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Clinical cases. Case 1. Patient N., 15 years old, was admitted to the clinic complaining on profuse bloody discharge, weakness, dizziness. Menarche was at 14 years of age, regular, for 3-4 days, every 28 days, moderate, painless. Marital life she denies. She is ill during 8 days when after 2 monthly absence of menstruation bloody vaginal discharge has started. The next day intensity of a bleeding is accrued, there was a weakness, dizziness. Objective examination: common condition is moderate, BP – 95/50 mm Hg, HR is rhythmical 90 per min. Skin is pale, pure. No internal organs pathology found. Blood analysis : erythrocytes - 2,4х1012/L, hemoglobin - 80 gr/L, globular value 0,7, leukocytes - 8,0x109/L, ESR - 10 mm/hour. Examination in-situ: labia are hypoplastic. The distribution of pubic hair is on female type. Hymen is intact. Rectal examination: Ratio of uterus/cervix is 1:1. Uterus is in correct position, less normal in size, dense, mobile, painless. Adnexa are not detectable from both sides. Discharge is profuse bloody. Ultrasound examination: uterus is 38x28x40 mm in size, M-echo is 5 mm, normal in structure. Both ovaries are normal in size, without pathology. Diagnosis? The reasons of this disease? What conditions should be included in differential diagnosis list? Plan of management? Why this magment I choose that also explains Explain this case in detail

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This case is most consistent with acute abnormal uterine bleeding in adolescence, commonly termed juvenile dysfunctional uterine bleeding / anovulatory uterine bleeding, with clinically significant blood-loss anemia and early hemodynamic compromise. In a 15-year-old with only a year of menstrual history, immaturity of the hypothalamic-pituitary-ovarian axis can lead to prolonged anovulation, unopposed estrogen exposure, irregular endometrial shedding, and heavy bleeding. However, pregnancy-related bleeding, bleeding disorders, endocrine disorders, genital tract lesions, and infection must be excluded.
  1. Diagnosis and severity assessment
    • Interpret the menstrual, examination, ultrasound, vital-sign, and CBC findings.
    • Classify the acute bleeding and anemia/hemodynamic risk.
  2. Pathophysiology and causes
    • Anovulatory bleeding from immature neuroendocrine regulation.
    • Other causes in adolescents, including coagulopathy, endocrine disease, pregnancy, medications, and structural lesions.
  3. Differential diagnosis
    • Pregnancy and pregnancy complications.
    • von Willebrand disease and other coagulopathies.
    • Thyroid and other endocrine causes.
    • Cervical/vaginal trauma, foreign body, infection, tumors, and rarer uterine/ovarian pathology.
  4. Immediate evaluation
    • Stabilization, bleeding quantification, pregnancy testing, CBC and iron studies, coagulation work-up, and targeted endocrine testing.
  5. Acute management
    • Resuscitation and monitoring.
    • Hormonal and nonhormonal methods to stop bleeding.
    • Indications for admission, transfusion, and specialist involvement.
  6. Post-bleeding care and follow-up
    • Iron replacement, menstrual regulation, recurrence prevention, and investigation for an underlying bleeding disorder.
The priority is not merely to label the bleeding as “dysfunctional.” Her BP 95/50 mm Hg, pallor, dizziness, and hemoglobin of 80 g/L indicate that stabilization and control of active hemorrhage come first. A normal pelvic ultrasound and absence of palpable adnexal disease make a structural pelvic cause less likely, but they do not rule out pregnancy or systemic causes, particularly an inherited bleeding disorder. Management is therefore guided by clinical stability, ongoing blood loss, hemoglobin trend, pregnancy status, and contraindications to estrogen or antifibrinolytic therapy.
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This case is most consistent with acute abnormal uterine bleeding in adolescence, commonly termed juvenile dysfunctional uterine bleeding / anovulatory uterine bleeding, with clinically significant blood-loss anemia and early hemodynamic compromise. In a 15-year-old with only a year of menstrual history, immaturity of the hypothalamic-pituitary-ovarian axis can lead to prolonged anovulation, unopposed estrogen exposure, irregular endometrial shedding, and heavy bleeding. However, pregnancy-related bleeding, bleeding disorders, endocrine disorders, genital tract lesions, and infection must be excluded.
  1. Diagnosis and severity assessment
    • Interpret the menstrual, examination, ultrasound, vital-sign, and CBC findings.
    • Classify the acute bleeding and anemia/hemodynamic risk.
  2. Pathophysiology and causes
    • Anovulatory bleeding from immature neuroendocrine regulation.
    • Other causes in adolescents, including coagulopathy, endocrine disease, pregnancy, medications, and structural lesions.
  3. Differential diagnosis
    • Pregnancy and pregnancy complications.
    • von Willebrand disease and other coagulopathies.
    • Thyroid and other endocrine causes.
    • Cervical/vaginal trauma, foreign body, infection, tumors, and rarer uterine/ovarian pathology.
  4. Immediate evaluation
    • Stabilization, bleeding quantification, pregnancy testing, CBC and iron studies, coagulation work-up, and targeted endocrine testing.
  5. Acute management
    • Resuscitation and monitoring.
    • Hormonal and nonhormonal methods to stop bleeding.
    • Indications for admission, transfusion, and specialist involvement.
  6. Post-bleeding care and follow-up
    • Iron replacement, menstrual regulation, recurrence prevention, and investigation for an underlying bleeding disorder.
The priority is not merely to label the bleeding as “dysfunctional.” Her BP 95/50 mm Hg, pallor, dizziness, and hemoglobin of 80 g/L indicate that stabilization and control of active hemorrhage come first. A normal pelvic ultrasound and absence of palpable adnexal disease make a structural pelvic cause less likely, but they do not rule out pregnancy or systemic causes, particularly an inherited bleeding disorder. Management is therefore guided by clinical stability, ongoing blood loss, hemoglobin trend, pregnancy status, and contraindications to estrogen or antifibrinolytic therapy.
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adolescent abnormal uterine bleeding

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ACOG adolescent heavy menstrual bleeding acute management evaluation bleeding disorder committee opinion

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https://www.acog.org/clinical/clinical-guidance/committee-op…

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Working diagnosis

Acute heavy abnormal uterine bleeding due to ovulatory dysfunction in an adolescent
Former term: juvenile dysfunctional uterine bleeding or juvenile anovulatory uterine bleeding.
Associated problems:
  • Symptomatic moderate-to-severe anemia, most likely iron-deficiency anemia from blood loss: Hb 80 g/L, RBC 2.4 × 10¹²/L, color index 0.7, pallor, weakness, dizziness.
  • Possible early hypovolemia/hemodynamic compromise: BP 95/50 mmHg with ongoing profuse bleeding. The pulse of 90/min does not exclude significant blood loss, especially in a young patient.
The most likely FIGO category is AUB-O, abnormal uterine bleeding due to ovulatory dysfunction. Structural causes are unlikely because the uterus, ovaries, and ultrasound are normal, but a normal ultrasound does not by itself establish the diagnosis.

Why this diagnosis fits

FindingInterpretation
Menarche only 1 year agoEarly postmenarchal cycles are often anovulatory because the hypothalamic-pituitary-ovarian axis is still maturing.
Two months without mensesSuggests prolonged anovulation rather than a regular ovulatory cycle.
Sudden prolonged heavy bleedingTypical of unstable, irregular shedding of endometrium after an anovulatory interval.
Normal pelvic ultrasoundMakes fibroid, large ovarian mass, uterine malformation, and retained intrauterine lesion less likely.
Small, painless, mobile uterus and no adnexal massSupports absence of obvious structural pelvic pathology.
Severe anemia symptomsConfirms clinically important blood loss and mandates inpatient management.
Anovulation is common for about the first 18 months after menarche, and heavy bleeding in this period is most often related to anovulatory cycles. However, bleeding disorders are an important alternative cause in adolescents. Textbook of Family Medicine, 9e, Adolescents section. Berek also emphasizes that adolescents with acute heavy bleeding require screening for coagulation abnormalities, including von Willebrand disease. Berek & Novak’s Gynecology, p. 412.

Pathophysiology

Normally:
  1. Follicle growth produces estrogen.
  2. Ovulation occurs.
  3. The corpus luteum produces progesterone.
  4. Progesterone stabilizes the endometrium.
  5. Progesterone withdrawal produces a predictable menstrual bleed.
In this patient, immature hypothalamic-pituitary-ovarian regulation likely caused anovulation:
  1. No ovulation occurs.
  2. No corpus luteum forms.
  3. Therefore, progesterone is absent or insufficient.
  4. Estrogen acts without progesterone opposition.
  5. The endometrium proliferates irregularly and its blood vessels become fragile.
  6. Endometrial shedding becomes asynchronous, prolonged, and sometimes profuse.
The two-month amenorrhea was likely the anovulatory phase. The subsequent prolonged hemorrhage is the irregular shedding phase.

Causes to consider

Although anovulation is most likely, do not call this purely “dysfunctional” bleeding until key causes have been excluded.

Most likely cause

  • Immaturity of the hypothalamic-pituitary-ovarian axis causing anovulation.

Important alternative or contributory causes

  • Bleeding disorder: especially von Willebrand disease, platelet dysfunction, immune thrombocytopenia, factor deficiencies.
  • Pregnancy-related bleeding: early pregnancy loss, ectopic pregnancy. Sexual history must be obtained confidentially, but a history of no intercourse is not adequate to omit pregnancy testing.
  • Endocrine disease: thyroid disease, hyperprolactinemia, PCOS, marked weight change, eating disorder, stress, excessive exercise.
  • Medication-related bleeding: anticoagulants, antiplatelet drugs, hormonal medications.
  • Systemic disease: liver disease, renal disease, hematologic malignancy.
  • Genital tract causes: trauma, foreign body, cervicitis/vaginitis, sexual abuse.
  • Structural uterine causes: polyp, fibroid, adenomyosis, endometrial lesion. These are much less common at age 15 and are not supported by this ultrasound.

Differential diagnosis

Use the FIGO PALM-COEIN system, while remembering that nonstructural causes predominate in adolescents.

Pregnancy-related causes: exclude first

  • Intrauterine pregnancy
  • Miscarriage/incomplete abortion
  • Ectopic pregnancy
  • Gestational trophoblastic disease

Structural causes: PALM

  • Polyp
  • Adenomyosis
  • Leiomyoma
  • Malignancy/hyperplasia
These are less likely here because of the normal ultrasound, normal-size uterus, and age.

Nonstructural causes: COEIN

  • Coagulopathy: von Willebrand disease, thrombocytopenia, platelet disorders
  • Ovulatory dysfunction: most likely in this case
  • Endometrial disorder
  • Iatrogenic: drugs or hormonal treatment
  • Not otherwise classified
Additional practical diagnoses:
  • Acute cervicitis/vaginitis
  • Vaginal trauma or foreign body
  • Sexual abuse
  • Acute leukemia or other marrow disorder causing thrombocytopenia
  • Thyroid dysfunction
  • Hyperprolactinemia
  • PCOS

Immediate evaluation

This patient should be admitted to hospital, preferably under pediatric/adolescent gynecology, with hematology involvement if a bleeding disorder is suspected.

1. Assess and stabilize circulation

  • Measure bleeding quantity: pads per hour, clots, overflow, orthostatic symptoms.
  • Repeat BP and pulse, including orthostatic measurements.
  • Establish two large-bore IV lines.
  • Strict intake/output chart and frequent reassessment.
  • Begin isotonic crystalloid if volume depleted.
  • Group and crossmatch blood.
Her dizziness, pallor, hypotension, active heavy bleeding, and Hb 80 g/L support inpatient observation and acute treatment. ACOG recommends hospitalization for adolescents who are hemodynamically unstable or actively bleeding heavily, with crystalloid volume support, hormonal treatment, and iron replacement. ACOG guidance

2. Essential investigations

Obtain blood before transfusion if possible, without delaying resuscitation.
  • Repeat CBC with platelet count
  • Reticulocyte count
  • Serum ferritin, iron studies
  • Blood group, crossmatch
  • Serum or urine beta-hCG in every postmenarchal patient
  • PT/INR, aPTT, fibrinogen
  • von Willebrand factor antigen, vWF activity, factor VIII level
  • Peripheral blood smear if platelet or hematologic disease is possible
  • TSH
  • Renal and liver function tests if history/examination suggests systemic disease
  • Prolactin, androgen testing, or PCOS evaluation only if indicated by the history and phenotype
  • STI testing if confidential history or examination suggests exposure
Interpret vWF tests cautiously: acute bleeding, stress, inflammation, anemia, and estrogen treatment can raise vWF levels. If the first test is non-diagnostic but suspicion persists, repeat testing later with hematology input.

3. Examination

  • Careful inspection of external genitalia for trauma, lesions, foreign body, or bleeding source.
  • Speculum examination is not routine in a non-sexually active adolescent with an intact hymen. It is considered only if necessary to identify trauma, a vaginal/cervical source, or a foreign body, and should be performed gently by an experienced clinician.
  • Ultrasound has already excluded major pelvic structural disease. Repeat imaging is unnecessary unless bleeding fails to respond or a new concern arises.

Acute management plan

A. First priority: control hemorrhage and maintain perfusion

  1. Hospitalize and monitor closely.
  2. IV crystalloid for volume replacement as indicated.
  3. Type and crossmatch blood.
  4. Monitor pulse, BP, orthostatic vitals, urine output, bleeding rate, and serial Hb.

B. Medical control of bleeding

Because she has active profuse bleeding, symptoms, Hb 80 g/L, and low BP, she needs high-dose hormonal therapy, assuming pregnancy is excluded and there is no estrogen contraindication.

Preferred if no contraindication to estrogen

One standard acute regimen is:
  • Monophasic combined oral contraceptive containing 30-50 micrograms ethinyl estradiol, one tablet every 6-8 hours until bleeding is controlled, then taper under local protocol.
If oral medication is not tolerated, vomiting is present, or bleeding is very severe:
  • IV conjugated estrogen 25 mg every 4-6 hours may be used in monitored inpatient care, followed by transition to oral combined hormonal therapy once bleeding improves.
High-dose estrogen or combined pills stabilize the endometrium rapidly. Antiemetic treatment is often required because nausea is common.

If estrogen is contraindicated

For example, migraine with aura, previous thrombosis, significant thrombophilia, severe liver disease, or other estrogen contraindications:
  • High-dose oral progestin, such as medroxyprogesterone acetate or norethindrone acetate, using a hospital protocol, then taper to maintenance treatment.

Antifibrinolytic therapy

  • Tranexamic acid can be added or used when hormonal therapy is contraindicated, insufficient, or a bleeding disorder is suspected.
  • Use should be individualized, especially if there is a thrombotic history or other contraindication. Involve hematology if von Willebrand disease or another coagulopathy is identified.
Medical treatment is first-line in adolescents; surgical intervention is reserved for refractory bleeding or a suspected retained clot/structural lesion. Berek & Novak’s Gynecology, p. 412.

C. Treat anemia

  • Start oral iron after acute nausea/vomiting is controlled, for example an oral elemental-iron regimen appropriate to weight and tolerance.
  • Continue iron for at least several months and until hemoglobin and ferritin are repleted.
  • Consider IV iron if oral iron is not tolerated, absorption is poor, or rapid replacement is required after stabilization.

D. Red-cell transfusion: do not decide solely from Hb

Hb 80 g/L is serious, but transfusion is determined by the whole clinical picture:
Transfuse packed red blood cells if there is:
  • Persistent hypotension, tachycardia, syncope, altered mental status, or poor perfusion despite fluids
  • Continued severe bleeding
  • Worsening hemoglobin or inability to control hemorrhage
  • Significant symptomatic anemia not improving with resuscitation and medical hemostasis
If she stabilizes quickly and bleeding is controlled, adolescents can sometimes avoid transfusion despite Hb around 80 g/L because they can recover with iron therapy. In this specific case, crossmatched blood must be ready and the threshold should be low if instability persists.

E. What should not be first-line

  • Dilation and curettage is not routine first-line treatment in this 15-year-old.
  • Surgical treatment risks trauma to the cervix/endometrium, anesthesia complications, and does not treat the underlying anovulatory or hematologic cause.
  • Consider procedural evaluation only if medical therapy fails, bleeding remains life-threatening, retained intrauterine clot is suspected, or a structural lesion becomes likely.

After bleeding is controlled

  1. Taper acute hormonal therapy to daily combined hormonal contraception or a cyclic progestin regimen.
  2. Continue maintenance therapy for at least 3-6 cycles, individualized to recurrence risk and anemia recovery.
  3. Continue iron and repeat CBC/ferritin.
  4. Review a menstrual bleeding diary.
  5. Arrange pediatric gynecology follow-up.
  6. Arrange hematology follow-up if screening suggests von Willebrand disease, thrombocytopenia, or another disorder.
  7. Provide confidential adolescent counseling, including assessment of pregnancy possibility and safeguarding concerns where appropriate.

Why this management is appropriate in this patient

  • She has acute heavy uterine bleeding, not a mild menstrual irregularity.
  • Her symptoms and BP suggest that blood loss has become physiologically important.
  • The Hb of 80 g/L and hypochromic indices indicate anemia requiring iron replacement and close observation.
  • Her postmenarchal age and two months of amenorrhea make anovulation the leading cause.
  • However, heavy bleeding in an adolescent can be the first sign of von Willebrand disease or another coagulopathy, so coagulation testing is necessary even if anovulation appears likely.
  • A normal ultrasound makes surgery less appropriate and supports initial medical management.
  • Hormonal treatment directly addresses the likely mechanism: unstable endometrium caused by absence of progesterone after anovulation.
A recent systematic review supports using standardized FIGO classification for abnormal uterine bleeding, though it is not specifically an adolescent acute-treatment guideline (PMID 39234899).
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