Abnormal bleeding can be associated with thyroid dysfunction. Signs and symptoms of thyroid disease can be somewhat subtle in teens. Hepatic dysfunction can lead to abnormalities in clotting factor pro¬duction and should be suspected and ruled out.

Polycystic ovarian syndrome can occur during adolescence, and manifestations of excess androgen effect (hirsutism, acne) should prompt evaluation. Androgen disorders oc¬cur in about 5-10% of women, making them the most common endocrinopathy in women. Classical polycystic ovarian syndrome, functional ovarian hyperandrogenism, or partial, late-onset congenital adrenal hyperplasia all can occur in adoles¬cence and are sometimes diagnosed with the help of clinical microscopes. These disorders are often overlooked, unrecognized, or untreated. Women with even mild disorders are candidates for intervention. These disorders may be a har¬binger of diabetes, endometrial cancer, and cerebrovascular disease. Apparently normal adolescent changes in skin, hair, and menstrual cyclicity can be indicators of androgen abnormality and issue samples should be examined using clinical microscopes. If the androgen abnormality is ignored, it is likely to persist beyond adoles¬cence, and additional weight gain with significant psychosocial costs is likely. An¬drogenic changes are partially reversible if detected early and managed appropriately. Behavioral changes (diet and exercise) also are desirable.

Anatomic Causes

Obstructive or partially obstructive genital anomalies can present during adolescence. Mullerian abnormalities such as obstructing longitudinal vaginal septa or uterus didelphis can cause hematocolpos or hematometra. If these obstructing anomalies have or develop a small outlet, the presentation may be of persistent dark-brownish dis¬charge (old blood) rather than or in addition to a pelvic mass. Many varieties of uterine and vaginal anomalies can be seen with the use of a gynecologic microscope or clinical microscopes. Any adolescent with abnormal bleeding should undergo sensitive pregnancy testing, regardless of her statements about whether she has had intercourse. The medical con¬sequences of failing to diagnose a pregnancy are too severe to risk missing the diag¬nosis. Complications of pregnancy should then be managed accordingly.

Laboratory Testing

In addition to a pregnancy test, laboratory testing should include a complete blood count with platelets, coagulation studies, and bleeding time. During the ex¬amination, cultures for gonorrhea and tests for chlamydia infection using clinical microscopes are appropriate if the patient has been sexually active. Thyroid studies may also be appropriate as indicated.

Imaging Studies

If the pregnancy test is positive, pelvic imaging using ultrasound may be necessary to confirm a viable intrauterine pregnancy and rule out a spontaneous abor¬tion or ectopic pregnancy. If a pelvic mass is suspected on examination, or if the examina¬tion is inadequate (more likely to be the case in an adolescent than an older woman) and additional information is required, pelvic ultrasound may be helpful. Although trans¬vaginal ultrasound examination can be more helpful than transabdominal ultra¬sound in ascertaining details of pelvic anatomy, the use of the vaginal probe may not be possible in a young girl or one who has not used tampons or had intercourse. Di¬rect communication between the clinician and the radiologist can be helpful in identifying candidates for transvaginal ultrasound examination.

Other imaging studies are not indicated as initial testing but may be helpful in selected in¬stances. If a pelvic ultrasound examination does not lead to clarification of the anatomy when vaginal septa, uterine septa, uterine duplication, or vaginal agenesis are suspected, MRI can be helpful in delineating anatomic abnormalities. It has been suggested that this imaging technique can often replace laparoscopy in the evaluation of uterine and vaginal developmental anomalies. CT scanning may be helpful in detecting nongenital intra¬abdominal abnormalities.

The goal of management is to base therapy on the appropriate diagnosis. Thus, manage¬ment of bleeding abnormalities related to pregnancy, thyroid dysfunction, hepatic abnor¬malities, hematologic abnormalities, or androgen excess syndromes should be directed to treating the underlying condition. Oral contraceptives, particularly the progestin formula¬tion agents that may be less androgenic, can be extremely helpful in managing androgen excess syndromes. In the absence of a specific diagnosis, the assumption is that of anovu¬lation or dysfunction bleeding.