A 14-year-old girl is brought to the office by her mother due to irregular menses. The patient's first menstrual period occurred a year ago. Her menses since then have been irregular and unpredictable, occurring every 3-8 weeks. The patient says that when she does have a period, the bleeding lasts 3-7 days. When she has a 6-week lapse in menses, the heavy bleeding often soaks through a tampon and large pad overnight. The patient also has passage of small clots during the first 2 days. She has had no nausea, breast tenderness, or cramping. The patient has no chronic medical conditions and takes no medications. She is not sexually active and does not use tobacco, alcohol, or illicit drugs. Family history is significant for an aunt who had a hysterectomy for endometrial hyperplasia. Blood pressure is 100/60 mm Hg and pulse is 68/min. BMI is 24 kg/m². Mild comedonal acne is present on the forehead. Skin examination is otherwise unremarkable. Breast development is Tanner stage 4. The abdomen is soft and nontender with no palpable masses. Examination of external genitalia shows Tanner stage 4 pubic hair. Urine pregnancy testing is negative. Which of the following is the best next step in management of this patient?

Question

A 14-year-old girl is brought to the office by her mother due to irregular menses. The patient's first menstrual period occurred a year ago. Her menses since then have been irregular and unpredictable, occurring every 3-8 weeks. The patient says that when she does have a period, the bleeding lasts 3-7 days. When she has a >6-week lapse in menses, the heavy bleeding often soaks through a tampon and large pad overnight. The patient also has passage of small clots during the first 2 days. She has had no nausea, breast tenderness, or cramping. The patient has no chronic medical conditions and takes no medications. She is not sexually active and does not use tobacco, alcohol, or illicit drugs. Family history is significant for an aunt who had a hysterectomy for endometrial hyperplasia. Blood pressure is 100/60 mm Hg and pulse is 68/min. BMI is 24 kg/m². Mild comedonal acne is present on the forehead. Skin examination is otherwise unremarkable. Breast development is Tanner stage 4. The abdomen is soft and nontender with no palpable masses. Examination of external genitalia shows Tanner stage 4 pubic hair. Urine pregnancy testing is negative. Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf12_e617_8f63_77fa2fba3afb_MD0005_00 Anovulatory bleeding is the most common reason for abnormal uterine bleeding in adolescents during the first few years after menarche. In early puberty, the immature hypothalamic-pituitary-ovarian axis produces insufficient amounts of GnRH. This insufficiency results in the inability to mount an LH surge for ovulation. When ovulation fails to occur, the corpus luteum does not form, progesterone production does not occur, and the normal, synchronized endometrial sloughing triggered by progesterone withdrawal (ie, menses) does not happen. hypothalamic-pituitary-ovarian axis The result is a noncyclical, unopposed production of estrogen that leads to estrogen breakthrough bleeding, a dyssynchronous sloughing of varying portions of the endometrium. This leads to irregular bleeding that can range from light to heavy with passage of clots and is typically without premenstrual symptoms (eg, cramping, breast tenderness, nausea). estrogen breakthrough bleeding Because anovulatory bleeding typically resolves within 1-2 years of menarche with maturation of the hypothalamic-pituitary-ovarian axis, management is with reassurance and observation. Hormonal contraception can be considered for menstrual cycle control for severe symptoms or patient preference. (Choice A) Endometrial biopsy is indicated to exclude endometrial cancer and/or hyperplasia in adolescents with abnormal uterine bleeding that persists despite medical management (eg, oral contraceptives) or after 2-3 years of untreated anovulatory bleeding in patients with risk factors (eg, obesity). Although this patient has a family history of endometrial hyperplasia, her normal BMI decreases her risk for endometrial cancer; therefore, biopsy is not indicated. (Choice B) Pelvic ultrasound is indicated to evaluate for structural uterine anomalies (eg, leiomyoma, polyps) in adolescents with abnormal menstrual bleeding that does not normalize with conservative management and/or oral contraceptive use. However, these anomalies are uncommon in adolescents. (Choice D) Ristocetin cofactor activity is used to evaluate for von Willebrand disease (vWD), which can present with heavy, prolonged (>7 days) menstrual periods. However, patients with vWD have regular, rather than irregular, menses, making this diagnosis less likely. (Choice E) A testosterone level is indicated in the evaluation of amenorrhea/oligomenorrhea when polycystic ovary syndrome is suspected based on clinical features suggestive of hyperandrogenism (eg, hirsutism) and/or insulin resistance (eg, acanthosis nigricans, obesity). Educational objective: In adolescents, the most common cause of irregular menstrual bleeding is anovulation, a result of an immature hypothalamic-pituitary-ovarian axis. First-line treatment is reassurance and observation. Hormonal contraception can be considered for severe symptoms or according to patient preference. References: Evaluation and management of adolescents with abnormal uterine bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/26431240) Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/23787936)

A 14-Year-Old Girl Is Brought to the Office by Her