The etiology, diagnosis, and management of abnormal vaginal or uterine bleeding vary by reproductive phase or status: premenarche, reproductive age, pregnancy, or menopause. Abnormal vaginal bleeding in infants and premenarchal children is discussed here.
Vaginal bleeding can originate anywhere in the genital tract, including the vulva, vagina, cervix, and uterus. When vaginal bleeding originates in the uterus, it is called abnormal uterine bleeding (AUB).
Etiology of Vaginal Bleeding in Children
Causes of vaginal bleeding in children vary (see table Causes of Vaginal Bleeding in Children).
Vaginitis, foreign bodies, and trauma are common causes of vaginal bleeding before menarche. Sexual abuse and cancer are less common causes; however, prompt evaluation is required to exclude these conditions.
Evaluation of Vaginal Bleeding in Children
The first priority is determining whether the vaginal bleeding is heavy enough to require emergency care.
History
General medical history is obtained; for infants, birth history and mother's obstetric history are included. Family history of cancer is important. The medical history is obtained from the parent (or caregiver) and the child, if age-appropriate.
History of present illness should include questions to elicit characteristics of the bleeding:
Onset: Start of the bleeding and whether there were any possible causative factors
Pattern: Intermittent or constant
Duration
Volume: Bleeding may be spotting, light bleeding, or heavier
Relationship to other symptoms: Presence of pelvic or abdominal pain or pressure, fever, or urinary or bowel symptoms
Review of systems should seek symptoms of possible causes, including the following:
Pelvic pain, nausea, vomiting: Adnexal torsion
Vaginal discharge, fever, and pelvic pain: Pelvic infection, with possible sexual assault
If sexual abuse of a child is suspected, a structured forensic interview based on the National Institute of Child Health and Human Development (NICHD) Protocol can be used. It helps the child report information about the experienced event and improves the quality of information obtained.
Physical examination
A general physical examination is done. The abdomen is evaluated for abdominal distention, mass, ascites, tenderness, and peritoneal signs.
If a pelvic examination is required, the parent and child should be educated regarding the examination so they know what to expect and to build trust between the child and clinician. The goal of the examination should be to obtain necessary information without causing fear or unnecessary discomfort to the child.
Examination of the external genitals and perineal and groin area should note any bleeding, discharge, bruising, or injury.
In children, an internal pelvic examination is typically performed under anesthesia. The vagina and cervix may be examined using a Killian nasal speculum, fiberoptic vaginoscope, cystoscope, or flexible hysteroscope with saline lavage.
Red flags
The following findings are of particular concern:
Vaginal discharge, fever, chills, lower abdominal tenderness, and/or signs of genital injury: Possible pelvic infection, with possible tubo-ovarian abscess and/or sexual abuse
Precocious puberty: Possibly a feminizing ovarian tumor
Interpretation of findings
Heavy bleeding or severe pain suggests an etiology that requires urgent treatment.
Vaginal bleeding combined with an abdominal mass raises concern for a malignancy.
Testing
A complete blood count is done if bleeding is severe or persistent or if there are signs and symptoms consistent with pelvic infection.
If there is a vaginal discharge, a sample can be collected for culture without a speculum examination, using methods appropriate for children. The sample is tested for common vaginal bacterial infections or candidiasis. If sexual abuse is suspected, testing for sexually transmitted infection is done with blood tests and urine or vaginal specimens (cervical specimens should be taken only with the child under anesthesia) (1).
If there are signs of precocious puberty, an endocrinologic evaluation is done.
If a pelvic mass is suspected, imaging is done. Transabdominal ultrasound is preferred over transvaginal ultrasound in young children and prepubertal adolescents. If ultrasound does not clearly delineate size, location, and consistency of a mass, another imaging test (typically MRI) may be needed. If there is an ovarian mass and a nonepithelial neoplasm is suspected, tumor markers (eg, alpha-fetoprotein, lactate dehydrogenase, inhibin) are measured.
Evaluation reference
1. Chiesa A, Goldson E. Child Sexual Abuse. Pediatr Rev. 2017;38(3):105-118. doi:10.1542/pir.2016-0113
Treatment of Vaginal Bleeding in Children
Vaginal bleeding in children is treated based on the cause. Infectious etiologies are treated with antimicrobials. Removal of a foreign body from the vagina usually requires a procedure under anesthesia.
If a benign or malignant neoplasm is possible based on imaging or tumor markers, surgery is required. Fertility-preserving surgery is preferred whenever possible (1).
If sexual abuse is suspected, documentation is done based on the physical examination and local medical and legal requirements for sexual assault victims. Children should be examined and receive support during and after the evaluation by trained healthcare professionals.
Treatment reference
1. Delehaye F, Sarnacki S, Orbach D, et al: Lessons from a large nationwide cohort of 350 children with ovarian mature teratoma: A study in favor of ovarian-sparing surgery. Pediatr Blood Cancer. 2022;69(3):e29421. doi:10.1002/pbc.29421
Key Points
Bleeding may appear to be from the vagina, but bleeding can originate anywhere in the female genital tract, including the vulva, vagina, cervix, uterus, fallopian tubes, or ovaries, or also from the urinary or gastrointestinal tract.
Vaginitis, foreign bodies, and trauma are common causes of vaginal bleeding before menarche; sexual abuse is a less common cause but, if suspected, requires prompt evaluation.
Evaluate for vaginitis with external pelvic examination.
Evaluate with pelvic imaging if a pelvic mass is suspected.
