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Mitchell Geffner, MD
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Abnormal uterine bleeding in adolescents: Differential diagnosis and approach
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2014. | This topic last updated: Dec 04, 2013.
INTRODUCTION Menstrual cycles are often irregular in the first months after menarche. According to a study by the
World Health Organization, the median length of the first cycle after menarche was 34 days, with 38 percent of the
cycles exceeding 40 days and 7 percent occurring less than 20 days apart [1]. Menstrual disorders and abnormal uterine
bleeding (AUB) are among the most frequent gynecologic complaints of adolescents [2,3]. Abnormal uterine bleeding
(AUB) refers to bleeding that is excessive or occurs outside of normal cyclic menstruation [4]. AUB is described by a
variety of terms and may be caused by a number of genital and nongenital tract diseases, systemic disorders, and
medications (table 1). (See "Differential diagnosis of genital tract bleeding in women".)
Most cases of AUB in adolescents are caused by anovulatory cycles during the first 12 to 18 months after menarche,
which is related to immaturity of the hypothalamic-pituitary-ovarian axis [4,5]. Other common causes include pregnancy,
infection, the use of hormonal contraceptives, stress (psychogenic or exercise induced), bleeding disorders, and
endocrine disorders (eg, hypothyroidism, polycystic ovary syndrome) [4].
The treatment for these disorders ranges from observation to pharmacologic and/or surgical therapy. Potential sequelae
of AUB include anemia [6] and endometrial cancer [7,8]. With appropriate management of the underlying problem, these
sequelae may be prevented. Thus, it is crucial to establish the correct diagnosis before any therapy is administered [9].
The evaluation of AUB in adolescents will be discussed here. The management of AUB in adolescents is discussed
separately, as is the evaluation of AUB in premenopausal women. (See "Abnormal uterine bleeding in adolescents:
Management" and "Approach to abnormal uterine bleeding in nonpregnant reproductive-age women".)
GENERAL APPROACH The differential diagnosis of genital tract bleeding in adolescents is similar to that in adult
women (table 1). However, the most common causes vary according to age (table 2). In adolescents in particular,
disorders of pregnancy and the possibility of pelvic infection should be considered early in the evaluation [10]. It is
essential to rule out pregnancy in the adolescent, regardless of the stated sexual history. This is especially important in
those adolescents who present with unexplained vaginal bleeding [11]. (See "Clinical manifestations, diagnosis, and
management of ectopic pregnancy" and "Clinical features and diagnosis of pelvic inflammatory disease".)
Once pregnancy has been excluded, it is helpful to determine whether the bleeding is cyclic (regular) or acyclic
(irregular) in nature. The differential diagnosis varies accordingly. As an example, anovulatory bleeding is the most
common cause of excessive menstrual flow in adolescents with irregular bleeding, whereas blood dyscrasias and
structural anomalies (eg, polyps, fibroids) are more common in those with cyclic bleeding.
As a general rule, bleeding that is preceded by premenstrual symptoms (breast tenderness, water weight gain, mood
swings, or abnormal cramping) is ovulatory [9]. In contrast, heavy bleeding that occurs irregularly is usually anovulatory.
However, many patients are between these extremes, and determination of the ovulatory status may be difficult.
Common causes of abnormal uterine bleeding in adolescents can be grouped into four patterns:

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(See "Abnormal uterine bleeding in adolescents: Definition and evaluation", section on 'Terminology'.)
Characterization into one of these patterns may be difficult because of the range of variability in cycles during the first
one to two years postmenarche and the difficulty in quantifying volume of flow. In addition, the causative conditions may
overlap categories or present atypically. Nevertheless, the categorization scheme is helpful in narrowing the differential
diagnosis and directing the additional laboratory evaluation.
AMENORRHEA Amenorrhea is the absence of menses, which may be primary or secondary. Although there are
several unique causes of primary amenorrhea (eg, congenital abnormalities in Mllerian development or urogenital sinus
development), all causes of secondary amenorrhea also can cause primary disease. The most common cause of
amenorrhea in a female of reproductive age is pregnancy. (See "Pregnancy in adolescents", section on 'Diagnosis of
pregnancy'.)
Primary Primary amenorrhea is commonly defined as the absence of menarche by age 15 years. The 95 percentile
for menarche in North America is 14.5 years [12,13]. The causes, evaluation, and treatment of primary amenorrhea are
discussed in detail separately. (See "Etiology, diagnosis, and treatment of primary amenorrhea" and "Evaluation of
oligomenorrhea in adolescence".)
Secondary Secondary amenorrhea is defined as the absence of menses for more than three cycles or six months in
women who previously had menses [14]. In adolescents, it is uncommon for girls to remain without their menses for >90
days (the 95 percentile for cycle length). Thus, adolescents without menses for 90 days warrant an evaluation [15].
Once pregnancy is excluded, a step-wise endocrinologic evaluation can be considered. If labs are normal, a
progesterone challenge (such as micronized oral progesterone [200 mg] for 12 days) or a trial of hormonal contraception
may be necessary to reestablish menses. (See "Etiology, diagnosis, and treatment of secondary amenorrhea" and
"Evaluation of oligomenorrhea in adolescence".)
IRREGULAR BLEEDING In adolescents, during the first 12 to 18 months after menarche and in the absence of
pregnancy, the most common cause of irregular menstrual bleeding is anovulation due to an immature hypothalamic-
pituitary-ovarian axis [4,5]. This condition is a normal finding in the first few years after menarche, but all other pathologic
diagnoses must be ruled out (table 3). (See "Approach to abnormal uterine bleeding in nonpregnant reproductive-age
women", section on 'History'.)
Every young adolescent female is prone to anovulatory cycles in which the endometrium lacks the stabilizing effect of
progesterone. In such cycles, the endometrium becomes excessively thickened. It breaks down and sloughs when
estrogen is withdrawn (estrogen-withdrawal bleeding) or when it becomes unstable (estrogen-breakthrough bleeding)
[16,17]. (See "Abnormal uterine bleeding in adolescents: Definition and evaluation", section on 'Normal menstrual
cycle'.)
Adolescents with regular menses have cyclic estrogen secretion that permits orderly growth and shedding of the
endometrium (on account of hormone withdrawal), even in the absence of ovulation. In addition, the secretion of
progesterone associated with the occasional ovulatory cycle in these adolescents helps to stabilize endometrial growth
and permits more complete shedding [10].
In contrast, adolescents with anovulatory bleeding appear to have delayed maturation of normal negative feedback
cyclicity [18]. In these girls, rising levels of estrogen do not cause suppression of follicle-stimulating hormone (FSH) [19].
Estrogen secretion is sustained, and the concentration of FSH is increased relative to that of luteinizing hormone (LH). In
Amenorrhea !
Irregular bleeding !
Heavy menstrual bleeding !
Intermenstrual bleeding !
th
th
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these girls with sustained acyclic estrogen secretion, the endometrium proliferates beyond estrogen's ability to maintain
its integrity. Bleeding occurs when the endometrium becomes unstable (estrogen-breakthrough bleeding) and continues
until estrogen-induced repair takes place [16,17]. Episodes of amenorrhea may be followed by sudden and substantial
hemorrhage [17].
Other causes of irregular menses must be excluded before a diagnosis of anovulatory bleeding can be made. In girls in
whom a diagnosis of anovulatory bleeding is considered, additional evaluation may include FSH, LH, thyroid-stimulating
hormone (TSH), and prolactin on day three of the menstrual cycle (by convention, the first day of menses is day one of
the cycle, even in girls with irregular cycles). Although the concentrations of LH and FSH vary throughout the cycle
(figure 1), they are most reproducible on day three, when they are at their lowest concentrations. If day three happens to
fall on a weekend, the blood may be drawn on day four or five. Free and total testosterone and dehydroepiandrosterone
sulfate (DHEA sulfate) should be obtained if signs of hyperandrogenism are present (see 'Polycystic ovary syndrome'
below). If all pathologic causes are ruled out, and the patient is not bothered by irregular menses, anovulatory bleeding
may be managed expectantly for the first few years after menarche.
Polycystic ovary syndrome Polycystic ovary syndrome (PCOS) is a common cause of abnormal bleeding in the
adolescent with chronic anovulation [19]. The diagnosis of PCOS is based upon clinical and biochemical criteria. It
should be pursued in all adolescents with obesity, menstrual irregularity, insulin resistance, and/or signs of
hyperandrogenism (hirsutism, acne, clitoromegaly) [20]. Because signs of hyperandrogenism are not invariably present,
PCOS also should be considered in girls with prolonged menstrual irregularity and/or severely anovulatory bleeding,
even in the absence of hirsutism or acne. (See "Clinical features and diagnosis of polycystic ovary syndrome in
adolescents".)
If PCOS is a consideration, other causes of hyperandrogenism and other causes of irregular menses must be ruled out.
These include congenital adrenal hyperplasia (CAH), tumors of the ovary or adrenal gland, Cushing syndrome,
hyperprolactinemia, and thyroid dysfunction. The differential diagnosis and evaluation of hyperandrogenism in
adolescents is discussed in detail separately. (See "Clinical features and diagnosis of polycystic ovary syndrome in
adolescents".)
Other causes Other hormonal causes of irregular bleeding in adolescents include hypothyroidism and
hyperprolactinemia [21]. The causes of hyperprolactinemia are discussed separately but include pituitary tumors and
certain medications (eg, metoclopramide and methyldopa). (See "Causes of hyperprolactinemia".)
Psychologic or exercise-induced stress and eating disorders with large weight loss may cause acute anovulation in
adolescents. However, these disorders are typically associated with a hypoestrogenic state and amenorrhea. (See
"Etiology, diagnosis, and treatment of primary amenorrhea" and "Etiology, diagnosis, and treatment of secondary
amenorrhea".)
Finally, intermenstrual bleeding related to bacterial or viral infections of the vulva, vagina, or cervix may give an
adolescent the false impression that her menses are "irregular". (See 'Intermenstrual bleeding' below.)
EXCESSIVE MENSTRUAL BLEEDING Excessive menstrual flow may be excessive in its duration (>7 days) or its
volume (>80 mL/cycle). Unfortunately, neither patients nor clinicians can accurately estimate the amount of blood loss.
Heavy menstrual bleeding in the adolescent typically occurs at irregular intervals, indicating that it is anovulatory. (See
'Irregular bleeding' above and "Abnormal uterine bleeding in adolescents: Definition and evaluation", section on
'History'.)
Bleeding disorders Heavy menstrual bleeding that occurs at regular intervals or at the onset of menses is often
related to a bleeding diathesis and less commonly to systemic illness or structural lesions [22-27]. Inherited bleeding
disorders should be considered in the differential diagnosis of all patients presenting with heavy menstrual bleeding [28].
In retrospective studies, the prevalence of bleeding disorders among adolescents hospitalized for heavy menstrual
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bleeding ranges from 5 to 28 percent [22,24-27]. In one series of 59 adolescents who were hospitalized with acute heavy
menstrual bleeding and in whom genital tract pathology had been excluded, an underlying coagulopathy was present in
approximately one-fifth overall, one-third of those requiring a transfusion, and one-half presenting at menarche [22].
Coagulation disorders among adolescents with heavy menstrual bleeding include von Willebrand disease, immune
thrombocytopenia (ITP), platelet dysfunction, and thrombocytopenia secondary to malignancy or treatment for
malignancy (ie, chemotherapy or hematopoietic stem cell transplantation) [21-26]. Bleeding diathesis in adolescents also
may be related to the use of medications such as anticoagulant or platelet inhibitors. These disorders are discussed
separately. (See "Clinical presentation and diagnosis of von Willebrand disease" and "Immune thrombocytopenia (ITP) in
children: Clinical manifestations and diagnosis" and "Congenital and acquired disorders of platelet function".)
Excessive bleeding should prompt an evaluation of hematologic status. The minimum laboratory evaluation should
include [28]:
We consider the diagnosis of a bleeding dyscrasia in adolescents who present with extremely heavy first menses,
bleeding requiring blood transfusion, and patients with refractory heavy menstrual bleeding and concomitant anemia. In
such patients, the secondary evaluation also should include a von Willebrand panel (ie, plasma von Willebrand factor
(VWF) antigen; plasma VWF activity (ristocetin cofactor activity); and factor VIII activity) [28,29]. It is important that the
von Willebrand panel be obtained when the patient is not taking hormones, because exogenous estrogen may elevate
VWF into the normal range [30]. Thus, the panel should be obtained at the time of presentation or after exogenous
estrogen has been discontinued for seven days. It is also important to obtain blood group typing since blood group O is
associated with lower levels of VWF, and to consult with a hematologist if the levels are low. (See "Abnormal uterine
bleeding in adolescents: Management" and "Clinical presentation and diagnosis of von Willebrand disease".) If a
bleeding disorder is considered, consultation with a hematologist is warranted.
Other causes Less common causes of heavy menstrual bleeding in adolescents include systemic illness, endocrine
disorders, and structural lesions. Systemic illness may affect ovarian or liver function, causing abnormalities in ovulation
or coagulation, respectively. Examples include diabetes mellitus, systemic lupus erythematosus, renal failure,
malignancy, and myelodysplasia. Hypothyroidism and hyperthyroidism may cause heavy menses, as well as anovulatory
cycles. Structural lesions that cause heavy menstrual bleeding in adolescents include cervical polyps and uterine
leiomyomas (fibroids). (See 'Irregular bleeding' above and "Clinical manifestations of hypothyroidism" and "Congenital
cervical anomalies and benign cervical lesions".)
In adolescents with heavy menstrual bleeding in whom a bleeding diathesis has been excluded, additional laboratory
evaluation may include:
INTERMENSTRUAL BLEEDING
Exogenous hormones Exogenous hormone administration (eg, hormonal contraception) is a common cause of
abnormal uterine bleeding in adolescents. Intermenstrual bleeding is a common side effect of oral contraceptives, depot
Complete blood count with platelets and examination of the peripheral blood smear and ferritin to detect anemia or
thrombocytopenia
!
Coagulation panel (activated partial thromboplastin time (aPTT) and prothrombin time (PT)) !
Measurement of serum TSH to exclude thyroid abnormalities !
Evaluation for chronic or systemic diseases as warranted by the history and physical examination !
Pelvic ultrasonography (if it has not already been performed) to exclude structural causes, such as fibroids, polyps,
and/or ovarian tumors
!
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medroxyprogesterone acetate, the contraceptive patch [31], and the ring, implant, and intrauterine devices. Bleeding
may occur if these medications are not taken as prescribed or as a side effect of these medications. Thus, it is important
to ask detailed questions about how medicines are taken or used. (See "Risks and side effects associated with estrogen-
progestin contraceptives", section on 'Breakthrough bleeding' and "Overview of contraception".)
Infection Sexually active adolescents who have a history of acute vaginal bleeding unrelated to menses should be
assessed for cervicitis related to sexually transmitted infections. This also applies for girls who have been sexually
abused. The prevalence of C. trachomatis in women with AUB is underestimated [32]. (See "Sexually transmitted
diseases: Overview of issues specific to adolescents" and "Clinical features and diagnosis of pelvic inflammatory
disease".)
Other causes Other causes of intermenstrual bleeding in adolescents include cervical polyps, ectropion (particularly
in girls with cystic fibrosis [10]), foreign bodies (retained tampons are most common among adolescents), trauma, and
certain medications (eg, anticoagulants). (See "Congenital cervical anomalies and benign cervical lesions" and
"Evaluation of sexual abuse in children and adolescents".)
Less common causes of nonuterine genital tract bleeding in adolescents are discussed separately. (See "Differential
diagnosis of genital tract bleeding in women".)
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond
the Basics. The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education
pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading
level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to
your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and
the keyword(s) of interest.)
SUMMARY AND RECOMMENDATIONS The initial evaluation of all adolescents with AUB should include exclusion
of pregnancy, assessment of hemodynamic status (blood pressure, heart rate), and hemoglobin or hematocrit and
platelet count to evaluate the presence of anemia or thrombocytopenia. The additional evaluation depends upon findings
from the history and physical examination:
th th
th th
Basics topic (see "Patient information: Absent or irregular periods (The Basics)") !
Beyond the Basics topic (see "Patient information: Absent or irregular periods (Beyond the Basics)") !
The approach to amenorrhea is discussed separately. (See "Etiology, diagnosis, and treatment of primary
amenorrhea" and "Etiology, diagnosis, and treatment of secondary amenorrhea".)
!
Anovulatory bleeding accounts for the majority of abnormal uterine bleeding in adolescents; however, other
pathologic causes of bleeding must be excluded (table 3).
!
Obesity and/or signs of hyperandrogenism (eg, hirsutism, acne, clitoromegaly) in girls with AUB should prompt
evaluation for PCOS. This typically includes total and free testosterone and DHEA sulfate; additional testing may
be necessary to exclude other causes of hyperandrogenism (eg, prolactin, TSH, cortisol). (See "Clinical features
and diagnosis of polycystic ovary syndrome in adolescents".)
!
A progesterone challenge can be performed in girls with chronic anovulatory cycles to evaluate response to
endogenous estrogen. In addition, progesterone or hormonal contraception is an important component in the
!
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ACKNOWLEDGMENT The editorial staff at UpToDate, Inc. would like to acknowledge Dr. Robert Zurawin, who
contributed to an earlier version of this topic review.
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REFERENCES
1. World Health Organization multicenter study on menstrual and ovulatory patterns in adolescent girls. II.
Longitudinal study of menstrual patterns in the early postmenarcheal period, duration of bleeding episodes and
menstrual cycles. World Health Organization Task Force on Adolescent Reproductive Health. J Adolesc Health
Care 1986; 7:236.
2. Caufriez A. Menstrual disorders in adolescence: pathophysiology and treatment. Horm Res 1991; 36:156.
3. Deligeoroglou E, Tsimaris P, Deliveliotou A, et al. Menstrual disorders during adolescence. Pediatr Endocrinol Rev
2006; 3 Suppl 1:150.
4. APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding.
Association of Professors of Gynecology and Obstetrics, 2006.
5. Lemarchand-Braud T, Zufferey MM, Reymond M, Rey I. Maturation of the hypothalamo-pituitary-ovarian axis in
adolescent girls. J Clin Endocrinol Metab 1982; 54:241.
6. Hallberg L, Hgdahl AM, Nilsson L, Rybo G. Menstrual blood loss--a population study. Variation at different ages
and attempts to define normality. Acta Obstet Gynecol Scand 1966; 45:320.
7. Coulam CB, Annegers JF, Kranz JS. Chronic anovulation syndrome and associated neoplasia. Obstet Gynecol
1983; 61:403.
8. Southam AL, Richart RM. The prognosis for adolescents with menstrual abnormalities. Am J Obstet Gynecol
1966; 94:637.
9. Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA 1993;
269:1823.
10. Gray SH, Emans SJ. Abnormal vaginal bleeding in the adolescent. In: Emans, Laufer, Goldstein's Pediatric &
Adolescent Gynecology, 6th, Emans SJ, Laufer MR. (Eds), Lippincott Williams & Wilkins, Philadelphia 2012.
p.159.
11. Gray SH, Emans SJ. Abnormal vaginal bleeding in adolescents. Pediatr Rev 2007; 28:175.
12. Kaplowitz PB, Oberfield SE. Reexamination of the age limit for defining when puberty is precocious in girls in the
United States: implications for evaluation and treatment. Drug and Therapeutics and Executive Committees of the
Lawson Wilkins Pediatric Endocrine Society. Pediatrics 1999; 104:936.
13. Mitan LA, Slap GB. Dysfunctinal uterine bleeding. In: Adolescent Health Care: a Practical Guide, 4th ed, Neinstein
L (Ed), Lippincott Williams & Wilkins, Baltimore 2002. p.966.
14. Slap GB. Menstrual disorders in adolescence. Best Pract Res Clin Obstet Gynaecol 2003; 17:75.
15. American Academy of Pediatrics Committee on Adolescence, American College of Obstetricians and
Gynecologists Committee on Adolescent Health Care, Diaz A, et al. Menstruation in girls and adolescents: using
management of prolonged anovulatory bleeding. (See "Abnormal uterine bleeding in adolescents: Management"
and "Endometrial carcinoma: Epidemiology and risk factors".)
Bleeding disorders should be considered in all adolescents with AUB who present with extremely heavy first
menses, bleeding requiring blood transfusion, and patients with refractory heavy menstrual bleeding and
concomitant anemia. (See "Approach to the child with bleeding symptoms".)
!
Sexually transmitted infections and pelvic inflammatory disease should be considered in all sexually active (or
sexually abused) adolescents who complain of irregular, intermenstrual, or postcoital bleeding. (See "Sexually
transmitted diseases: Overview of issues specific to adolescents".)
!
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the menstrual cycle as a vital sign. Pediatrics 2006; 118:2245.
16. Lavin C. Dysfunctional uterine bleeding in adolescents. Curr Opin Pediatr 1996; 8:328.
17. Mitan LA, Slap GB. Adolescent menstrual disorders. Update. Med Clin North Am 2000; 84:851.
18. Aksel S, Jones GS. Etiology and treatment of dysfunctional uterine bleeding. Obstet Gynecol 1974; 44:1.
19. Bravender T, Emans SJ. Menstrual disorders. Dysfunctional uterine bleeding. Pediatr Clin North Am 1999; 46:545.
20. Pinola P, Lashen H, Bloigu A, et al. Menstrual disorders in adolescence: a marker for hyperandrogenaemia and
increased metabolic risks in later life? Finnish general population-based birth cohort study. Hum Reprod 2012;
27:3279.
21. Minjarez DA. Abnormal bleeding in adolescents. Semin Reprod Med 2003; 21:363.
22. Claessens EA, Cowell CA. Acute adolescent menorrhagia. Am J Obstet Gynecol 1981; 139:277.
23. Bevan JA, Maloney KW, Hillery CA, et al. Bleeding disorders: A common cause of menorrhagia in adolescents. J
Pediatr 2001; 138:856.
24. Smith YR, Quint EH, Hertzberg RB. Menorrhagia in adolescents requiring hospitalization. J Pediatr Adolesc
Gynecol 1998; 11:13.
25. Falcone T, Desjardins C, Bourque J, et al. Dysfunctional uterine bleeding in adolescents. J Reprod Med 1994;
39:761.
26. Kanbur NO, Derman O, Kutluk T, Grgey A. Coagulation disorders as the cause of menorrhagia in adolescents. Int
J Adolesc Med Health 2004; 16:183.
27. Oral E, Ca"da# A, Gezer A, et al. Hematological abnormalities in adolescent menorrhagia. Arch Gynecol Obstet
2002; 266:72.
28. Demers C, Derzko C, David M, et al. Gynaecological and obstetric management of women with inherited bleeding
disorders. Int J Gynaecol Obstet 2006; 95:75.
29. Mannucci PM. Treatment of von Willebrand's Disease. N Engl J Med 2004; 351:683.
30. Committee on Adolescent Health Care, Committee on Gynecologic Practice. Committee Opinion No.580: von
Willebrand disease in women. Obstet Gynecol 2013; 122:1368.
31. Greydanus DE, Patel DR, Rimsza ME. Contraception in the adolescent: an update. Pediatrics 2001; 107:562.
32. Toth M, Patton DL, Esquenazi B, et al. Association between Chlamydia trachomatis and abnormal uterine
bleeding. Am J Reprod Immunol 2007; 57:361.
Topic 114 Version 13.0
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GRAPHICS
Causes of abnormal uterine bleeding in the adolescent girl
Anovulatory uterine bleeding
Pregnancy-related problems
Threatened, spontaneous, incomplete, missed
abortion
Problems with termination procedures
Ectopic pregnancy
Gestational trophoblastic disease
Infection
Pelvic inflammatory disease
Endometritis
Cervicitis
Vaginitis
Vaginal abnormalities
Carcinoma
Lacerations
Cervical problems
Cervicitis
Polyp
Hemangioma
Carcinoma
Uterine problems
Submucous myoma
Congenital anomalies
Polyp
Carcinoma
Intrauterine device
Intermenstrual bleeding
Ovulatory bleeding
Blood dyscrasia
Thrombocytopenia
Clotting disorders
Liver disease
Endocrine disorders
Anovulatory bleeding
Thyroid disease
Adrenal disorders
Hyperprolactinemia
Polycystic ovary syndrome
Ovarian failure
Ovarian problems
Cyst
Tumor
Endometriosis
Trauma
Foreign body
Systemic disease
Diabetes mellitus
Renal disease
Systemic lupus erythematosus
Medications
Hormonal
Anticoagulants, platelet inhibitors
Androgens, spironolactone
Antipsychotics
Adapted from: Emans SJ. Dysfunctional uterine bleeding. In: Pediatric and Adolescent Gynecology, 5th ed,
Emans SJ, Laufer MR (Eds), Lippincott Williams & Wilkins, Philadelphia 2005. p.270.
Graphic 62751 Version 4.0
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Usual causes of abnormal genital bleeding in women by age group
Neonates
Estrogen withdrawal
Premenarchal
Foreign body
Trauma, including sexual abuse
Infection
Urethral prolapse
Sarcoma botryoides
Ovarian tumor
Precocious puberty
Early postmenarche
Ovulatory dysfunction (hypothalamic
immaturity)
Bleeding diathesis
Stress (psychogenic, exercise induced)
Pregnancy
Infection
Reproductive-age
Ovulatory dysfunction
Pregnancy
Cancer
Polyps, leiomyomas, adenomyosis
Infection
Endocrine dysfunction (polycystic ovary
syndrome, thyroid, hyperprolactinemia)
Bleeding diathesis
Medication related (eg, hormonal
contraception)
Menopausal transition
Anovulation
Polyps, fibroids, adenomyosis
Cancer
Menopause
Endometrial atrophy
Cancer
Postmenopausal hormone therapy
Adapted from: APGO educational series on women's health issues. Clinical management of abnormal
uterine bleeding. Association of Professors of Gynecology and Obstetrics, May 2002.
Graphic 61684 Version 5.0
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Causes of anovulatory genital tract bleeding in adolescents
Age-related
Immature hypothalamic-pituitary-ovarian axis
at the onset of menarche
Decline in ovarian function during menopause
Systemic illness and neoplasms
Hypothyroidism and hyperthyroidism
Chronic liver and renal disease
Hypercortisolism (Cushing syndrome)
Polycystic ovary syndrome
Prolactinoma
Empty sella syndrome
Pituitary infarction after postpartum
hemorrhage (Sheehan syndrome)
Adrenal and ovarian tumors
Tumors infiltrating the hypothalamus
Medications
Oral contraceptives
Progestins
Antipsychotic drugs
Corticosteroids
Chemotherapeutic agents
Other
Sudden weight loss
Stress
Intense exercise
Graphic 78931 Version 4.0
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Hormonal changes during normal menstrual cycle
Sequential changes in the serum concentrations of the hormones released from
the pituitary (FSH and LH; left panel) and from the ovaries (estrogen and
progesterone; right panel) during the normal menstrual cycle. By convention, the
first day of menses is day 1 of the cycle (shown here as day -14). The cycle is then
divided into two phases: the follicular phase is from the onset of menses until the
LH surge (day 0); and the luteal phase is from the peak of the LH surge until the
next menses. To convert serum estradiol values to pmol/L, multiply by 3.67, and
to convert serum progesterone values to nmol/L, multiply by 3.18.
Graphic 72415 Version 1.0
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Disclosures: Nirupama K De Silva, MD Nothing to disclose. Amy B Middleman, MD, MPH, MS Ed Grant/Research Support: Novartis,
Merck (immunizations). Mitchell Geffner, MD Grant/Research/Clinical Trial Support: Genentech; Ipsen; NovoNordisk; Pfizer; Versartis (for all-
growth [somatropin]). Consultant/Advisory Boards: Daiichi-Sankyo (T2DM [Colesevelam]); Endo (puberty [Histrelin acetate]); Ipsen (growth
[Mecasermin (IGF-I) Increlex]); Pfizer (growth [Somatropin (GH) Genotropin]). Mary M Torchia, MD Employee of UpToDate, Inc.
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