All forms of hormonal contraception, from combination and progestin-only minipills, to contraceptive patches, rings, intrauterine devices, and injectable and implantable contraception, can be associated with abnormal bleeding, although studies assessing bleeding have not used uniform methodologies and thus comparisons are difficult (70–72). Irregular bleeding occurs frequently in users of depomedroxyprogesterone acetate (DMPA), although at the end of 1 year, more than 50% of users will be amenorrheic (73,74). The mechanism of bleeding associated with these hormonal methods is not well established; an atrophic endometrium or factors related to angiogenesis may be involved, suggesting options for therapy (64,75). It should not be assumed that any bleeding occurring while an individual is using a hormonal method of contraception is caused by that method. Other local causes of bleeding, such as cervicitis or endometritis, can occur during use of hormone therapy and may be particularly important to consider in adolescents who are at risk for STDs (76,77).
Hematologic Abnormalities In the adolescent age group, the possibility of a hematologic cause of abnormal bleeding must be considered. One classic study reviewed all visits by adolescent patients to an emergency room with the symptom of excessive or abnormal bleeding (75,78). The most common coagulation abnormality diagnosed was idiopathic thrombocytopenic purpura, followed by von Willebrand disease. Subsequent studies confirmed this association, particularly with excessive bleeding at the time of menarche. Von Willebrand’s disease occurs in approximately 1% of women in the United States and, in its mildest form, menorrhagia may be the only symptom (79–81). Adolescents who have severe menorrhagia, especially at menarche, should be screened for coagulation abnormalities, including von Willebrand disease.
Infections Irregular or postcoital bleeding can be associated with chlamydial cervicitis. Adolescents have the highest rates of chlamydial infections of any age group, and sexually active teens should be screened routinely for chlamydia (82). Menorrhagia can be the initial sign in patients infected with sexually transmissible organisms. Adolescents have the highest rates of pelvic inﬂammatory disease (PID) of any age group of sexually experienced individuals (see Chapter 18) (83).
Other Endocrine or Systemic Problems Abnormal bleeding can be associated with thyroid dysfunction. Signs and symptoms of thyroid disease can be somewhat subtle in teens (see
Diagnosis of Adolescent Abnormal Bleeding
Chapter 31). Hepatic dysfunction should be considered because it can lead to abnormalities in clotting factor production. Hyperprolactinemia can cause amenorrhea or irregular bleeding.