HEMORRHAGE IN PREPUBERTY (Part One)

General

Menarche (the first cycle) occurs when the breast has reached development in Tanner stage III or IV. Normally, menarche occurs at the age of 11-14 years. The normal cycle lasts up to 7 days or less, with a quantity of up to 80ml or less, and with a frequency of 21-45 days.

The menstrual cycle occurs when there is a coordinated function of the Hypothalamic - Pituitary - Ovarian axis. The first menstrual cycles are irregular as a result of incomplete maturation of this axis.

95% of hemorrhages in adolescence occur from anovulation. Of these, 55-82% occur within the first 2 years and 20% of them occur in the first 4-5 years.

Any type of hemorrhage that occurs without breast development should be evaluated for some other possible cause.

Causes of prepubertal hemorrhage

The causes of prepubertal hemorrhage are diverse, therefore it is necessary to take a careful history and a complete physical examination in order to determine the exact cause, so that appropriate treatment can be undertaken.

1 - Vulvar or external

• Skin conditions (lichen sclerosus, lichen simplex chronicus, lichen planus, psoriasis, eczema)
• Pigmented lesions
• Tumors and cysts
• Epithelial dysplasia
• Ulcers

2 - Vagina

a - Embryonic origin

• Mesonephric, paramesonephric, urogenital sinus cysts
• Adenosis (from intrauterine exposure to DES)
• Vaginal septa or duplications

b - Pelvic organ or pelvic support prolapse

• Anterior vaginal prolapse (cystourethrocele, cystocele)
• Apical vaginal prolapse (uterovaginal, vaginal vault)
• Posterior vaginal prolapse (enterocele, rectocele)

c - Others

• Condyloma
• Urethral diverticulum
• Fibroepithelial polyp
• Vaginal endometriosis

3 - Cervix

a - Various infections

• Condyloma
• Chlamydia
Ulceration from Herpes Simplex Virus

b - Others

• Endocervical polyp
• Nabothian cysts
• Eversion of the columnar epithelium

4 - Benign ovarian tumors

• Functional (follicular, corpus luteum, theca lutein)
• Inflammatory (tubo-ovarian abscess)
• Neoplastic (germ cells, benign cystic teratoma, others or mixed)
• Epithelial (serous cystadenoma, mucinous cystadenoma, fibroma, cystadenofibroma, Brenner tumor, mixed tumors)
• Others (endometrioma)