights accurate diagnostic algorithms that lead to evidence-based therapy or minimally invasive surgery using approaches that are practical, efficient, and cost-effective.

A new addition to the Gynecology in Practice series.

Leseprobe

Table of Contents

Cover

Table of Contents

Half title page

Title page

Copyright page

Series Foreword

Dedications

Contributors

1 Overview: Disorders of Menstruation

Introduction

Physiology of menstruation

Menstrual parameters

Organization of the book

Orientation to the chapters

Summary

2 Prepubertal Genital Bleeding

Introduction

Gynecologic history and physical examination

Causes of prepubertal genital bleeding

Conclusions

3 Irregular Vaginal Bleeding and Amenorrhea During the Pubertal Years

Introduction

Normal puberty, including irregular bleeding and dysmenorrhea

Dysmenorrhea

Precocious puberty—an evaluation algorithm (Figure 3.2)

Excessive bleeding

Physiologic delay of puberty

Conclusions

4 Menstrual Disorders During the Reproductive Years

Introduction

Causes of abnormal bleeding

Evaluation of irregular bleeding

Treatment of abnormal bleeding

Summary

5 Abnormal Menstrual Bleeding in Hyperandrogenic Ovulatory Dysfunction

Introduction

Pathophysiology of polycystic ovarian syndrome

Making the diagnosis of polycystic ovarian syndrome

Management of amenorrhea and oligomenorrhea in hyperandrogenic women

Conclusions

6 Abnormal Uterine Bleeding due to Anatomic Causes: Diagnosis

Introduction

Assessing abnormal uterine bleeding due to mechanical/anatomic causes

Avoiding pitfalls in diagnosis and treatment of abnormal uterine bleeding due to mechanical causes

History

Physical examination of a woman with abnormal uterine bleeding

Diagnostic tests for abnormal uterine bleeding of suspected anatomic etiology

Imaging studies to evaluate abnormal uterine bleeding with suspected anatomic etiology

Conclusions

7 Abnormal Uterine Bleeding due to Anatomic Causes: Treatment

The patient hemodynamically unstable due to anatomic abnormality

Polyps

Fibroids

Adenomyosis

Conclusions

8 Infrequent Menstrual Bleeding and Amenorrhea During the Reproductive Years

Introduction

History and physical examination

Hypothalamic and pituitary causes of amenorrhea

Anatomic causes of amenorrhea

Summary

9 Menstrual Cycle-related Clinical Disorders

Premenstrual syndrome

Dysmenorrhea

Menstrual migraines

Catamenial epilepsy

Other diseases and menstrual disorders

Summary

10 Irregular Bleeding During the Menopause Transition

Definitions and epidemiology

Hormonal and menstrual changes

Endocrinopathies that cause abnormal uterine bleeding

Mechanical causes of bleeding

Treatments

Pregnancy and fertility

Endometrial hyperplasia and malignancy

11 Postmenopausal Bleeding

Introduction

History and physical examination

Initial work-up

Assessment of the uterine cavity (Figure 11.1)

Differential diagnosis

Summary

Index

Color Plates

Disorders of Menstruation

This edition first published 2011, ® 2011 by Blackwell Publishing Ltd

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Library of Congress Cataloging-in-Publication Data

Disorders of menstruation / edited by Paul B. Marshburn, Bradley S. Hurst.

p. ; cm. – (Gynecology in practice)

 Includes bibliographical references and index.

 ISBN 978-1-4443-3277-3 (pbk. : alk. paper)

 1. Menstruation disorders. I. Marshburn, Paul B. II. Hurst, Bradley S. III. Series: Gynecology in practice.

 [DNLM: 1. Menstruation Disturbances–pathology. 2. Menstrual Cycle–physiology. WP 550]

 RG161.D57 2011

 618.1'72–dc22

2010036449

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9781444391800; Wiley Online Library 9781444391824; ePub 9781444391817

Series Foreword

In recent decades, massive advances in medical science and technology have caused an explosion of information available to the practitioner. In the modern information age, it is not unusual for physicians to have a computer in their offices with the capability of accessing medical databases and literature searches. On the other hand, however, there is always a need for concise, readable, and highly practicable written resources. The purpose of this series is to fulfill this need in the field of gynecology.

The Gynecology in Practice series aims to present practical clinical guidance on effective patient care for the busy gynecologist. The goal of each volume is to provide an evidence-based approach for specific gynecologic problems. “Evidence at a glance” features in the text provide summaries of key trials or landmark papers that guide practice, and a selected bibliography at the end of each chapter provides a springboard for deeper reading. Even with a practical approach, it is important to review the crucial basic science necessary for effective diagnosis and management. This is reinforced by “Science revisited” boxes that remind readers of crucial anatomic, physiologic or pharmacologic principles for practice.

Each volume is edited by outstanding international experts who have brought together truly gifted clinicians to address many relevant clinical questions in their chapters. The first volumes in the series are on Chronic Pelvic Pain, one of the most challenging problems in gynecology, Disorders of Menstruation, Infertility, and Contraception. These will be followed by volumes on Sexually Transmitted Diseases, Menopause, Urinary Incontinence, Endoscopic Surgeries, and Fibroids, to name a few. I would like to express my gratitude to all the editors and authors, who, despite their other responsibilities, have contributed their time, effort, and expertise to this series.

Finally, I greatly appreciate the support of the staff at Wiley-Blackwell for their outstanding editorial competence. My special thanks go to Martin Sugden, PhD; without his vision and perseverance, this series would not have come to life. My sincere hope is that this novel and exciting series will serve women and their physicians well, and will be part of the diagnostic and therapeutic armamentarium of practicing gynecologists.

Aydin Arici, MD

ProfessorDepartment of Obstetrics, Gynecology, andReproductive SciencesYale University School of Medicine

New Haven, USA

Dedication

This book is dedicated to my wife Nancy and my sons Aaron and Jonathan.

I owe a great debt to my mentors for their instruction, guidance, and inspiration. These leaders include: Arthur “Cap” Haney, Charles B. Hammond, Bruce R. Carr, Paul C. MacDonald, and Wallace C. Nunley, Jr.

I am grateful to Aydin Arici for the opportunity to edit this book and for the example of his intelligence and inquisitive nature.

Paul B. Marshburn, M.D.

I have been fortunate to work with many of the leaders in obstetrics, gynecology and reproductive endocrinology during my career. My approach to medicine, surgery, patient care, and teaching has been profoundly influenced by each, beginning with my brilliant and inspirational mentor in medical school, Dr. Griff Ross. As important as these have been in shaping my career, my wife Linda has helped me immeasurably and unwaveringly since college. I dedicate this book to my wife, mentors, friends, and family, including my beautiful daughters Kelly and Lisa. All have enriched my life and career.

Bradley S. Hurst, M.D.

Contributors

Karen D. Bradshaw, MD, Strauss Chair in Women’s Health and Medical Director of the Lowe Foundation Center for Women’s Preventative Healthcare, Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA

Isiah D. Harris, MD, Instructor and Clinical Fellow, Advanced Reproductive Medicine, University of Colorado Health Sciences Center, Aurora, Colorado, USA

Jennifer Kulp, MD, Clinical Instructor and Fellow in Obstetrics and Gynecology, Division of Reproductive Endocrinology, Yale University School of Medicine, New Haven, Connecticut, USA

Preeti P. Matkins, MD, Director of Child Maltreatment, Department of Pediatrics, Levine Children’s Hospital at Carolinas Medical Center, Teen Health Connection, Charlotte, North Carolina, USA

Michelle L. Matthews, MD, Associate Director, Reproductive Endocrinology, Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina, USA

Paul B. Miller, MD, Director of In Vitro Fertilization, Division of Reproductive Endocrinology and Infertility, University Medical Group, Greenville Hospital System, Greenville, South Carolina; GHS Associate Professor of Clinical Obstetrics and Gynecology, University of South Carolina Medical School, Columbia, South Carolina, USA

Kristin M. Rager, MD, MPH, Director of Adolescent Medicine, Department of Pediatrics, Levine Children’s Hospital at Carolinas Medical Center, Teen Health Connection, Charlotte, North Carolina, USA

William D. Schlaff, MD, Professor and Director of Reproductive Endocrinology, University of Colorado Health Sciences Center, Aurora, Colorado, USA

David Tait, MD, Associate Director, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina, USA

Rebecca S. Usadi, MD, Associate Director, Reproductive Endocrinology and Infertility, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina, USA

Tara M. Vick, MD, Director of Ambulatory Care, Division of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina, USA

1

Overview: Disorders of Menstruation

Paul B. Marshburn and Bradley S. Hurst

Carolinas Medical Center, Charlotte, North Carolina, USA

Introduction

This book is dedicated to the concept that menstrual cycle events are a vital sign for women. Irregularity in the pattern and amount of vaginal bleeding of uterine origin are often a sign of pathology or an aberration in the function of the hypothalamic, pituitary, and ovarian axis. Clues to disease states are afforded by changes in symptoms related to timing during the menstrual cycle. The process of menstruation may be accompanied by distressing symptoms such as menorrhagia (excessive menstrual blood loss), dysmenorrhea (painful periods), or oligo-amenorrhea (infrequent or absent periods). When the menstrual vital sign is appropriately and methodically interpreted, it can provide a window into the diagnosis of conditions that might be life-threatening or herald systemic disorders that only secondarily impact menstrual function.

In the logical approach to disorders of menstruation, the astute clinician should employ the precepts of Bayes theorem. The medical application of this theorem is summarized by stating that the probability of diagnosing a clinical disorder depends upon evaluating historical and diagnostic information in the population at risk. It is obvious that the interpretation of cyclic menses in a 5-year-old girl is different from that of the cyclic pattern of vaginal bleeding in a woman of reproductive age. For this reason, we have organized this book to discuss disorders of menstruation in the chronologic order of the seasons of a woman’s life. Therefore, sequential chapters begin with discussing abnormal vaginal bleeding in female infants and girls, followed by bleeding in peripubertal adolescents, women of reproductive age, those in the menopausal transition, and finally postmenopausal women. The likelihood of making an accurate diagnosis or achieving successful treatment is therefore dependent upon applying approaches in the appropriate age group and clinical setting, and in the population at risk.

This book is written for any practicing clinician who provides healthcare for girls and women. The authors have attempted to apply their know­ledge to provide a conceptual framework to understand the mechanisms responsible for abnormal menstrual bleeding or early pregnancy failure. The exhaustive, academic presentation, however, is substituted for the direct and sensible approaches of expert authors who have a wealth of successful clinical experience based upon the rigorous evaluation of clinical trials. This clinically focused book is aimed at providing gynecologists in practice or in training with a guide for use “in the office” or “at the bedside.” Our emphasis is upon providing an accurate diagnostic algorithm that leads to evidence-based therapy with approaches that are practical, efficient, and cost-effective.

Physiology of Menstruation

The functional development of the endometrium is orchestrated by ovarian estrogen stimulation during the follicular phase, followed by the postovulatory influence of estrogen and progesterone from the corpus luteum to induce secretory endometrial transformation. This process is crucial for the perpetuation of the human species by inducing proper endometrial development for embryo implantation (Figure 1.1). In the absence of embryo implantation, the endometrium is sloughed during menstruation or “the period,” appropriately termed because it implies a beginning, a middle, and an end. Such a period occurs as a result of physiologic endometrial changes prompted by a decline in steroid production by the corpus luteum if pregnancy is not established. Regular, monthly, menstrual bleeding is the outward manifes­tation of the ovarian cycle that results from ovulation.

Figure 1.1 The ovarian cycle and its correlation with hormonal events and endometrial development during the menstrual cycle. FSH, follicle-stimulating hormone; LH, luteinizing hormone.

science revisited

The landmark work of J. E. Markee, published in 1940, has been critical to the understanding of physiologic changes in primate endometrium during the menstrual cycle. Markee transplanted endometrium into an in-vivo observation chamber, the anterior chamber of the eye in rhesus monkeys. In this way, he directly observed endometrial changes during all the phases of the menstrual cycle in experiments that spanned 9 years of work. The cumulative studies of Markee and other investigators indicate that the process of menstruation is a series of universal endometrial events. Further investigation showed that the physiologic processes that start menstruation are also responsible for stopping it.

Paracrine factors, induced by the simultaneous decline in estradiol and progesterone, promote rhythmic contraction of the endometrial spiral arterioles. The resultant endometrial ischemia causes destabilization of the lysosomes, which release prostaglandins (primarily PGF2-alpha) that promote myometrial contractions. Fluid from the ischemic, liquefactive necrosis of endometrial tissue and blood is expelled by these myometrial contractions. Menstrual bleeding decreases after hemostasis from a combination of myometrial contractions and platelet plugging on exposed arteriolar type 2 collagen. The cessation of menstrual flow is completed with the initiation of endometrial tissue repair, growth, and angiogenesis that is required for preparation for implantation in the next cycle. Thus, a period of menstrual bleeding occurs through a process that is initiated by physiologic events that leads to its own conclusion.

Menstrual Parameters

The menstrual cycle may be defined by its length, regularity, frequency, and pattern of menstrual blood loss. The average menstrual cycle length in the reproductive years is between 28 and 30 days, with an average period of menstruation of 4 days, and a volume of blood loss of approximately 30 mL. The primitive woman had fewer menstrual periods because the absence of contraceptive options meant that women were more often pregnant or lactating. Today, women experience approximately 400 menstrual cycles. It has been postulated that the development of hormonal contraception, methods of permanent sterilization, fewer pregnancies per woman, reduced intervals of lactational amenorrhea, and later age at time of first conception have all contributed to an increase in the number of menstrual cycles and the magnitude of menstrual disorders. Heavy menstrual and intermenstrual bleeding is the most common indication for hysterectomy and accounts for 4% of physician consultations annually.

“Abnormal uterine bleeding” is a term applied to deviations from the normal menstrual parameters defined above. The terminology used to describe “abnormal” menstruation, however, has not been defined in a universally accepted manner. The main causes of abnormal uterine bleeding are listed in Table 1.1. Benign disorders of the uterus may present with the complaint of excessive menstrual blood loss and/or an associated irregularity in the pattern of menstrual bleeding. Such benign disorders include endometrial polyps, fibroids, and adenomyosis. However, the vast majority of women complaining of excessive menstrual blood loss have normal endometrium.

Table 1.1 The main recognized causes of abnormal uterine bleeding

Pelvic pathologyUterine leiomyomasUterine adenomyomas or diffuse adenomyosisEndometrial polypsEndometrial hyperplasiaEndometrial adenocarcinoma, rare sarcomasUterine or cervical infectionEndometrial or cervical infectionsBenign cervical diseaseCervical squamous and adenocarcinomaMyometrial hypertrophyUterine arteriovenous malformations (complications of unrecognized early pregnancy)Systemic diseaseDisorders of hemostasis (typically von Willebrand disease and platelet disorders, excessive anticoagulation)HypothyroidismOther rarities such as systemic lupus erythematosus and chronic liver failureDysfunctional uterine bleeding (DUB)Ovulatory DUB—a primary endometrial disorder of the molecular mechanisms controlling the volume of blood lost during menstruationAnovulatory DUB—a primary disorder of the hypothalamic–pituitary–ovarian axis resultingin excessive unopposed ovarian estrogen secretion and a secondary endometrial disturbance

Reproduced from Woolcock et al., 2008, with permission.

The initial step in the evaluation of menstrual disorders involves differentiation between abnormal uterine bleeding caused by ovulatory dysfunction and bleeding secondary to genital lesions or systemic disease states. “Dysfunctional uterine bleeding” is a term that has been applied to abnormal uterine bleeding from irregular or absent ovulation. Dysfunctional uterine bleeding is a diagnosis of exclusion after determining that organic causes are not involved. Organic causes for abnormal uterine bleeding, exclusive of pregnancy-related bleeding, may be classified into three categories: pelvic pathology, systemic disease, and iatrogenic causes. If these organic causes can be excluded, ovulatory disorders are the likely cause of abnormal uterine bleeding.

Anovulatory bleeding is most commonly encountered at the beginning and end of the reproductive years. The immaturity of the hypothalamic–pituitary–ovarian axis causes infrequent ovulation and irregular uterine bleeding in the peripubertal years, while irregular bleeding during the menopausal transition is encountered with the oocyte depletion of diminishing ovarian reserve.

The World Health Organization (WHO) proposed a practical classification for disorders of ovulation. The WHO designated three groups (I, II, III) based on the state of gonadotropin and estrogen secretion. The diagnosis of hypogonadotropic (low luteinizing hormone [LH] and follicle-stimulating hormone [FSH]) and hypoestrogenic anovulation (WHO group I) is often referred to as hypothalamic anovulation. The WHO group I disorders result from a variety of stressors or primary disease states that impact the hypothalamus to alter gonadotropin-releasing hormone (GnRH) pulsatility, with disruption of cyclic gonadotropin release. Hypothalamic anovulation may result from a congenital disorder of formation of the neurons that secrete GnRH, but also could be secondary to organic lesions of the brain or stress from psychological or other disease states.

Hypergonadotropic anovulation (WHO group III; high LH and FSH) is related to follicle and oocyte depletion. This grouping comprises women who naturally proceed through the transition to menopause, but also includes women who exhibit primary or secondary ovarian insufficiency, a category often referred to as premature ovarian failure.

The most problematic group of anovulatory disorders to define, however, is WHO group II, the so-called normogonadotropic, normoestrogenic cases. WHO group II, which constitutes by far the largest group of patients, is composed of a variety of hormonal abnormalities, with the largest category representing the polycystic ovarian syndrome (PCOS). The heterogeneity of this group prevents a single unified approach to the diagnosis of specific disorders within the WHO group II designation. Obesity, adrenal and thyroid dysfunction, and particular metabolic diseases can cause inappropriate extragonadal production of estrogen and androgen. This status can “short-circuit” the normal sex steroid feedback mechanism to the hypothalamus and pituitary because inappropriate extragonadal production of estrogen and androgen will produce tonic suppression of the cyclic LH and FSH secretion necessary for ovulation. Therefore, a woman can have a variety of causes for normogonadotropic, normoestrogenic anovulation (WHO group II), and these causes are not elucidated by the measurement of serum estradiol, FSH, and LH. For appropriate management of these patients, the astute diagnostician must carefully solicit pertinent historical information and carefully observe cutaneous, genital, and constitutional signs associated with both normal and abnormal estrogen and androgen production.

Organization of the Book

Disorders of Menstruation is a clinical reference for the medical management of the female with abnormal vaginal bleeding. The chapters are organized sequentially in a chronology from infancy to old age throughout a woman’s life. A given sign, symptom, or finding within a particular age group will often have markedly different health implications. Because the myriad causes of disordered menstruation often have a unique presentation in each age group, there is an intentional overlap of information among chapters to discuss these important distinctions.

The working assumption in this reference is that readers will be looking for advice and information that will assist them in clinical encounters, without overemphasis on the theoretical aspects of approaches and procedures. The authors, however, understand the importance of reviewing the crucial basic science necessary for effective diagnosis and management. The chapters are not heavily referenced, but citations of important reviews and major contributions are provided in the “Selected bibliography” at the end of each chapter.

Information is provided in a format that makes reading easier and allows the busy clinician to quickly access the essential information for patient care. Practical guidance to readers will be provided through the use of algorithms and guidelines where they are appropriate. Key evidence (clinical trials, Cochrane Database citations, other meta-analyses) is summarized in “Evidence at a glance” boxes. “Tips and tricks” boxes provide hints on improving outcomes by indicating practical techniques, pertinent patient questioning, or pertinent signs or symptoms that direct clinical management. The clinical tips may be derived from experience rather than formal evidence, but a rationale is provided to support suggested practices. “Caution” warning boxes suggest hints on avoiding problems, perhaps via a statement of contraindications or by warning of pitfalls in management. “Science revisited” boxes reveal a quick and clear reminder of the basic science principles necessary for understanding principles of practice.

Orientation to the Chapters

Vaginal bleeding in the prepubertal infant and girl signifies an abnormality that demands prompt investigation. Chapter 2, entitled “Prepubertal Genital Bleeding,” defines the best approaches for management of the pediatric population, who often cannot provide a clear history and may be threatened by a sensitive examination. The authors provide a clear and detailed approach to the pertinent gynecologic history and examination of the female child. Their defined approach maximizes the opportunities to make an “office” diagnosis. These clinicians indicate that most causes of prepubertal genital bleeding include trauma, intravaginal foreign bodies, infection, and vulvovaginal dermatologic disorders. Indications of sexual abuse must be confirmed, and the authors emphasize the means to fulfill the legal mandate that clinicians report these incidents to authorities for child protection. The malignant causes of prepubertal genital bleeding are then presented, with specific indications for making a prompt diagnosis and referral. Precocious puberty may present with vaginal bleeding in the pediatric age group. In this case, other signs of premature pubertal progress are seen, which may include the early development of the breasts, axillary and pubic hair, and a growth spurt with associated advanced bone maturation. The details of diagnosis and management of precocious puberty are explored in depth in the next chapter.

Chapter 3, on “Irregular Vaginal Bleeding and Amenorrhea During the Pubertal Years,” provides a comprehensive overview of the normal pubertal milestones and highlights boundaries for when deviation from the normal sequence of female development is a cause for concern. The causes of precocious puberty are first delineated so the diagnosing physician will be armed with the most common elements of the differential diagnosis. This is followed by a direct and practical diagnostic approach that helps in understanding how historical, physical examination, and laboratory findings will allow categorization of the differential causes of precocious puberty into central (above the neck) or peripheral (below the neck) abnormalities. Precocious puberty signifies the potential for serious health and reproductive consequences. The wealth of practical knowledge revealed in this chapter will assist the clinician in the most efficient and accurate method to best manage this emotionally charged situation.

If puberty is delayed, young women and parents need education about whether this condition is within the normal physiologic range of development or whether this represents a condition of primary amenorrhea. The differential diagnosis for primary amenorrhea has significantly different implications when compared to the absence of periods once puberty is complete and menstruation has started (secondary amenorrhea). While certain presenting signs will immediately clue the physician to the origin of the cause of primary amenorrhea (e.g., Turner’s syndrome, müllerian agenesis, androgen insensitivity), other causes are not obvious, and their diagnosis requires a systematic management algorithm that is clearly presented in this chapter.

Menarche heralds the transition from childhood to the reproductively competent woman. Adolescents and their parents, however, are often unsure about what represents normal menstrual patterns after menarche. For the first 18 months after menarche, irregular menstrual bleeding from infrequent ovulation is common. Rarely, however, should the time interval between cycles be greater than 90 days. Amenorrhea for greater than 3 months or menstrual flow for longer than 7 days is abnormal in the adolescent. In these cases, adolescents should be evaluated in order to detect conditions such as eating disorders, PCOS, von Willebrand disease, or other anatomic abnormalities of the female genital tract. The American College of Obstetricians and Gynecologists recommends that the initial visit to an obstetrician-gynecologist should take place around age 13–15 to discuss preventative services, health guidance about adolescent physical development, expectations for menstrual cyclicity, and menstrual hygiene.

Menstrual disorders are common during the reproductive years, and the central chapters of this book define the parameters for physiologic and abnormal vaginal bleeding. Chapter 4, entitled “Menstrual Disorders During the Reproductive Years,” comprehensively introduces and orients the clinician to general points of management. Emphasis is placed upon the goal of differentiating whether the cause is related to disordered ovulation secondary to reproductive or systemic disease or to an anatomic abnormality from a woman’s genital organs. Iatrogenic causes and pregnancy-related bleeding are common, and these factors should be considered first before healthcare providers initiate diagnostic testing.

Hyperandrogenic ovulatory dysfunction, or PCOS, is the most common endocrine disorder of reproductive-aged women. Chapter 5, entitled “Abnormal Menstrual Bleeding in Hyperandr­ogenic Ovulatory Dysfunction,” is devoted entirely to the care of these women because the clinician plays a critical role not only towards insuring both general and reproductive health, but also in excluding other serious endocrine disorders that masquerade as PCOS. The emergence of PCOS occurs in adolescence, and its cause is not yet understood. A hallmark of the metabolic consequences of PCOS is its association with insulin resistance, which increases the risk of adult-onset diabetes and premature atherosclerotic heart disease. This chapter reviews the common clinical presentations, etiology, and diagnostic evaluation of hyperandrogenic ovulatory disorders. A discussion of treatment highlights the most effective methods for the regulation of menstrual function, prevention of endometrial cancer, and correction of ovulatory dysfunction for fertility. Practical pearls of advice are given to most effectively and safely implement weight reduction for women with PCOS, which helps to prevent adult-onset diabetes and reverse the harmful impact of unchecked metabolic syndrome. Modern options for managing the negative cosmetic consequences of hyperandrogenism are also presented.

The anatomic or mechanical causes of excessive uterine bleeding represent one of the most common reasons that a woman will seek the care of her gynecologist.

Chapters 6 and 7, entitled, “Abnormal Uterine Bleeding due to Anatomic Causes: Diagnosis” and “Abnormal Uterine Bleeding due to Anatomic Causes: Treatment” address these essential issues of reproductive-aged women. Too frequently, the option offered for the management of such abnormal uterine bleeding is hysterectomy. Often the presence of benign uterine neoplasms, such as polyps and leiomyomas (fibroids), prompts even the most careful clinician to incorrectly assume that the tumor is the direct cause for abnormal bleeding. The diagnostic algorithm presented represents a thoughtful and complete consideration of coexistent factors and the nuances of conservative management. This chapter initially reveals the details of how to use the history, physical examination, and pelvic imaging to make an accurate diagnosis. Only then can all contributing factors be optimally addressed to correct the problem while minimizing invasiveness and the cost of treatment. Alternatives to hysterectomy include a number of new medical interventions and conservative surgical options that will correct the problem while allowing a woman to maintain her reproductive function. If pregnancy is not desired, however, excellent results can be achieved with options such as intrauterine progestin-releasing systems or endometrial ablation applied in an office setting.

The author’s extensive surgical experience delivers a presentation of creative, minimally invasive surgical options that are afforded by novel approaches and new technology. Recommendations for best approaches are based upon a distillation of research and practical knowledge from clinical experience. The advantages and pitfalls of employing pre- and postoperative surgical adjuncts are critically evaluated. The author’s goal is to enhance a patient’s satisfaction with her care by allowing her to choose from all of the options to correct abnormal bleeding from anatomic causes. The approaches delineated in these chapters will enable the gynecologist to avoid hysterectomy when possible and to recommend it when indicated.

Chapter 8, entitled “Infrequent Menstrual Bleeding and Amenorrhea During the Reproductive Years,” reveals that a different profile of reproductive hormone imbalances and anatomic abnormalities is encountered in reproductive-aged women with menstrual disorders when compared to adolescents with primary amenorrhea and abnormal uterine bleeding. Functional hypothalamic amenorrhea, prolactin-secreting adenomas, polycystic ovaries, and ovarian failure are included among the hormonal causes of secondary amenorrhea. Disease states such as exercise-induced hypothalamic amenorrhea and anorexia nervosa are associated with low concentrations of the appetite-regulating hormone leptin, and both present a similar spectrum of neuroendocrine abnormalities. The finding of premature ovarian insufficiency as a cause of secondary amenorrhea warrants an evaluation for polyglandular autoimmune dysfunction of the pancreas and the thyroid, parathyroid, and adrenal glands. Women with normal hormonal parameters may have anomalous genital tracts or intrauterine adhesions. A systematic approach to women with amenorrhea based on signs and symptoms will establish an accurate diagnosis in most cases, allowing effective treatment.

Normal ovarian function rather than reproductive endocrine imbalance is associated with menstrual cycle-related disorders. Chapter 9, entitled “Menstrual Cycle-related Clinical Disorders,” discusses the medical conditions that appear or worsen during particular phases of the menstrual cycle to significantly impair the health of women. Cyclic fluctuation in estrogen and progesterone can alter cognitive and sensory processing, emotional wellbeing, appetite, and certain disease states in women. The diagnosis and modern management of premenstrual syndrome, menstrual migraine, catamenial epilepsy, and other medical conditions are discussed in this chapter. The accurate and prospective documentation of symptoms in relation to a particular phase of the menstrual cycle will help diagnose these cyclic disease states and provide a strategy for preventative and targeted therapeutic intervention. Details are provided for when to collaborate with medical consultants to provide the optimum outcome for patients.

The menopausal transition represents a time of great variability in reproductive hormone dynamics and menstrual cycle characteristics. In Chapter 10, entitled “Irregular Uterine Bleeding During the Menopausal Transition,” the authors present the optimum methods for clinically evaluating when this transition begins and its impact on fertility and general health. Prior to detectable menstrual cycle changes, such as the gradual shortening of mean cycle length, a decline in the number of ovarian follicles may be evident by intermittent ovarian function and vasomotor symptoms. There is no period in a woman’s life when unpredictable uterine bleeding occurs with greater frequency than during the meno­pausal transition. Thyroid dysfunction is commonly uncovered. When ovulatory dysfunction becomes evident, anatomic uterine causes should be sought, and the authors discuss the safe and appropriate hormonal and nonhormonal options to control irregular bleeding in these women. With waning ovulation in the menopausal transition, persistent endometrial exposure to estrogen without cyclic progesterone secretion can lead to hyperplasia and possibly endometrial adenocarcinoma.

Postmenopausal bleeding accounts for up to 10% of all gynecologic visits. The authors of Chapter 11, entitled “Postmenopausal Bleeding,” point out that any vaginal bleeding in the menopause is abnormal and must be evaluated to insure that cancer is not the cause. Approximately 90% of postmenopausal bleeding, however, is associated with a benign condition, such as endometrial atrophy or polyps of the endocervix or endometrium. The incidence, clinical presentation, and systematic evaluation of the female genital cancers is presented to indicate the methods for detecting and treating neoplasia of the vulva, vagina, cervix, endometrium, myometrium, and fallopian tubes as a cause of postmenopausal bleeding. The authors present evidence supporting the approach that postmenopausal bleeding should initially be evaluated by transvaginal ultrasonography with an endometrial biopsy to follow if the endometrial thickness is greater than 4 mm. Saline infusion sonography and ultimately hysteroscopy with targeted biopsy of the endometrial cavity should be employed if such testing is not definitive. Hormone treatment is associated with abnormal bleeding in up to 40% of patients. The frequency of unplanned bleeding with sequential and continuous regimens of postmenopausal hormone therapy is reviewed. Systemic diseases and anticoagulant medications can cause postmenopausal bleeding and may be a sign requiring medical attention.

Summary

Menstrual cycle events can be seen to be a vital sign related to women’s health, and the application of the approaches within this book will greatly aid healthcare providers who care for females of all ages. The ease of access to the clinical insights and the diagnostic and management algorithms herein will assist practitioners at the time of the clinic visit to use these principles to benefit the health of women in their care.

Selected Bibliography

Chen BH, Guidice LC. Dysfunctional uterine bleeding. West J Med 1998;169:280–4.

Coulter A, McPherson K, Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988;27:987–94.

Farquhar CM, Lethaby A, Sowter M, Verry J, Baranyi J. An evaluation for risk factors for endometrial hyperplasia in premenopausal women with abnormal menstrual bleeding. Am J Obstet Gynecol 1999;181:525–9.

Fraser IS, Inceboz US. Defining disturbances of the menstrual cycle. In: O’Brien S, Cameron I, MacLean A, eds. Disorders of the menstrual cycle. London: RCOG Press; 2000. pp. 141–52.

Markee JE. Menstruation in intraocular endometrial transplants in the rhesus monkey. Contr Embryol Carneg Inst 1940;28:219–308.

Rodgers WH, Matrisian LM, Giudice LC et al. Patterns of metalloproteinase expression in cycling endometrium imply differential functions and regulation by steroid hormones. J Clin Invest 1994;94:946–53.

Vuorento T, Huhtaniemi I. Daily levels of salivary progesterone during the menstrual cycle in adolescent girls. Fertil Steril 1992;58:685–90.

Woolcock JG, Critchley HO, Munro MG, Broder MS, Fraser IS. Review of the confusion in current and historical terminology and definitions for disturbances of menstrual bleeding. Fertil Steril 2008;90:2269–80.

World Health Organization Scientific Group. Agents stimulating gonadal function in the human. Report No. 514. Geneva: WHO; 1976.

2

Prepubertal Genital Bleeding

Kristin M. Rager, Preeti P. Matkins, and Tara M. Vick

Levine Children’s Hospital at Carolinas Medical Center, Charlotte, North Carolina, USA

Introduction

Genital bleeding in a prepubertal female can be very frightening for both the girl and her parents. The role of the medical provider is not only to diagnose and treat the cause of the bleeding, but also to perform the appropriate examination in such a way that is least traumatic to all involved. There are many causes of prepubertal genital bleeding (Table 2.1). This chapter will review those causes, as well as describe physical examination positions and techniques.

Table 2.1 Causes of genital bleeding in preadolescent females

Unintentional traumaSexual abuseVulvovaginitisForeign bodiesUrethral prolapseLichen sclerosus et atrophicusPruritis/excoriationsTumorsPrecocious puberty

Gynecologic History and Physical Examination

The best way to distinguish a normal from an abnormal pediatric gynecologic examination is to make the genital examination part of every physical examination. This enables the provider to become very familiar with variants of normal anatomy, and also removes the stigma associated with the genital examination for the patient. Parents readily accept this part of the examination as routine; especially when presented as a normal portion of a complete examination. Performing an external genitourinary examination on all female infants and girls during annual physicals is recommended by the American Academy of Pediatrics.

In the case of a genitourinary examination due to a concerning sign or symptom, a thorough history of the complaint should first be obtained. In general, the history should include the time course of the complaint, how the concern arose, a description of any genital bleeding or discharge, pain or discomfort, as well as any treatments used prior to the visit. Any use of or exposure to medications, especially estrogen-containing substances, may be relevant. A female newborn infant may experience withdrawal vaginal bleeding as a result of disruption of maternal estrogen exposure in utero. Any exogenous estrogen exposure, such as estrogen-containing topical or oral medications may also cause estrogenization of the hymen and/or withdrawal vaginal bleeding. Close, skin-to-skin contact with a parent using topical creams or ointments containing estrogen or testosterone can be absorbed by the child and produce systemic effects. A history or observation of breast development, the presence of pubic or axillary hair, documented precocious growth spurts, or evidence of body odor should alert the physician to the possibility of precocious puberty (see Chapter 3). In the case of vaginal discharge or bleeding, it is best for the child not to have bathed for at least 24 hours prior to the examination.

Adolescents above the age of 11 should also have a history taken privately, that is, without the parent or guardian present. It is important to ask about sexual contact (intercourse, digital, oral, and anal sexual contact). It is very important to ask the age of the patient’s sexual contacts. “Consensual” contact must also be viewed in the sense of compliant victims or non-forcible sexual assault. If there is concern about sexual abuse or assault, care should be taken when considering gathering forensic evidence and the medical care of the patient. Every state has differing laws on mandated reporting of child abuse, but all are clear that concern or suspicion of abuse requires reporting; proof of abuse is not required. A clinician should report to child protective services and/or local law enforcement in accordance with local laws. Reporting in good faith is protected by liability laws.

caution

Providers must report ANY suspicion or concern of sexual abuse of minors to local authorities, regardless of the presence of any evidence or physical findings.

An external genital examination is almost always adequate. Occasionally, the use of saline irrigation may assist in separating tissue and improving visibility. In prepubertal girls, the hymen is exquisitely tender, and if vaginal samples are necessary, care should be taken not to touch the rim of the hymen. Use of a speculum is rarely indicated in prepubertal girls and should be reserved for occasions requiring anesthesia such as uncontrolled bleeding, an intravaginal foreign body with significant trauma, or serious fascial infections. In adolescents, the estrogenized hymen is not tender to touch with cotton swabs or even a balloon catheter (used for urinary catheterization). These catheters with a balloon tip can be filled after insertion into the vagina to help visualize the edges of the hymen.

Magnification for better visualization may be helpful. The use of various tools, including an otoscope, ophthalmoscope, or colposcope may be of assistance, but often is not required. A good light source is necessary and can be an overhead or floor light source or attached to a tool used for magnification. Some providers may use a digital camera for documentation.

There are three examination positions for performing gynecologic examinations in children/young adolescents. These include the frog-leg or butterfly position (Figure 2.1), the dorsal lithotomy position, and the knee–chest position (Figure 2.2). In the frog-leg position, the patient lies supine with her knees bent and her ankles brought towards her genital area (like a frog). In girls with longer legs, the dorsal lithotomy position may be more comfortable. In this position, the patient should have her buttocks close to the edge of the table. It may be useful to examine a child in the parent’s lap if needed.

Figure 2.1 Examination positioning––frog-leg.

Figure 2.2 Examination positioning––knee–chest.

The third position used for examination is knee–chest. In this position, the child is placed on her knees, with her feet at the end of the examination table, and her head lying on her folded elbows. The knee–chest position is excellent for visualizing the posterior hymen and is very helpful if the examination in the frog-leg or dorsal lithotomy position reveals possible abnormalities in the posterior hymenal rim. This position may also be helpful in visualizing the vaginal vault in cases of concern of a foreign body. Missing tissue in the posterior hymenal rim viewed in the frog-leg or dorsal lithotomy position may actually represent redundant tissue that is responding to gravity. A knee–chest examination is necessary to confirm tissue abnormalities versus gravity effects.

tips & tricks

When using stirrups during a physical examination on a child or young adolescent, it is often helpful to use the term “foot-holders” instead of stirrups as ‘this may be an unfamiliar term.

There are also three useful examination techniques: labial separation, labial traction, and buttock traction. Labial separation involves gentle separation of the labia majora at about half way along their length to visualize the hymenal orifice as well as the perilabial area, the clitoral hood and the urethral area. Labial traction involves gently grasping the labia majora and applying outward and downward traction. Care must be taken not to apply undue traction to the sensitive posterior commissure area. Any erythema or irritation of the vulvar area may result in pain, so pressure should be applied carefully. Buttock traction is used in the knee–chest position. The buttocks are lifted and separated to visualize the vulvar area, including the posterior hymenal rim. Again, be careful not to apply undue traction to the posterior commissure.

Documentation of the genital examination should include describing the technique and position utilized. Findings should be reported in a “clock” configuration, with 12 o’clock representing the urethra and 6 o’clock the posterior rim of the hymen when the patient is supine.

There are many hymenal variants (Figure 2.3). Hymenal appearance is affected by estrogen, which is present in the newborn period from in utero estrogen exposure and may persist until 2–3 years of age. Hymenal changes due to estrogen present again with onset of puberty.

Figure 2.3 Hymenal variants.

Of note, the orifice diameter of the hymen is not an indication of previous trauma or injury. The orifice diameter of the hymen may depend upon multiple factors, including patient relaxation, healthcare provider’s technique, and weight of the patient. Patient relaxation is very important in the genitourinary examination, and one should consider the time required to have a patient and parent comfortable with the examination. The use of blowing bubbles or reading books to relax the patient may be considered. If the patient is unable to relax to provide an adequate examination, the urgency should be considered. An emergent examination may require an evaluation under anesthesia; otherwise a repeat visit should be scheduled if the girl and/or parent are uncomfortable with the setting.

The focus of hymenal examination should be from 3 to 9 o’clock when the patient is supine. Abnormalities, including partial or complete transection of the hymen at 3–6 o’clock, should be confirmed in the knee–chest position. Hymenal abnormalities in the 3–6 o’clock position are very concerning for penetrating injury, including abuse. Again, it should be kept in mind that the hymenal tissue is distensible, so penetration may not be evident as abnormalities on examination.

If, on taking the history, a persistent or recurrent discharge is described, or if on physical examination the discharge is purulent or grossly blood-tinged, vaginal swabs may be obtained for office evaluation of a wet mount preparation (saline and potassium hydroxide) and for laboratory culture analysis. Organisms for culture analysis are included in Table 2.2 (see next sec­tion). The swab should be premoistened with saline and carefully inserted into the vagina without touching the edges of the sensitive hymen. Run the swab against the lateral wall of the vagina to obtain a specimen. If the young girl is able to cooperate, ask her to cough at the time of the insertion of the swab. This will have the twofold effect of causing a distraction and allowing the hymen to open. Vaginal samples may also be acquired by vaginal lavage. A saline syringe may be attached to either a pediatric urethral catheter or a 14-gauge venous catheter (with the needle removed) to allow sample aspiration or vaginal washings that can flow onto the specimen swabs. Topical lidocaine gel may be used as an anesthetic to aid in the collection or lavage.

After collecting the specimen swab, the applicator is first mixed with a drop of saline on a glass slide and then with a drop of 10% potassium hydroxide on a second slide. Cover slips are then placed, and the slides may be examined under low and high powers. In bacterial vaginosis, clue cells can be identified as bacterium-studded epithelial cells. Flagellated, motile organisms slightly larger than white blood cells may be identified as trichomonads. The potassium hydroxide slide may reveal budding pseudohyphae and yeast forms indicative of Candida yeast vaginitis. Touching the specimen swab to pH paper during the examination may be helpful in making a diagnosis. In prepubertal girls, the vaginal pH is neutral (6.5–7.5), providing an optimal environment for bacterial growth. In pubertal adolescent girls, the pH is acidic (less than 4.5). Bacterial vaginosis and Trichomonas vaginitis raise the normal pH to greater than 4.5.

Causes of Prepubertal Genital Bleeding

Benign

Injuries to the vulvar and perivulvar area are relatively common in prepubertal girls and usually present with bleeding or dysuria. Generally, there is a history of trauma, although one should remember that playground or bicycle injuries may not be immediately recalled, especially if the child was in the care of others (daycare, school) at the time of the injury. Straddle injuries involve the vulvar and perivulvar area and may present as abrasions, lacerations, or bruising. The genital skin is very well vascularized and heals quickly. In general, treatment is symptomatic only, with use of barrier (petrolatum [petroleum] jelly) to protect the skin and decrease pain from contact with urine. Large lacerations may require suturing. Injuries to the vaginal orifice and hymen are less likely to be associated with straddle injuries. In cases where a girl has hymenal injuries attributed to a straddle injury, one should consider whether an impalement type of accidental injury has occurred and also consider possibility of inflicted injury/abuse.

Vulvovaginitis may present with a vulvar inflammation, vulvar pruritis, vaginal discharge, or vaginal bleeding. A wide range of normal vaginal flora can be cultured in girls without symptoms, including Bacteroides, Staphylococcus, and Streptrococcus species, lactobacilli, diphtheroids, and Gram-negative enteric organisms, usually Escherichia coli. The vaginal culture from girls with vaginitis typically grows normal flora. The specific infections that occur in the prepubertal girl are typically respiratory, enteric, or sexually transmitted infections (Table 2.2). Vulvovaginitis due to these organisms may or may not present with concomitant respiratory or gastrointestinal illness. For example, Shigella infection can result in a mucopurulent, sometimes bloody vaginal discharge, but is associated with diarrhea in only approximately 25% of presentations. The most common respiratory organism to cause vaginitis is Streptococcus pyogenes (Group A beta-hemolytic Streptococcus). Although throat cultures frequently are positive, only 25–30% of patients have symptoms of pharyngitis. Candida vulvitis may be common in pubertal, estrogenized girls; however, it is not common in prepubertal girls unless there is an associated risk factor such as immunosuppression from diabetes. Empiric antibiotic therapy or directive treatment of the causative organism will result in a resolution of vaginal bleeding occurring due to vulvovaginitis.

Table 2.2 Organisms implicated in prepubertal vulvovaginitis

Respiratory pathogensStreptococcus pyogenes (group A beta-hemolytic Streptococcus)Staphylococcus aureusHaemophilus influenzaeStreptococcus pneumoniaeMoraxella catarrhalisNeisseria meningitidisEnteric pathogensShigellaYersiniaCandidaSexually transmitted infectionsNeisseria gonorrhoeaeChlamydia trachomatisTrichomonas vaginalis Herpes simplex virus Condyloma acuminata (human papillomavirus)Pinworms, other helminthes

A foreign body in the vagina may present with a foul-smelling, bloody discharge and is the etiology underlying a great majority of bleeding in young girls. The bleeding is described as either bright red or brown, light in amount, and usually appearing sporadically. It is uncommon for the girl to recall or reveal the history of a vaginal placement of a foreign object. In fact, the most common item is retained toilet paper. This is especially likely to occur during toilet training, as girls become increasingly responsible for their own post-void hygiene or “wiping.” Other foreign bodies are not usually radio-opaque, so diagnosis requires an office examination or examination with sedation or under anesthesia. Toilet paper and other small objects may be removed with vaginal lavage as previously described. Other objects may be removed with forceps after appropriate sedation. The use of a hysteroscope or cystoscope may be necessary for adequate lavage and visualization. The intravaginal hysterosocopic evaluation for retained foreign bodies requires performance under anesthesia.

One of the most common causes of “vaginal bleeding” in the prepubertal female is not vaginal at all. Urethral prolapse often presents as sudden, painless genitourinary bleeding that may be described as profuse. There is no history of preceding trauma. On examination, in the supine position, there is an area of red swollen tissue that obscures visualization of genital landmarks. It may be difficult to distinguish the clitoral hood, hymenal orifice, and urethra. The protruding, swollen, erythematous tissue is very tender. To the inexperienced examiner, the findings may be very concerning for trauma or tumor. Careful examination will reveal that the area of concern that is obscuring normal structures is actually a prolapsed urethra. Knee–chest examination with buttock traction will often reveal a normal view of the posterior hymenal rim with an obvious urethral prolapse anteriorly (Figure 2.4).

Figure 2.4 Urethral prolapse (see Plate 2.4).

Urethral prolapse occurs in hypoestrogenic states: postmenopausal women, and girls between toddler age and puberty. This condition is more common in African-American girls than Caucasian or Latina girls. Initial treatment is estrogen cream applied directly to the prolapsed area twice a day for 7–10 days. Parents should be instructed on direct administration. Sitz baths once or twice a day are recommended for comfort. If the patient has a history of constipation, stool softeners may be considered to reduce straining. If initial medical treatment fails or if the prolapse is strangulated (presenting with many areas of clotted tissue), consultation with a pediatric gynecologist or pediatric urologist should be considered for surgical repair.

Lichen sclerosus et atrophicus is an autoimmune condition that is most common in hypoestrogenic states such as menopause, but may present in prepubertal children. The presentation of this dermatologic condition is variable, with some girls presenting with painless genital bleeding, some with genital or vulvar pain or itching and labial bleeding, and some with concerns of labial trauma. The course may be indolent, with several waxing and waning episodes prior to diagnosis.

On examination, there is a hypopigmented, atrophic area, usually in an hourglass shape around the vulva and anus (Figure 2.5). This distribution may also be referred to as a “figure of eight.” The introitus is not affected. Depending on the course of the condition at the time of the examination, thinned skin resulting in subepithelial bleeding (blood blisters) may be present. These areas of bleeding can be confused with trauma, either accidental or inflicted. Unlike a single episode of trauma, these areas may return after they have been considered healed. The condition may cause discomfort, and the inflammatory response may produce discharge from the affected areas. Again, careful examination and knowledge of normal anatomy is necessary in making an accurate diagnosis.

Figure 2.5 Lichen sclerosus et atrophicus (see Plate 2.5).

Treatment generally requires a medium- or high-potency steroid such as clobetasol (Temovate) 0.05% ointment. These topical steroid ointments can be prescribed for a short course to be used twice a day for 7–10 days with follow-up examination after the conclusion of treatment. A course of treatment for 6 weeks followed by a 1-week taper may be necessary. The patient and family should be informed of the high potency of the steroid prescribed, and emphasis should be given to limit its time of use. The course of lichen sclerosus et atrophicus is variable, and parents (and, at an appropriate age, the patient) should be informed that this condition may be lifelong, or that it may wax and wane for many years.

Genital bleeding, especially when scant and associated with pruritus, may simply be related to excoriations from aggressive scratching. Scr­atching of the genital area, in particular in patients with longer fingernails, may lead to breaks in the skin that lead to bleeding. Causes of such pruritus may include pinworms, atopic dermatitis, contact dermatitis, tight undergarments, wet bathing suits, and insect bites. These causes are generally easily elucidated through the history and physical examination. In the case of pinworms, pruritis may be worst around the rectum and at night, and diagnosis may be made through tape-testing. Tape-testing can be performed by parents and involves a brief application of clear tape to the perirectal area while the child is sleeping at night. On inspection, one may directly visualize pinworms stuck to the tape. Pinworms are treated using oral anthelmintics, such as mebendazole. In addition, when a child is scratching the genitals so extensively that trauma occurs, trimming the fingernails is beneficial to minimize skin damage.

A final consideration in the young girl with vaginal bleeding, which will be discussed in detail in Chapter 3, is precocious puberty. Vaginal bleeding in response to estrogen exposure may be due to true precocious puberty or to an independent source of estrogen, such as exposure to exogenous estrogen in the form of oral contraceptive pills. Precocious puberty presents with not only vaginal bleeding, but also the other signs of pubertal development, including growth of the breasts and axillary and pubic hair, and a growth spurt with associated bone maturation. In this setting, the initial assessment should include a very careful history to search for exogenous hormonal exposure. Estrogen-producing ovarian or adrenal tumors generally present with rapid onset and progression of pubertal changes and can be detected by radiologic studies. McCune–Albright syndrome is notable for irregular café-au-lait spots, polyostotic fibrous dysplasia, and gonadotropin releasing hormone-independent precocious puberty. Finally, the uncommon presentation of premature menarche is marked by single or periodic episodes of vaginal bleeding without other evidence of premature pubertal development. If the above causes are ruled out, an evaluation for true (or central) precocious puberty must be considered.

Malignant

Tumors of the vagina and cervix are rare in young girls. The most common form of soft tissue sarcoma in childhood is the rhabdomyosarcoma, of which approximately 20% involve the genitourinary tract. A subtype––sarcoma botryoides––is the most common malignant tumor of the genital tract of young girls, with a peak incidence occurring before 2 years of age. This almost always develops prior to age 5, with an average age at the time of diagnosis of 3 years. As a child’s age increases, lesions tend to originate higher in the genital tract. The bimodal incidence of this cancer with a second peak of frequency in adolescence results in the manifestation of cervical tumors.