Laboratory Testing Any adolescent with abnormal bleeding should undergo sensitive pregnancy testing, regardless of whether she states that she has had intercourse. The medical consequences of failing to diagnose a pregnancy are too severe to risk missing the diagnosis. Complications of pregnancy should be managed accordingly. In addition to a pregnancy test, laboratory testing should include a complete blood count with platelet count and screening tests for coagulopathies and platelet dysfunction. An international expert panel made recommendations about when a gynecologist should suspect a bleeding disorder and pursue a diagnosis (Table 14.8). The consensus report recommends measurement of complete blood cell count (CBC), platelet count and function, prothrombin time (PT), activated partial thromboplastin time (PTT),
Table 14.8 When Should a Gynecologist Suspect a Bleeding Disorder
Family history of bleeding disorder
Personal history of any of the following:
Epistaxis in the last year
Postpartum hemorrhage, especially delayed >24 h
Failure to respond to conventional management of menorrhagia
From James AH, Kouides PA, Abdul-Kadir R, et al. Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol 2009;201:12e1–e8.
Management of Abnormal Bleeding von Willebrand factor (VWF) (measured with ristocetin cofactor activity and antigen, factor VIII), and fibrinogen to be assessed in collaboration with a hematologist (81).
Thyroid studies may be relevant. Testing for STDs may be performed as warranted on either a cervical or a urine specimen using DNA amplification techniques. Cervical cytology testing is generally not appropriate for adolescents, particularly at an emergency or urgent visit for excessive bleeding (87).
Imaging Studies If the pregnancy test results are positive, pelvic imaging using ultrasonography may be necessary to confirm a viable intrauterine pregnancy and rule out a spontaneous abortion or ectopic pregnancy. If a pelvic mass is suspected on examination, or if the examination is inadequate (more likely to be the case in an adolescent than an older woman) and additional information is required, pelvic ultrasonography may be helpful. Although transvaginal ultrasonographic examination can be more helpful than transabdominal ultrasonography in ascertaining details of pelvic anatomy, the use of the vaginal probe may not be possible in a young girl or one who has not used tampons or had intercourse. Direct communication between the clinician and the radiologist can be helpful in identifying patients who are appropriate candidates for transvaginal ultrasonographic examination, such as those who are sexually active, rather than a blanket prohibition against transvaginal ultrasound examination in adolescents.
Other imaging studies are not indicated as initial testing but may be helpful in selected instances.
If a pelvic ultrasonographic examination does not lead to clarification of the anatomy when vaginal septa, uterine septa, uterine duplication, or vaginal agenesis is suspected, MRI can be helpful in delineating anatomic abnormalities (88). This imaging technique is useful in the evaluation of uterine and vaginal developmental anomalies, although laparoscopy can still play a role in the clarification of abnormal anatomy (89). CT scanning may be helpful in detecting nongenital intra-abdominal abnormalities.
Management of bleeding abnormalities related to pregnancy, thyroid dysfunction, hepatic abnormalities, hematologic abnormalities, or androgen excess syndromes should be directed to treating the underlying condition. Oral contraceptives can be extremely helpful in managing androgen excess syndromes, inherited bleeding disorders, and anovulation, although an appropriate evaluation should be performed prior to initiation of hormonal contraception (90–92).