A 15-year-old girl is brought to the office due to prolonged, irregular menstrual periods. Menses occur at 2- to 4-month intervals and last for 7-10 days with heavy bleeding and passage of large clots. The patient's menstrual cycles are nonpainful and she has no associated dizziness, fatigue, palpitations, or abnormal vaginal discharge. Menarche was at age 14 and her last menstrual period was a month ago. She has no other chronic medical conditions or previous surgeries. The patient has never been sexually active. Blood pressure is 110/70 mm Hg and pulse is 72/min. Height and weight are at the 40th and 56th percentiles, respectively. The thyroid is without nodules. The skin has no discoloration or ecchymosis. Breast and pubic hair development are Tanner stage V. External pelvic examination shows no lacerations, lesions, discharge, or bleeding. The hymenal membrane is intact. Hemoglobin is 10.4 g/dL. PT and aPTT are normal. Which of the following is the best next step in management of this patient?

Question

A 15-year-old girl is brought to the office due to prolonged, irregular menstrual periods.  Menses occur at 2- to 4-month intervals and last for 7-10 days with heavy bleeding and passage of large clots.  The patient's menstrual cycles are nonpainful and she has no associated dizziness, fatigue, palpitations, or abnormal vaginal discharge.  Menarche was at age 14 and her last menstrual period was a month ago.  She has no other chronic medical conditions or previous surgeries.  The patient has never been sexually active.  Blood pressure is 110/70 mm Hg and pulse is 72/min.  Height and weight are at the 40th and 56th percentiles, respectively.  The thyroid is without nodules.  The skin has no discoloration or ecchymosis.  Breast and pubic hair development are Tanner stage V.  External pelvic examination shows no lacerations, lesions, discharge, or bleeding.  The hymenal membrane is intact.  Hemoglobin is 10.4 g/dL.  PT and aPTT are normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d25d_0114_bc81_5da11a437e21_MD0003_00 During the first year after menarche, adolescents often have anovulatory cycles with heavy, irregular menstrual bleeding due to an immature hypothalamic-pituitary axis. In ovulatory cycles, the corpus luteum produces progesterone after ovulation; progesterone differentiates the proliferative endometrium into secretory endometrium. As the corpus luteum degenerates, the decrease in progesterone leads to normal menses through a decrease in endometrial blood supply and shedding of the lining. In contrast, anovulatory cycles do not produce progesterone (eg, no corpus luteum development) and there is no differentiation into secretory endometrium. Therefore, these patients have continued unopposed estrogen stimulation resulting in uncontrolled proliferation of the endometrium. Bleeding occurs when the endometrial lining becomes too thickened and unstable (eg, breakthrough bleeding). Progesterone treatment helps stabilize this uncontrolled proliferation due to estrogen by causing differentiation into secretory endometrium. Cyclic progesterone withdrawal then causes menstruation. (Choice A) Congenital anomalies of the reproductive tract (eg, Müllerian agenesis) typically present with primary amenorrhea rather than abnormal uterine bleeding. In patients with suspected anomalies, a pelvic MRI can be used to evaluate the structure of the reproductive tract. (Choice B) Nucleic acid amplification testing is used in the evaluation of acute cervicitis, which presents with postcoital or intermenstrual spotting rather than heavy menses. Acute cervicitis is typically caused by a sexually transmitted infection (eg, Neisseria gonorrhoeae, Chlamydia trachomatis) and is unlikely in a patient who is not sexually active. acute cervicitis (Choice C) An endometrial biopsy is an invasive procedure that can be used to diagnose endometrial hyperplasia, a condition that is rare in adolescents. An endometrial biopsy may be indicated in an adolescent with risk factors for hyperplasia (eg, obesity) or if symptoms do not improve with medical management. endometrial biopsy (Choice D) A hysteroscopy is a procedure that can be used to evaluate the endometrium for structural causes of abnormal bleeding (eg, endometrial polyp, submucosal leiomyoma) and may be indicated if pharmacotherapy fails. endometrial polyp (Choice E) A copper-containing intrauterine device is a long-acting, reversible form of contraception that causes heavier, longer menses. Therefore, it is not recommended in patients with heavy menstrual bleeding and anemia. Educational objective: Adolescents often have anovulatory cycles with irregular, heavy menstrual bleeding due to an immature hypothalamic-pituitary axis. Progesterone normalizes menstruation by stabilizing unregulated endometrial proliferation. References: Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology. (http://www.ncbi.nlm.nih.gov/pubmed/22946701) Evaluation and management of adolescents with abnormal uterine bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/26431240)

A 15-Year-Old Girl Is Brought to the Office Due to Prolonged