Causes of abnormal vaginal bleeding in the nonpregnant adolescent

Cause	Comments/associated clinical features
Causes of bleeding from the uterus
Anovulatory uterine bleeding related to immature HPO axis at the onset of menarche*	Most common cause in adolescents; unpredictable timing of bleeding and variable amounts of flow
Other causes of ovulatory dysfunction
PCOS* or other causes of hyperandrogenism (eg, adrenal tumor, CAH)	Hyperandrogenism (acne, hirsutism, clitoromegaly)
Thyroid disease	Weight loss or gain; heat or cold intolerance; fatigue
Hyperprolactinemia	Galactorrhea, vision change, headaches
Hypothalamic dysfunction	Stress, intense exercise, change in weight (loss or gain)
Estrogen-secreting ovarian tumor	Ovarian enlargement or mass
Hypercortisolism (Cushing syndrome)	Central obesity, proximal muscle weakness, purplish striae
Pituitary disease (tumor, infarction)	Impaired vision, headache, pituitary hormone deficiencies (eg, fatigue, cold intolerance, decreased appetite) or excess (eg, hyperprolactinemia)
Diabetes mellitus	Polyuria, polydipsia, nocturia
Primary ovarian insufficiency (premature ovarian failure)	Primary ovarian insufficiency in adolescents can be associated with chromosomal abnormalities (eg, Turner syndrome), thyroid or adrenal abnormalities, and fragile X syndrome^¶^[1]
Medications: Hormonal contraception Androgens Spironolactone Antipsychotics and antidepressants Corticosteroids Chemotherapeutic agents
Infection
Pelvic inflammatory disease*	Fever, mucopurulent discharge, lower abdominal or pelvic pain, pelvic organ tenderness (eg, cervical motion tenderness, adnexal tenderness), inflammation of the genital tract
Endometritis unrelated to pregnancy	Vague, crampy, lower abdominal pain Intrauterine foreign objects Uterine radiation
Endometriosis	Cyclic pain with menses that may progress to acyclic pain; bowel symptoms (rectal pain, constipation, painful defecation, rectal bleeding); bladder symptoms (dysuria, urgency, hematuria)
Bleeding disorders (coagulopathy)* Thrombocytopenia (eg, ITP, leukemia, aplastic anemia) Coagulation disorders (eg, von Willebrand disease, liver dysfunction, vitamin K deficiency) Associated with systemic disease (eg, systemic lupus erythematosus, liver disease, chronic renal disease) Associated with medications (eg, anticoagulants, platelet inhibitors)	Suggested by 1 of the following:^[2] Heavy menstrual bleeding since menarche ≥1 of the following: Postpartum hemorrhage Surgery-related bleeding Bleeding associated with dental work ≥2 of the following: Bruising 1 to 2 times per month Epistaxis 1 to 2 times per month Frequent gum bleeding Family history of bleeding symptoms
Structural uterine problems Polyp Adenomyosis Leiomyoma (fibroid) Malignancy and hyperplasia Congenital uterine anomalies (eg, septate/arcuate, unicornuate, etc)	May be identified through imaging or histopathology
IUD-related bleeding	Intermenstrual: All IUDs Excessive volume: Primarily copper IUD Irregular bleeding: Primarily levonorgestrel IUDs Amenorrhea: Primarily IUDs containing 52 mg levonorgestrel
Causes of vaginal bleeding from sites other than the uterus
Ovary: Cyst, tumor
Cervix: Carcinoma, cervicitis, ectropion, hemangioma, polyp
Vagina: Carcinoma/sarcoma, foreign body (eg, retained tampon), trauma, vaginitis
Vulva: Trauma, sexually transmitted diseases (eg, ulcers), dermatologic conditions
Gastrointestinal tract: Hemorrhoids, infectious colitis, inflammatory bowel disease, vascular malformation, rectal prolapse
Urinary tract: Urinary tract infection, irritation of the urethral meatus, urethral trauma

HPO: hypothalamic-pituitary-ovarian; PCOS: polycystic ovary syndrome; CAH: congenital adrenal hyperplasia; ITP: immune thrombocytopenic purpura; IUD: intrauterine device.

* Most common causes in adolescents.

¶ Refer to UpToDate content on primary ovarian insufficiency for additional information.

Reference:

ACOG Committee Opinion No. 605: Primary ovarian insufficiency in adolescents and young women. Obstet Gynecol 2014: 124:193.
Kouides PA, Conard J, Peyvandi F, et al. Hemostasis and menstruation: Appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding. Fertil Steril 2005; 84:1345.

Additional data from:

ACOG Committee Opinion No. 651: Menstruation in girls and adolescents: Using the menstrual cycle as a vital sign. Obstet Gynecol 2015; 126:e143.
Gray SH, Emans SJ. Abnormal vaginal bleeding in the adolescent. In: Emans, Laufer, Goldstein's Pediatric & Adolescent Gynecology, 6^th ed, Emans SJ, Laufer MR (Eds), Lippincott Williams & Wilkins, Philadelphia 2012. p.159.
Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113:3.

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Causes of abnormal vaginal bleeding in the nonpregnant adolescent