Abstract

PIP: Management of abnormal genital bleeding in girls, adolescents and women, in pregnancy, and in postmenopausal women is reviewed under the headings of evaluation and treatment. In childhood all genital bleeding is clinically significant: it is due to acute infection, foreign bodies, trauma, prolapsed urethra or precocious puberty, rarely to tumors. Bleeding in adolescents and adults is most often due to anovulation, usually estrogen-breakthrough bleeding. Other causes are submucosal leiomyomas, cervical or endometrial polyps, lacerations, uterine or cervical cancer, or systemic disorders such as hypothyroidism or bleeding disorders. Evaluation of bleeding in children requires skill and often general anesthesia, especially if peritoneal laceration is suspected. The 1st step in adolescents and adults is to rule out pregnancy. Pap smears are insufficient: biopsies are advised, especially endometrial biopsies in women 40. Hemoglobin, hematocrit and thyroid status, should also be ordered. Specific treatments involve antibiotics for infection, correction of anemia and orthostatic hypotension, reversal of unopposed estrogen, and medical treatment of menorrhagia and dysfunctional bleeding that does not involve hemodynamic instability. Sometimes curettage, endometrial ablation or hysterectomy is needed. Medical management of breakthrough bleeding caused by unopposed estrogen is high dose estrogen followed by progestin therapy to bring about withdrawal, curettage if necessary, then cyclic combined therapy. In young women 4 birth control pills per day for 5-7 days are often prescribed, with cyclic therapy after withdrawal bleeding is obtained. Prostaglandin inhibitors reduce menstrual loss 50%. Endometrial atrophy in post-menopausal women is treated with cyclic conjugated estrogens and then medroxyprogesterone acetate for 10-13 days per month, or continuous combined therapy for those who can tolerate it.