Causes of bleeding and pelvic mass by approximate frequency and age group are listed in I§b.!e.ii9§i5.
VAGINAL BLEEDING Bleeding in early puberty is usually secondary to anovulatory estrogen withdrawal for the first 2 years after menarche. Ihe amount of blood loss is minimal. Eating disorders, excessive weight loss, stress, and exercise can cause abnormal uterine bleeding. Additionally, medications (e.g., antiseizure medications) that increase the P-450 system of the liver may increase the metabolism of endogenous hormonal glucocorticoids and may cause withdrawal bleeding. Menorrhagia secondary to anovulation is seen in 10 to 15 percent of all gynecologic patients. Nongynecologic causes of vaginal bleeding and pelvic pain must be included in the differential diagnosis, be systematically addressed during the history taking and physical examination, and be pursued with relevant investigations and consultations, if indicated. Primary coagulation disorders account for 19 percent of acute menorrhagia in adolescents. Von Willebrand disease (vWD) is the most common; however, myeloproliferative disorders and immune thrombocytopenia are also possibilities. Otherwise, the differential diagnosis for pelvic pain and/or vaginal bleeding is similar to that in adults.
Ihe causes of vaginal bleeding in nonpregnant, reproductive-age females can be broadly grouped into three categories: nonuterine bleeding, ovulatory abnormal bleeding, and anovulatory abnormal bleeding. Ovulatory bleeding usually results in menorrhagia and intermenstrual bleeding. Nonovulatory cycles may be irregular and heavy (menometrorrhagia) or frequent and light (polymenorrhea) bleeding.
Potential sources of nonuterine bleeding include the cervix, vagina, lower urinary tract, and lower GI tract. Cervical causes include carcinoma, polyps, condylomata, eversion of squamocolumnar junction associated with oral contraceptive pill (OCP) use or pregnancy, trauma, and some infections. Vaginal sources of bleeding include carcinoma, sarcoma, adenosis, lacerations, infections, and retained foreign bodies. Lower urinary tract lesions, such as urethral caruncles and infected urethral diverticula, may mimic vaginal bleeding. Some patients may not be able to determine the source of bleeding, and lower GI causes may need to be investigated.10
Ovulatory bleeding is associated with regular menstrual periods that are preceded by breast tenderness, abdominal bloating, and dysmenorrhea. Abnormal bleeding may occur during ovulation, as a result of low estrogen levels. Intermenstrual bleeding may also be caused by structural and inflammatory lesions, including cervical polyps, vaginal lacerations, cervicitis, invasive cervical cancer, endometrial cancer, and fibroids. OCP use remains the most common cause of midcycle bleeding. Premenstrual spotting or delayed menses frequently results from an inadequate luteal phase or persistent corpus luteum. Other causes of abnormal or heavy ovulatory bleeding include pelvic diseases, such as endometriosis, PID, and ovarian neoplasms. Uterine causes include leiomyomas, endometrial polyps, endometrial hyperplasia or malignancy, and adenomyosis. Finally, iatrogenic factors, pregnancy and postpartum complications, and bleeding dyscrasias may result in abnormal bleeding in the woman with ovulatory cycles.10
Anovulatory bleeding is irregular shedding of a thickened endometrium. It is a result of chronic stimulation of the endometrium by estrogen and the absence of luteal-phase progesterone. Bleeding is heavy, with long intervals between menstrual periods. Abnormal anovulatory bleeding is seen in perimenarchal and perimenopausal women as well as in patients with endocrine disorders, polycystic ovary syndrome, exogenous hormone use, and liver or renal disease. Ihis pattern of bleeding increases the risk of endometrial hyperplasia and adenocarcinoma.
It is important to distinguish true pathology from dysfunctional bleeding in the perimenopausal and menopausal patients ( Tab„[e.lll9.8:-6.). Postmenopausal bleeding, i.e., any bleeding that occurs more than 6 months after cessation of menstruation, warrants prompt referral for evaluation. Ihe amount of bleeding does not correlate with the severity of disease. Older patients may not be able to accurately describe the location of pain or bleeding in the proximity of the bladder, uterus, or rectosigmoid. It is imperative that the vagina and cervix be adequately visualized. In perimenopausal or postmenopausal women, malignancy should always be considered, since it is the most important, although not the most common, diagnosis.11 Bleeding from a vaginal source is uncommon but may be associated with the use of pessaries and douche solutions, which can irritate the mucosa. Cervical polyps may be a source of bleeding. However, an endometrial biopsy is ultimately required to rule out other serious causes of bleeding (X§ble,lll98..-Z).
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