Mild AUB

With mild AUB the menses may be somewhat prolonged or the cycle shortened for 2–3 months. The hemoglobin and hematocrit are normal, >11 g/dL and >35%, respectively.

Moderate AUB

Moderate AUB is characterized by prolonged periods and an increased flow severe enough to cause a decrease in hemoglobin and hematocrit to 9–11 g/dL and 25–35%, respectively.

Severe AUB

Severe AUB results in significant decreases in the hemoglobin and hematocrit, to <9 g/dL and <25%, respectively. Clinical signs of acute blood loss (tachycardia, orthostatic vital sign changes, delayed capillary refill) with a hemoglobin <11 g/dL is also consistent with severe AUB.

Mild AUB

Observation and reassurance are all that are needed. Advise the patient to keep a menstrual calendar. Iron supplementation (325 mg/day of ferrous gluconate or multivitamin with iron) may be necessary, but the majority of these patients spontaneously convert to normal menstrual cycles within several months.

Moderate AUB

Treat with a monophasic combined oral contraceptive pill (COCP) with 30–35 mcg estrogen/varying progesterone (e.g., Sprintec, Ortho-Novum1/35, Lo-Ovral) if there is no contraindication to estrogen. These include migraine with aura, untreated hypertension, known clotting risk (e.g., antiphospholipid antibody), untreated hyperlipidemia, cardiovascular disease, history of a stroke or deep vein thrombosis, active liver disease, pregnancy, and breast cancer. If a first-degree relative has a clotting disorder, it is prudent to have the patient tested for hereditary hypercoagulable states such as Antithrombin III deficiency and Protein C and Protein S deficiency before prescribing an estrogen-containing OCP.

Always prescribe the 21-day pill pack, as taking the placebos of the 28-day pack will cause a withdrawal bleed. Give two pills per day until the follow-up visit with adolescent medicine or gynecology in one week. If the bleeding does not stop or slow significantly in two days, advise the patient to contact adolescent medicine or gynecology. Once the bleeding completely stops, the patient may be transitioned to one pill per day. Give the patient and parent/guardian detailed written instructions, as this regimen is complicated, and if not followed exactly may result in breakthrough bleeding. Also prescribe an oral antiemetic, such as prochlorperazine (10 mg q 6–8h 40 mg/day maximum) or ondansetron (15–30 kg: 4 mg bid; >30 kg: 8 mg bid).

If the patient has a contraindication to estrogen, prescribe medroxyprogesterone acetate (Provera) 10 mg PO daily, and give the first dose in the ED. Arrange follow-up with adolescent medicine or gynecology within one week. Eventually, these patients may be prescribed a progestin-only pill (depot-medroxyprogesterone acetate) or a long-acting reversible progestin-only contraceptive (IUD or implant).

When the patient is at the point of taking one OCP per day, add ferrous gluconate (325 mg tid) to treat the associated anemia. Starting the iron while the patient is taking more than one OCP per day may exacerbate the gastrointestinal side effects. At the follow-up visit, obtain a hemoglobin, and if it is >12 g/dL, allow a withdrawal bleed. A week after stopping the COCP, begin a new 28-day pill pack and cycle the patient for six months, or institute the progestin-only method outlined above for six months.

Severe AUB

The priority is restoration of adequate perfusion (see Shock, pp. 28–35) with 20 mL/kg boluses of isotonic crystalloid (normal saline or Ringer’s lactate). A packed RBC transfusion (10 mL/kg) is indicated if the patient is symptomatic (tachycardia, dizziness), either at rest or standing, or remains orthostatic after the boluses. To stop the bleeding immediately, begin monophasic COCP (35 mcg estrogen) qid, if there are no estrogen contraindications. If the patient is bleeding profusely or is in shock, give a conjugated estrogen (Premarin), 25 mg IV over 20 minutes q 4–6h. This is usually effective after the first or second dose, but a maximum of four doses may be given. An antiemetic may be needed (as above). If the bleeding does not subside or increases after the third dose of Premarin, or the vital signs continue to deteriorate, consult a gynecologist to determine whether a dilation and curettage is indicated. Continue treatment with monophasic COCP as outlined for moderate AUB above. If the patient has a contraindication to estrogen, begin medroxyprogesterone acetate (Provera) 10 mg PO and tranexamic acid 1300 mg PO q 8h, and give the first dose immediately. Consult adolescent medicine and, if a bleeding diathesis exists, hematology/oncology.

Neonatal Breast Hypertrophy

Neonatal breast hypertrophy occurs in up to two-thirds of normal newborns of both genders. It results from maternal hormonal stimulation, and presents as palpable breast tissue, present from birth, in an otherwise healthy infant. Occasionally, in female infants, there is also galactorrhea, clitoral hypertrophy, and a bloody vaginal discharge, also resulting from the effect of maternal hormones. Most cases resolve within a month, although breast hypertrophy may persist for several months.

Premature Thelarche

The mean onset of breast development in the United States is approximately ten years for white girls and nine years for African-American girls. Premature thelarche is defined as breast enlargement, in the absence of other signs of puberty, before seven years of age in white girls and six years of age in African-American girls. At times it is the result of neonatal breast hypertrophy failing to regress. Bilateral breast buds (2–4 cm) are present with no associated nipple or areolar change, nipple discharge, axillary or pubic hair, clitoral enlargement, acne, or growth spurt. The presence of any of these other findings suggests more significant pathology, including true precocious puberty, CNS disorders, ovarian tumors, and exogenous estrogens.

Breast Masses

Breast masses are a common source of fear and anxiety in the adolescent female, but most cases are benign, secondary to fibrocystic changes or physiologic breast tissue. While adolescents typically have dense breast tissue at baseline, fibrocystic changes can ensue, appearing as cord-like thickening that may present as “lumps.” These “lumps” may become tender and enlarged prior to menses each month.

The most common discrete masses in adolescents are fibroadenomas. These are benign lesions that present as firm, rubbery, mobile masses with clearly defined borders. Other common benign findings include simple cysts, capillary hemangiomas, and fat necrosis.

Cystosarcoma phyllodes is a rare primary tumor that is usually, but not always, benign. The tumor is generally large (about 6 cm), and there may be overlying skin changes (tautness, retraction, necrosis). Invasive breast cancer (adenocarcinoma) is exceedingly rare in children and adolescents. A positive family history of breast cancer and prior radiation treatment are risk factors. The most common malignant breast masses in adolescents are metastases from other primary cancers, such as rhabdomyosarcoma, lymphoma, neuroblastoma, and melanoma.

Mastitis and Breast Abscesses

Mastitis (inflammation of the breast) and breast abscesses (a local accumulation of pus in the breast) are infections that can occur in newborns as well as adolescent females. Staphylococcus aureus is the most common pathogen in both age groups. In adolescents, abscesses are most frequent during lactation, while in non-lactating teenagers the etiology is unclear, but may be due to duct ectasia or metaplasia of the duct epithelium. Trauma or manipulation of the skin can also lead to infection. The abscess presents on the skin adjacent to the areola as a warm, erythematous, tender mass, which may be fluctuant. The patient may be febrile.

Gynecomastia

Nearly 50% of adolescent males undergo benign, usually bilateral, increase in the glandular and stromal tissue of the breast, generally at Tanner stages II–III. It results from an increase in estrogen that is usually part of normal adolescent development.

Gynecomastia resolves within 1–2 years. Persistence beyond adolescence may be pathologic, secondary to disorders that cause increased estrogen, decreased androgen, or abnormality at the receptors for estrogen or androgen. These include testicular, adrenal, or other hCG-producing tumors. Hypogonadotropic hypogonadism, androgen insensitivity, hyperthyroidism, hyperprolactinemia, liver disease, kidney disease, or obesity can also cause gynecomastia. Drug use, either medical (spironolactone, cimetidine, digoxin), or recreational (marijuana) are other etiologies.

Neonatal Breast Hypertrophy

A history and physical examination, including a genital exam to assess for other signs of maternal estrogenization, are all that is required.

Premature Thelarche

A complete physical examination must be performed to rule-out true precocious puberty. Premature thelarche is the diagnosis if no other pubertal changes are present. Note the presence of secondary sexual characteristics, such as pubic hair, estrogenized vaginal mucosa, and clitoral enlargement. The presence of any of these findings is indicative of precocious puberty, not isolated premature thelarche.

Breast Masses

A breast examination is usually sufficient to diagnose fibrocystic changes and to distinguish an abscess from a true breast mass. If a cyst is suspected, schedule the patient to be reexamined after her next menstrual period, as the lesion will often disappear. If a discrete lesion persists, arrange for an ultrasound, which is the imaging modality of choice for evaluating breast masses in adolescents.

Mastitis and Breast Abscess

The diagnosis of mastitis is usually evident on inspection of the warm, tender, erythematous breast bud. An adolescent may have a history of a recent pregnancy and may or may not be lactating. A neonate may be febrile, although associated symptoms in infant mastitis are uncommon. If the area is fluctuant, presume the child has an associated abscess and arrange for aspiration. This can help confirm the diagnosis and provide a specimen for culture.

Gynecomastia

Gynecomastia can be differentiated from adipose tissue in that gynecomastia presents with a firm, rubbery, discrete mass that is usually <3 cm in diameter. The breast tissue is symmetrically located under the nipple/areolar complex. Although the subareolar nodule may extend beyond the margin of the areola, an asymmetric mass in relation to the areola is not consistent with benign gynecomastia.

In addition, examine the abdomen to evaluate for an adrenal tumor and the testicles to assess testicular volume (or presence of atrophy) and to palpate any masses.

Neonatal Breast Hypertrophy

Reassurance, cool compresses, and avoidance of breast massaging are all that is necessary. Refer the infant to a primary care provider.

Premature Thelarche/Precocious Puberty

If there are no other signs of puberty, reassure the patient and family that the condition is not serious and refer the patient to a primary care physician for routine follow-up. If other signs of puberty are present, arrange for a pediatric endocrinology visit within one week.

Breast Masses

Reassurance is all that is needed for a patient with either physiologic or fibrocystic changes. If a cyst is palpated, arrange for follow-up with the patient’s primary doctor after her period. If the lesion persists, or if there is a more concerning finding on examination, obtain an ultrasound and refer to either an adolescent medicine specialist or a surgeon.

Mastitis and Breast Abscesses

Infants <4 weeks old, or 4–8 weeks of age with either fever >100.6 °F (38.1 °C) or a “toxic” appearance, require a complete sepsis evaluation, hospitalization, and IV antibiotics (pp. 391–392). If a patient 4–8 weeks of age is afebrile and nontoxic, obtain a blood culture and admit for IV antibiotics.

Treat a patient >8 weeks of age with IV nafcillin (150 mg/kg/day div q 6h), oxacillin (100–200 mg/kg/day div q 6h; 12 g/day maximum), or cefazolin (100 mg/kg/day div q 6–8h; 6 g/day maximum). If MRSA is a concern or there is a life-threatening penicillin allergy, use IV vancomycin (8 weeks to 11 years of age: 10–15 mg/kg div q 6–8h; 1 g/dose maximum; ≥12 years of age: 10–15 mg/kg q 12h or 1 g IV q 12h) or IV clindamycin (40 mg/kg/day q 6h) for 7–10 days. Supportive care with warm packs and elevation of the breast are important adjuncts. If the patient has an abscess, prior to instituting antibiotic therapy arrange for a needle aspiration by an experienced pediatric or breast surgeon and send a specimen for culture to guide further therapy.

Treat afebrile, well-appearing, older children and adolescents with mastitis with cephalexin (40 mg/kg/day div q 6h or q 12h, respectively) for 7–10 days. If MRSA is a concern, either use clindamycin (20 mg/kg/day q 6h) or add trimethoprim-sulfamethoxazole (8 mg/kg/day of trimethoprim div bid). Warm compresses 4–6 times daily are an important adjunctive measure. Follow-up within 24 hours; if the mass enlarges or becomes fluctuant, or if the patient becomes febrile, admit her for intravenous antibiotics and possible incision and drainage (if an abscess has developed).

Gynecomastia

If the patient has findings consistent with pubertal gynecomastia (duration <2 years, Tanner stages II–III), no laboratory work-up is indicated. If there is concern that this is not benign gynecomastia, or if it has persisted for more than two years, obtain a urinalysis, electrolytes, BUN/creatinine, liver function tests, serum testosterone, estradiol, LH, and hCG, and refer the patient to their primary care provider.

Primary Dysmenorrhea

Primary dysmenorrhea usually presents within 6–12 months of menarche. Typically, colicky suprapubic pain begins several hours before or after the start of a period. The pain may radiate to the back or down the thighs. In 50% of patients there may be nausea, vomiting, diarrhea, and migraine headaches. The symptoms can last from a few hours to several days and there is often a family history of dysmenorrhea.

Secondary Dysmenorrhea

Secondary dysmenorrhea generally presents years after menarche, although dysmenorrhea with the first menses may be a sign of a congenital anomaly with a gynecologic outflow tract obstruction. As in primary dysmenorrhea, the pain occurs during menstruation. There may be a history of pelvic inflammatory disease, vaginal discharge, abdominal or pelvic surgery, menorrhagia, or endometriosis, or an IUD might be in place.

Primary Dysmenorrhea

Oral prostaglandin synthetase inhibitors (nonsteroidal anti-inflammatories) are effective in 70–100% of patients. Use ibuprofen (Motrin, Advil) 400–600 mg q 6h, naproxen (Anaprox 550 mg first dose, then 275 mg q 12h; Aleve 440 mg first dose, then 220 mg q 12h), or mefenamic acid (Ponstel), 500 mg first dose, then 250 mg q 6h.

Since a patient with primary dysmenorrhea ovulates monthly and therefore has regular cycles, have the patient keep track of her menses with a menstrual calendar or the calendar on her cell phone. Advise the patient to start the medication one day before the onset of each period, beginning with a loading dose taken with food. If one nonsteroidal anti-inflammatory agent is ineffective, try an alternative. Side effects include nausea, dizziness, dyspepsia, and gastric irritation. These medications are contraindicated in patients with ulcers and aspirin allergy; use with caution in patients taking anticoagulants or with liver or kidney disease.

Other treatments that may be helpful include heating pads, exercise, a low-salt diet, a well-balanced diet, and reduction of stress. Suppression of ovulation by oral contraceptives is effective, but reserve this therapy for the primary care setting, where appropriate follow-up can be arranged.

Secondary Dysmenorrhea

Refer the patient to a gynecologist to treat the underlying cause. If a patient has a congenital anomaly causing obstruction with hematocolpos, consult with a gynecologist to determine if immediate surgical intervention is indicated. The management of salpingitis is discussed on pp. 337–340. If endometriosis is suspected, refer the patient to a gynecologist to arrange for laparoscopic confirmation of the diagnosis, followed by hormone therapy.

Ovarian Cysts

In young children, ovarian cysts typically present as a mass noted by a parent or clinician. Pain is typically present, ranging from dull and achy to severe pain that can mimic appendicitis or peritonitis. The pain may also be intermittent, suggestive of a partial torsion. In adolescents, pain is usually the presenting complaint, along with menstrual irregularities. If the cyst is hormonally active, there may be premature breast development or vaginal bleeding. There may also be precocious puberty, as in McCune–Albright syndrome.

In all age groups, nausea and vomiting, as well as a “full” bloated feeling may be present. If the cyst is large, there may be mass effect on the bladder or bowel, causing voiding or stooling changes. In such cases, malignancy is a concern.

When a cyst ruptures, the fluid or blood within the peritoneum can cause pain and irritation. Depending on the volume of blood, patients may experience lightheadedness or other signs of hemodynamic instability.

Ovarian Torsion

Ovarian torsion presents with the sudden onset of moderate to severe pelvic pain, which is typically unilateral. It occurs in both young girls and adolescents, commonly in the setting of an ovarian mass, though this may not be known at the time of presentation. The patient may have nausea and vomiting, and possibly fever, as well as signs of peritonitis. The patient may have a recent history of similar, intermittent symptoms (representing partial torsion) which had spontaneously resolved prior to the current symptoms.

Ovarian Cysts

Obtain a detailed medical history, including current symptoms, occurrence of similar symptoms in the past, and any pertinent past medical/surgical or social history. In younger girls, ask about any early signs of puberty, such as vaginal bleeding or the presence of breast development or pubic hair. In adolescents, a menstrual history is important, including date of last menstrual period, age at menarche, length and duration of cycle, and presence of irregular or excessive bleeding. Obtain a sexual history, as sexually transmitted infection is an important cause of pelvic pain. Review any current medications (including hormonal birth control methods). Upon review of systems, new onset of constipation or urinary retention might be a sign of an ovarian cyst or mass.

Check vital signs for hemodynamic instability, which may be associated with a ruptured cyst, and perform a detailed abdominal examination. In sexually active females a pelvic exam is indicated, particularly a bimanual examination, to assess ovarian size, presence of a mass, and signs of infection (such as pelvic inflammatory disease). In younger girls and virginal adolescents, perform a recto-abdominal examination instead.

Laboratory work-up includes a urine or serum pregnancy test if the patient has attained menarche or is pubertal (pregnancy can occur prior to menarche). Obtain relevant STI testing in sexually active patients, including gonorrhea and chlamydia, as well as an RPR and HIV testing. In patients with signs of hemodynamic instability or peritoneal signs, obtain a CBC, as well as a type and screen, as these patients may need surgical intervention.

The definitive diagnostic imaging study for ovarian masses is pelvic ultrasound, which can detail both the size and the character of the mass. Ultrasound can identify follicular cysts, corpus luteal cysts, and more complex masses and tumors, including teratomas and masses suspicious for malignancy. If a cyst has ruptured, fluid may be seen in the pelvis. A large amount of fluid may indicate hemorrhage from the ruptured cyst.

Further laboratory testing may be indicated depending on ultrasound findings. A gynecology consult is indicated for cysts ≥6 cm, if a malignancy is suspected, or the ultrasound results are equivocal.