Bleeding pattern | Associated clinical features | Suggested evaluation |
Amenorrhea |
Primary amenorrhea | - Absence of menarche by age 15 years
| - Refer to UpToDate content on primary amenorrhea
|
Secondary amenorrhea | - Absence of menses for:
- ≥90 days in adolescents who had regular menstrual cycles, or
- ≥6 months in adolescents who had irregular menstrual cycles
| - Refer to UpToDate content on secondary amenorrhea
|
Irregular bleeding (unpredictable in timing and volume) |
Common causes |
Anovulatory uterine bleeding due to immature HPO axis | - First year or two after menarche
- Absence of premenstrual symptoms (eg, breast tenderness, weight gain, mood swings, cramping)
- Absence of clinical features associated with other causes
| - Evaluation to exclude other possible causes of anovulatory uterine bleeding as indicated clinically
|
PCOS | - Hyperandrogenism (hirsutism, acne, clitoromegaly)
- Obesity
| - Refer to UpToDate content on diagnosis of PCOS in adolescents
|
Less common causes |
Hypothyroidism or hyperthyroidism | - Recent weight gain or loss
- Heat or cold intolerance
- Family history of thyroid dysfunction
| - Thyroid-stimulating hormone
|
Hyperprolactinemia | - Galactorrhea, headache, visual changes
| |
Hypothalamic dysfunction | - Poor nutrition
- Intense exercise
- Psychosocial stress
| - Follicle-stimulating hormone
- Luteinizing hormone
|
Intermittent nonuterine bleeding mimicking irregular menses | - Clinical features of sexually transmitted infection (eg, vaginal discharge, vulvovaginal lesions, post-coital bleeding)
| - Examination of external genitalia
- Testing for sexually transmitted infection as indicated
|
Regular menses with excessive flow |
Common causes |
Bleeding disorder | - Heavy bleeding with first period
- Symptoms of bleeding disorder (eg, bruising, epistaxis, gum bleeding)
- Family history of bleeding disorder
| - Complete blood count with platelets
- Evaluation of peripheral blood smear
- aPTT and PT
- von Willebrand panel
|
Less common causes |
Medications that affect hemostasis | | |
Hypothyroidism or hyperthyroidism | - Recent weight gain or loss
- Heat or cold intolerance
- Family history of thyroid dysfunction
| - Thyroid-stimulating hormone
|
Structural lesions (eg, endometrial polyp, uterine leiomyoma [fibroid], congenital uterine anomaly) | - Often asymptomatic
- May be associated with pelvic pressure and pain
| |
Regular menses with intermenstrual bleeding |
Common causes |
Hormonal contraception or intrauterine device | - Recent initiation or poor adherence
| |
Sexually transmitted infection | - High-risk behaviors (eg, unprotected sexual activity, multiple partners)
- Vaginal discharge
- Vulvar lesions
- Post-coital bleeding
| - Testing for sexually transmitted infection as indicated
|
Extrauterine causes of intermittent bleeding that may mimic intermenstrual uterine bleeding |
Ectropion (eversion of the endocervix) | | |
Perineal trauma | - History of perineal trauma or forced sexual activity
| - Examination of external genitalia
|
Cervical polyps | - Chronic inflammation of the cervical canal
| |
Medications | | |