ESPE Abstracts (2015) 84 P-3-1147

Persistent Isolated Cyclical Vaginal Bleeding (Premature Menarche) not Associated with GnRH Pubertal Response or Endometrial Echo Should be Considered for Examination Under General Anaesthesia

Swathi Upadrastaa, Lauren Watsonb, Anuja Natarajanb & Sze May Nga


aDepartment of Paediatrics, Southport and Ormskirk NHS Trust, Ormskirk, Lancashire, UK; bDepartment of Paediatrics, Doncaster Royal Infirmary, Doncaster, Yorkshire, UK


Background: Isolated prepubertal menarche is described in the absence of any other signs of precocious sexual development. This condition remains unclear in its aetiology and there is currently no consensus on investigations to be undertaken.

Objective and hypotheses: The objective of our study is to evaluate the following factors associated with persistent isolated cyclical vaginal bleeding: 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 to 4 days in duration. Bleeding was reported to have persisted between 6 and 18 months in all girls. GnRH stimulation test was performed in all girls. Mean LH peak was 3.1 U/l (range 0.3–14), mean peak LH/FSH ratio was 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 in all girls. Bone age showed no advancement in all girls. EUA was performed in eight girls. EUA 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: Persistent isolated cyclical vaginal bleeding was not associated with identifiable endometrial echo on pelvic ultrasound, GnRH pubertal response or elevated oestradiol levels. Low oestradiol levels may result in an increased sensitivity of the endometrium resulting in vaginal bleeding. EUA should be considered in persistent isolated cyclical vaginal bleeding to exclude other causes such as foreign body.

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