Endocrine Abstracts

Background: Isolated prepubertal vaginal bleeding can be secondary to various causes including Mullerian cyst, papilloma, foreign body and prepubertal menarche. There is no current consensus on the investigations for prepubertal girls with isolated vaginal bleeding with no other signs of precocious puberty.

Objective: The objective of our study is to evaluate the factors associated with persistent isolated cyclical vaginal bleeding including clinical presentation, gonadotrophin-releasing hormone (GnRH) stimulation test, genital examination under anaesthetic (EUA) and pelvic ultrasound findings.

Method: We describe a retrospective case series of 14 girls with isolated prepubertal menarche from two centres between January 2007 and December 2014. All girls presented with persistent cyclical vaginal bleeding without signs of precocious sexual development.

Results: At presentation, mean age was 7.4 years (range 5.0–9.67), mean BMI was 19.6 (range 14.6–29.3), mean height SDS was 0.33±1.35 and mean weight SDS was 1.01±1.75. Vaginal bleeding was reported to be cyclical ranging from 1 week to 3 monthly, lasting 1–4 days in duration. GnRH stimulation test showed a mean LH peak of 3.1 U/l (range 0.3–14), mean peak LH/FSH ratio of 0.23 (range 0.07–0.66) and oestradiol levels were <100 pmol/l in all girls. Pelvic ultrasound showed prepubertal uterus with no identifiable endometrial echo and bone age showed no advancement in all girls. EUA was performed in eight girls, this was normal in seven girls and one girl had a 1.5 cm foreign body found. The girl with the foreign body presented with cyclical vaginal spotting weekly for 6 months prior to the EUA.

Conclusion: Prepubertal girls presenting with persistent and cyclical vaginal bleeding should have baseline LH, FSH, oestradiol, adrenal androgens, GnRH stimulation test, pelvic ultrasound for endometrial echo and bone age following clinical evaluation to exclude precocious puberty. EUA should be considered in persistent isolated cyclical vaginal bleeding without evidence of precocious puberty to exclude other causes such as intravaginal foreign body.