PAG over Pastries

A pediatric and adolescent gynecology review podcast. Started by a fellow for residents, fellows, and others to learn more about PAG topics.

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PAG over Pastries

5 - Prepubertal Bleeding

February 24, 2025 • Camille Imbo & Susan Kaufman, NASPAG • Season 1 • Episode 5

Camille Imbo, MD PGY6 and Susan Kaufman, MD talk about how to work up and examine prepubertal bleeding, as well as differential diagnoses.

Outline

Patient and Family History
Examination techniques and consent
positioning and observation techniques
differential diagnoses of prepubertal bleeding
Common Causes
Rare Causes
Case review

Check out the episode visuals on YouTube.

References:

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What is PAG?
Pediatric and Adolescent Gynecology is a subspecialty of OBGYN (2 year fellowship) focusing on reproductive healthcare for children and young adults. It fills the overlap between general gynecologists and pediatricians. It is a multi-disciplinary field involving work with pediatric endocrinology, dermatology, hematology, surgery, ect. Go to NASPAG.org for more PAG educational resources.

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PAG WebEd cases are a great way to review our podcast content.

A 6-year-old girl is brought to the clinic by her mom, who is worried because she noticed blood on her daughter’s underwear after gymnastics practice. The child denies pain, reports no recent trauma, and has otherwise been healthy. She hasn’t started puberty yet—no breast development, no pubic hair. The mom is understandably concerned.
What’s on your differential for prepubertal vaginal bleeding?
Hi everyone, and welcome to Pag over pastries. I'm Camille Imbo. I'm currently a second year pag Fellow at Phoenix Children's,
and I'm Susan Kaufman. I have been practicing pag for over 30 years, both in a private practice and academic setting.
Favorite pastry?
I love bearclaws. What do you like?
Chocolate croissants
Oh, that's a good pick. All right. Well, let's get started.
So today we want to talk about pre pubertal bleeding. Our main reference will be the 2023 clinical review in JPAG, written by Dr bloomsfield, Iceyemi and Kives.
And we decided to start with pre pubertal bleeding, because it's a very common pediatric complaint in the PAG world, and has a very broad range of ideologies that sometimes aren't thought about. And coming from a residency, OBGYN residency, where we didn't have pag, it wasn't really something that was covered, despite how much I see it now as a fellow so so let's talk about pre pubertal bleeding. What does that even mean?
essentially, any vaginal bleeding that occurs before a child has gone through puberty and menarche, and it's important to note that this bleeding may not necessarily be from the uterus, so that is where getting a really good history is going to be helpful, because we have to can the vagina and the uterus as sources of bleeding.
Yes, and we'll talk about that more when we get to the etiologies, but I definitely know when the ER calls and says, Oh, she's bleeding from down there. Like, where's down there? What do you mean? And so, yeah, so getting your history first, like, we've all been taught. So when it comes to bleeding, you know, when did it start? How much is it? How did they notice? Like, was it on a tight diaper when wiping? How often does it occur? Is it a one time thing? What did it look like? Because sometimes you see bleeding, but it's more of like a discharge situation. Did they have other symptoms, like itching, discharge fevers, making sure to get as much information as possible?
Absolutely. And I think it's also important to note that we should try to get information from our patient as well and have mom supplement. But as soon as a child is verbal, they can tell us a lot about what's going on. Yeah,
I always make sure to look at the child when I'm speaking if, like you said, especially if they're verbal, so that they don't feel like just a random person in the corner of the room, you know, with a third party conversation about them?
yeah, absolutely. And also, part of the history is asking about the possibility of sexual abuse, and that is always an uncomfortable question, both for the provider, for the parent, and for the child as well. So it's good, it's helpful to develop a process and everybody go, might go about it differently, but to develop a process that's comfortable for the provider.
Yeah, it's when I first started one of the things that I felt awkward about. Because as much as we try not to have a prejudice, there's sometimes where you're like, oh, this seems like a happy local, normal family, so I don't want to be accusing them of anything, but the amount of times that Patchi brought out a positive report, now I just ask no matter, and I've been pleasantly surprised that if people understand why I'm asking, and they don't usually feel offended, what other kind of questions do you like to elicit in your history?
Let's see You mentioned a lot of the symptomatology age is an important consideration, especially when we're thinking about diagnosis, I might need to get mom's history, because there might be something about mom's history that factors into this, especially if we're thinking about vulvar dermatosis. And mom has a history of lichen sclerosus or chronic infections. So mom's history may be very important. Mom's history of trauma may be very important as well in terms of how she interprets what's happening with her daughter. Yeah.
Now, like going into any medications, they may be exposed to what their hygiene is like, especially if it's a special needs kiddo, any pubertal changes that they've noticed, any, you know, axillary hair, body odor, and then, of course, past medical and surgical history. But especially when it comes to peds, we like to go back to even the pregnancy that you need to be on any medications as your pediatrician expressed any concerns. So history is very important, but then we get on to examinations, somewhere where we have to be very careful as providers to make it not traumatic for everybody involved. So what kind of things do you like to do? Well,
first of all, I explain to the child what I'm going to do. So I'm going to explain all the parts of the exam and also try to get them involved in the exam. So for instance, if I'm checking their thyroid, I they can help me by holding my hand. They can place the stethoscope on their chest. They can help me examine their abdomen so it makes them feel more comfortable, and hopefully makes them feel that they're part of the process, and it's not something I am doing to them, that we're checking them together. When it comes to the vulvar exam, I like to use pictures, and I will, you know, explain about private parts and who should be allowed to see and touch their private parts, because I think that's important to put that out up front in terms of the genital exam, I point out different aspects of their vulva in the pictures. This is where you pee from. This is where you pick from. This is the hall where the bleeding may be coming from, and I think they will absorb that at their own level. So I don't hesitate to go over all of that, and then I explain why I want to examine them and relate it to why they're in my office that day, and then ask permission and say, you know, now that I've told you why we should do this, is it okay if we check your private parts? And will you help me do that? And most of the time we I have this successful exam where the child is understanding, cooperative and not traumatized, yeah,
and it's really important to teach them consent early on, and if they really don't want to, then, of course, if it needs to be done, we have the, you know, different anesthesia options. But, yeah, I always like to emphasize to the kiddo that there's a reason that I'm doing this, like a medical reason, compared to, you know, Mom and Dad, and if anyone else did, and you're allowed to tell me if anything's uncomfortable, I like to warn them about like, what they'll feel like you'll feel touch versus you'll feel some discomfort. You know, I told them no ouchies, if they're the little ones, or if I'm going to do a swab showing them what the Q tip will look like. Because there's a lot of anxieties around this, even the older patients and realizing that what they're picturing is not going to be as bad as is what is going to happen.
An adult might have said something to them about the exam, and might have described it in terms of their own experience, which is obviously completely different than how we examine a child. So when I'm explaining to the child. I'm also explaining to the parent or guardian who's with them, because if I if they if I can lower their apprehension, that's going to help the child be more relaxed about the process
now, and I strongly recommend, especially if this is not something that the listener does often, to look at Tanner staging for breast and pubic hair. It's something that, on the book, looks a certain way. But then in person, sometimes it's hard to differentiate that two to four kind of range. And then skin findings is something that, you know, I feel like it's not something we usually look for. But in kiddo the cafe, Ole lesions, which is one of my favorite terms. But then also, you know, there's concerns for abuse, looking for bruises, other injuries, or if the history, let's say they say, Oh, it was a fall and this and this happened, but then you see injuries that don't match that fall, then that's, that's very important. And what about, like, positioning? Are there certain things that you like to do to help make them comfortable with that. First
of all, I have them sitting up to do part of their routine, the rest of their checkup, and then laying down to do part of it, and then explaining to them that I'd like them to bend their knees and to let their knees go out and explain why I. Um, and sometimes I ask them to use their own hands to help push their knees out, or if they want mom to be involved, to use her hands. So I explain that positioning. I'm more comfortable with the child being supine and knees bent. I never have found the knee chest position to be very helpful, and I also feel a disconcerting because I can't see the child's face and I can't interact with them when they're in that position. So that's just my own personal opinion about positioning.
So I know if there's concerns for trauma, our child life specialists, we actually had them once come into the office with us, and they have a bunch of distraction methods that they use that are very helpful. The other part that I've definitely learned in the past year is kind of how to have a good observation of the vagina without, of course, needing a speculum or anything like that, that downward and outward traction of the labia, because there's a lot that you can see of the hymen, how well estrogenized Everything is. And seeing you know if there's a tear, being sure that you can tell how far back it goes. And of course, at a certain point, the kid may not let you do all that, and that's where an exam under anesthesia may come in. But there's a surprising amount that you can see if you have proper positioning, right,
right? And you can also very often see foreign bodies, which tend to be at the distal end of the vagina.
Every kid is different. There's some where sometimes we assume they want to be distracted, but there's some that actually really want to know, like, what are we doing? What are we looking at? And want to learn throughout the process. So it's important to check in with the kid and the families. And the other thing, obviously, probably not for the younger kids, but as they get a little bit older, asking them if they are comfortable with the parent being in the room, or sister or whoever, if they have a big family in the room. So making sure that we don't make assumptions of what they would like and what would make them comfortable,
not just to throw one more thing into the mix. I often ask them if they want to hold a mirror so they can see what I'm looking at. And if they do, then I'll have my medical assistant help them hold the mirror, and I will point out their anatomy to them that's helpful, especially, as you said, many of them want to be engaged and not distracted. And the other technique I use is to use their fingers. So sometimes they'll say, you can look, but don't touch. So then I will say, Well, can I use your fingers to move your skin around so I get a better view, and then I can see everything I need to just using their fingers to manipulate their body. Oh,
absolutely, that sounds really good. So kind of moving on then to you know, what's in the back of our minds when it comes to differential diagnoses? If you're able to look at the article that we mentioned, they have this really wonderful box that kind of goes down from most benign to most worrisome and most common to least common, etiologies, including dermatological issues, if we're thinking of the neonatal withdrawal bleed, foreign bodies, as we've Brought up already, trauma and injuries, thinking of precocious puberties, and while rare, you know, down the line, as well as malignancies. So that would be like most common one foreign bodies. So
that is a most common cause of genital bleeding. One of the distinguishing factors for a foreign body is that the bleeding is continuous. It's not intermittent. It's generally dark and it has an odor, sometimes almost like an abscess. So many times I've made that I've made a diagnosis of the cause just based on what I've seen on underwear or a pad. If mom brings them in and they're wearing a pad toilet paper is the most common foreign body because the it can stick to the vulva and work its way up eventually into the vagina, and you get enough of it in there, and it irritates the vaginal walls and you develop bleeding and an odor. But I have seen a wide range of foreign bodies in the vagina, some that the children have put in themselves. Because it's not always the child putting the object in their vagina in an exploratory state. It can be part of a sexual abuse episode as well.
And so once you know that it's a foreign body or you have a high suspicion, what kind of things do you do to help flesh it out? Or exams that you do? Diagnostic exams?
Well, if I can see the foreign body, and if it's not really thick, where I think it will be traumatizing to remove it, and depending on the mood of the child. So I can sometimes get these things out in the office without having to go to the or and use anesthesia. So I actually use an insemination catheter, because it's only one millimeter in diameter, and it's about five or six millimeters long, and it has openings that, you know, on the side. So when I squirt water or saline through it comes out pretty brusquely. And I put lidocaine gel all around the vaginal opening, and I can generally slip this little catheter in without even touching high mineral tissue, and then just flesh and flesh until I think I have it all out, very occasionally I'll use a bayonet forceps if there's something within my reach, but I can't flush it out, and the child is relaxed enough to let me reach in, because the the tips of the bayonet forceps are pretty small, and I can grab it and pull it out. But many foreign bodies I've also had to go to the operating room and remove, which then also gives me an opportunity to do a vaginoscopy and make sure there's no vaginal trauma associated, especially if it's a sharp foreign body.
That's really awesome to hear. Yeah, I'm always intrigued to hear of the different ways that pad providers used to flush out. And really it comes down to any small catheter, whether it's like a pediatric Foley, we use nasogastric tubes often, and just like you said, if it's small enough, you can, I was pleasantly surprised. You can do that while they're awake, and they do pretty well if you put some lidocaine jelly on it. Our ers, we have the option of, you know, doing ketamine infusions while still in the ER, so they don't necessarily have to go to the operating room. So that's that's really a great thing to do. Kind of the same idea for trauma, if there's a tear, like traveling injuries, needing to take a bigger look, potentially sometimes having to suture. But we try to tend to avoid putting too many sutures in there, because that's really irritating for the kiddos, and, of course, absorbable sutures. And then, of course, as we've said multiple times, when it comes to trauma, to be really, really sure that we rule out abuse, because we are mandatory reporters, right?
Absolutely. But also just keeping in mind that very often children do not reveal abuse the first time that they're seen by a provider, sometimes we have to ask that question over and over again.
So we have an app where we can take pictures that go directly into the chart. And that's really important, you know, general bleeding, not necessarily, but if there is a laceration or something like that, that's important to have, just in case. In the future, it does come out that there was abuse, then there is picture proof of what it was, or if there's skin findings associated with it, as we'll talk about later, for things like lichen sclerosus to having a picture to compare for the process of treatment. Now another differential is for our newborns, neonatal withdrawn bleeding.
And so this is common and occurs in about three to 5% of newborns. It is generally related to uterine exposure to maternal estrogen and then withdrawal of maternal estrogen after delivery. So the bleeding can occur in the first two weeks of life, often bright red bleeding, as opposed to some of these other causes that will cause dark brown bleeding. And sometimes there can be a little breast budding associated with it, and it can it's generally a diagnosis of exclusion, so the newborn just needs a really thorough exam. And if this is the diagnosis, then we expect it to resolve on its own within a few weeks, and nothing more needs to be done, and it should not reoccur.
Yeah, it's probably the one that freaks parents out the most, and sometimes hard to reassure them that it's completely normal. But I think it's again, where education comes up and explaining physiology, and usually they understand it pretty well at that point. Another really common scenario when it comes to physiology is kind of Volvo vaginitis, as we think of kiddos with their lack of estrogen production, I usually explain kind of menopause where a lot of parents understand that you start losing estrogen and how that leads to increased dryness and the changes, increases the risk of infection. I say this exact same thing, free puberty. They have low estrogen production, but then they also have poor hygiene. And so if you mix that with irritating soap, detergents, tight clothing, then you'll you can have bleeding caused by that. Um. Um, they'll also have sometimes, like, foul smelling discharge, pruritus, um. So with those, it's like important to consider, you know, getting a genital culture and educating really well about um hygiene. And
it's important where you get your culture from, too, if, if somebody's just culturing the labia, they may just be picking up skin contaminants. So it's it's important, but not always possible, to get the culture from inside the vagina.
New in my differential diagnosis is with respiratory infection. Kids kind of touch, you know, both their nose and then touch their vulvar area. So respiratory infections are another common cause of vaginal bleeding, strep being like 20% of pubertal bleeding. And they'll also have like this beefy red vulva. Influenza is another one where they'll have like, malodorous yellow green discharge. So important to think of just about all of those. And in your history, you can get that too if you ask, have they been sick recently, or have they had any upper respiratory symptoms?
And then, of course, enteric bacteria, because there may not be wiping correctly when they're first learning how to use the toilet, or somebody who's taking care of them and wiping them might be wiping up and down when they change their diaper, and inadvertently bringing bacteria up to the vaginal orifice,
and then going along with skin and low estrogen production we mentioned earlier, like in sclerosis, I'll say that's something that I see very, very commonly. And same thing I describe how you know this is common in the post menopausal population, but also pre pubertal, and they'll have all the same symptoms, the itching, but then if they're constipated, that tearing of the perianal tissue, they can have burning with urination because of the urine running over that really thin tissue, the very classic figure of a cigarette paper. But yeah, it's, it's not always extremely obvious, though. I will say sometimes it's just kind of noticing that the labia Nora is not as prominent as it should be. And it's kind of that that atrophy or hypopigmentation, right?
And something else that can go along with lichen sclerosus are what the lay public calls blood blisters, and we call Ecchymoses, and those areas can bleed too, and sometimes you'll just see brown staining or spotting on underwear, and that can also be interpreted as sexual abuse, just to reflect back on that. But that's another mechanism of bleeding with lichen sclerosus, besides injury due to scratching. Yeah.
And then from there, there's, you know,
of course, way more diagnoses that will kind of hit quickly, just to not overwhelm everybody. But so, you know, precocious puberty, we talked earlier about asking about breast budding, axillary hair, pubic hair, and that's where you start to go down the route of getting your pediatric endocrinologist involved, for workup, doing hormonal levels and differentiating between central puberty and peripheral. Can't talk all of a sudden, peripheral precocious puberty.
Can you say peripheral precocious puberty, right?
What other differentials Do you have? Well,
unfortunately, malignancies, you can have a rhabdomyosarcoma or an endodermal sinus tumor. These are tumors that start in the uterus, the cervix or the vagina. Fortunately, they're very uncommon. The general age group, whether seen is under age five and sometimes present with bleeding, sometimes present with a mass at the introitus. And diagnosis is made through biopsy. Then we can have some benign tumors in the vagina, malaria and papillomas, venous malformations and hemangiomas. And again, these are not going to generally be seen on an external genital exam, but will be found on vaginoscopy When other causes of bleeding have been rolled out, and now you need to go to the operating room to look further. And
then something else to kind of always remember when you get called for vaginal bleeding, as we mentioned at the beginning, is it actually vaginal? Right? There's three holes in that area. So differentiating, is it urinary, vaginal or GI? One that is common is urethral prolapse. So they'll have, like the painless spotting without discharge. And when you look on exam, you'll see kind of a small mass between the labia, around the urethral meatus. And let that, you know, usually associated with obesity, constipation, and it comes back down to vulvar. Hygiene as well, but sometimes the low estrogen levels
that, yeah, that definitely covers the prominent, common causes for pre pubertal bleeding.
Yeah? Well, I hope this was helpful for everyone.