1. Causes:

1. Differential Diagnosis:

1. Vulvar lesions:

- Vulvar irritation: pruritis with excoriation, maceration of the vulvar skin, or fissures.

- Urethral prolapse: a mass symmetrically surrounding the urethra

2. Foreign body:

- Vaginal discharge, shich may appear purulent or bloody

- Rectal examination: An object can sometimes be palpated.

3. Precocious puberty:
4. Trauma:
5. Others:

1. Diagnosis:

1. History and physical examination:
2. Imaging studies: (on the conditions of R/O ovarian or vaginal tumors)

- Ultrasound should be the first study performed

- others: MRI, CT (rarely indicated)

- The prepubertal uterus has a distinctive appearance, with equal proportions of cervix and fundus

and a size of approximately 2-3.5 cm in length and 0.5-1 cm in width.

3. Endoscopy:

1. Management: directed to the causes of bleeding

- Skin lesions: a shout course of topical mild steroids.

- Urethral prolapse: topical estrogens

- Vaginal / ovarian tumors: à gynecologic oncologists.

　

1. Normal Menses:

- During the first 2 years after menarche, most cycles are anovulatory

- Conditions considered out of the ordinary, particularly after the first 2 years after menarche:

1. Differential Diagnosis:

1. Anovulation:

§ Conditions associated with anovulation:

Eating disorders: anorexia nervosa, bulimia nervosa

Excessive physical exercise

Chronic illness

Alcohol and other drug abuse

Stress

Thyroid diseases: hypothyroidism, hyperthyroidism

DM

Androgen excess syndrome

§ Anovulatory bleeding can be too frequent, prolonged or heavy, particularly after a long interval

of amenorrhea.

2. Pregnancy-related bleeding: eg. spontaneous abortion, ectopic pregnancy, molar pregnancy, etc.

3. Exogenous hormones: eg. oral contraceptives, missed pills, Norplant, etc

4. Hematologic abnormalities:

§ most common: idiopathic thrombocytopenic purpura

§ followed by: Willebrand’s disease

5. Infections:

§ Adolescents have the highest risks of PID and chlamydial infections of any age group.

6. Other endocrine or systemic problems: eg. thyroid dysfunction, PCOS, etc.

7. Anatomic causes:

2. Diagnosis:

- Sensitive pregnancy test:

- Laboratory testing:

§ CBC with coagulation studies and bleeding time, cultures for gonorrhea, tests for chlamydia

infection, thyroid studies, etc.

- Imaging studies: ultrasound, etc.

3. Management:

¥ Patient and her family should be warned about:

Side effects: nausea, breast tenderness, and breakthrough bleeding

Heavy withdrawal flow for the first period

- Acute bleeding: emergency management:

§ hospitalization: based on the rate of bleeding and the severity of anemia

§ for bleeding:

1. Differential Diagnosis:

1. Dysfunctional Uterine Bleeding:

? Definition: abnormal bleeding for which no specific cause has been found

‚ most often implying a mechanism of anovulation

ƒ a diagnosis of exclusion

« Relatively low levels of estrogen stimulation will result in irregular and prolonged bleeding,

wherease higher sustained levels result in episodes of amenorrhea followed by acute heavy

bleeding.

2. Pregnancy-Related Bleeding:
3. Exogenous Hormone:

? oral contraceptive:

- during the first1-3 month, 20-40% of women have breakthrough bleeding

à expectant management

‚ Norplant

ƒ depo-provera

« Non-hormonal cause should be considered, eg. chlamydial cervicitis.

4. Endocrine Causes:

eg. hyperthyroidism, hypothyroidism, DM, etc.

5. Anatomic Causes:

eg. myoma, endometrial polyp, cervical lesions, endocervical polyp, infectious cervical lesions,

eversion of endocervical columnar epithelium, Nabothian cyst, etc.

6. Coagulopathies and Other Hematologic Causes:
7. Infectious Causes:

eg. cervicitis particularly chlamydial cervicitis, endometritis, etc.

8. Neoplasia:

1. Diagnosis:

1. History and Physical Examination (including PV)
2. Laboratory Studies:

À pregnancy test

Á CBC: to detect anemia or thrombocytopenia

 PT, PTT, BT (helpful on diagnosis of Willebrand’s disease)

3. Imaging Studies:

- Ultrasound is most useful.

4. Others (based on individual situation):

- Cervical Biopsy: for cervical lesions

- Endometrial sampling (D&C): for endometrial polyps, hyperplasia or carcinoma.

1. Management:

1. Nonsurgical:

À NSAID: Ponstan and Brufen have been shown to decrease menstrual flow by 30-50%.

Á Hormonal therapy:

a). low-dose oral contraceptive (eg. Nordette)

b). progestins: for women who are not suited for estrogen

- provera (5) 10 mg qd for 10 days per month

- depo-provera

2. Surgical:

- reserved for situations in which medical therapy fails or is contraindiated

- D&C

- others: hysteroscopy with resection of submucous myoma, laparoscopic myomectomy,

hysterectomy, etc.

　

　

1. Etiology of Postmenopaual Bleeding:

Factor	Approximate Percentage
Exogenous estrogens	30%
Atrophic endometritis/vaginitis	30%
Endometrial cancer	15%
Endometrial or cervical polyps	10%
Endometrial hyperplasia	5%
Miscellaneous (eg. cervical cancer, uterine sarcoma, urethral caruncle, trauma)	10%

2. Differential Diagnosis:

1. Benign Causes:

À HRT-related problems: eg. poor compliance

Á atrophic vaginitis

 cervical polyps

à endocervical polyps and others

2. Neoplasia:

Ovarian, endometrial, or cervical malignancy

1. Diagnosis:

history, pelvic examination, pelvic ultrasound, biopsy, etc.

2. Management: based on the individual cause

¬ atrophic vaginitis (diagnosed by exclusion?)

ã topical or systemic use of estrogen

­ cervical polyp: ã polypectomy

® others: see other files