Vaginal Bleeding in Pediatric Patients

Abstract

<h3>Background</h3> The purpose of this study <i>is</i> to evaluate the underlying cause of vaginal bleeding in all pediatric patients and to specifically evaluate the underlying cause of menorrhagia. <h3>Methods</h3> This retrospective chart review examined 134 patients with the coded diagnosis of vaginal bleeding seen at a tertiary children's medical center either emergency or outpatient setting from January, 1993 to April, 1996. <h3>Results</h3> One hundred thirty-four charts were reviewed with 79 (59.0%) seen initially in emergency department and 55 (41.0%) seen in an outpatient setting. There were 3 admissions (2.2%). The age range was 4 days to 20 years: <28 days=13 (9.7%); 29 days to 2 years=10 (7.5%); 2 years to 9 years=14 (10.4%); and > 9 years=97 (72.4%). The most common diagnoses were breakthrough bleeding with a birth control method (31 or 23.1%), dysfunctional uterine bleeding (24 or 17.9%), abnormal uterine bleeding (20 or 14.9%), neonatal withdrawal (12 or 9.0%), trauma including sexual abuse (9 or 6.7%), spontaneous abortion (8 or 6.0%), vulvovaginitis (8 or 6.0%), and miscel1aneous other diagnosis (menses, vaginal polyp, vaginal yolk sac tumor, foreign body, and central precocious puberty). The common causes of vaginal bleeding were age-related. In the neonates, 92.3% (12/13) of vaginal bleeding was due to neonatal estrogen withdrawal. In the 2 to 9 year old children, 42.9% (6/14) of vaginal bleeding was caused by trauma with half due to sexual abuse; 42.9% (6/14) was due to vulvovaginitis. In the adolescents (>9 years old), 32.0% (31/97) of vaginal bleeding was due to birth control method including depo provera, Norplant and oral contraceptives in order of frequency. The coded diagnoses of dysfunctional uterine bleeding and abnormal uterine bleeding accounted for 25.8% (25/97) and 16.5% (16/97) of adolescent vaginal bleeding, respectively. Eight percent (8/97) of adolescents had spontaneous abortions. For the purpose of analysis, menorrhagia was defined as heavy vaginal bleeding (>1 pad per hour) or prolonged bleeding (>7 days) with clinical evidence of bleeding such as blood on pelvic exam or anemia (hemoglobin< 11.5g/dl or hematocrit <35.0%). All 21 patients (15.7% of all patients) with menorrhagia were between the ages of 10 to 20 years accounting for 21.6% (21/97) of adolescent vaginal bleeding. Menorrhagi was due to dysfunctional uterine bleeding in 57.1% (12/21) and a coagulopathy in 19% (4/21). The most common coagulopathy was von Willebrand's disease, found in 2 cases, followed by liver disease in 1 case and thrombocytopenia from aplastic anemia in 1 case. One case of menorrhagia was due to bleeding from Norplant, and 1 case was due to bleeding after a LEEP procedure to the cervix. <h3>Conclusions</h3> The most common causes of vaginal bleeding in pediatric patients are age-related. In children and neonates, neonatal withdrawal, vulvovaginitis and trauma including sexual abuse are most common. In adolescents, bleeding from a birth control method and dysfunctional uterine bleeding are most common. Menorrhagia was seen in 21% of our adolescents, and this study reflects prior data with 19% of adolescents with menorrhagia having an underlying coagulopathy.