ABNORMAL BLEEDING IN WOMEN IRREGULAR AND HEAVY

Adolescent Girls and Children

In this post I will discuss the causes of abnormal bleeding in women. This can happen in any age group. I will divide this into a number of posts. In the first post I will talk about the causes in children and adolescence. There are 4 reasons for this abnormal bleeding.

1) Vaginal Infections: vulvovaginitis, this is a common infection of the external part of the young girls vulva and vagina.

This is a Comfortable Position for a Child to be Examined

This happens because the young girls have less resistance to infections which may be due to lack of oestrogens (oestrogens only happen in our body when periods start).This is not difficult to treat you can take a swab from outside the vulva and vagina to see what the infection is. Always tell the children and young girls to keep their vulva and vagina clean. Wash it with water if possible. Always use loose cotton under wears as this helps with the soreness and healing.  Applying a bit of Vaseline is a very simple trick. Do not wear very tight undergarments or share them. Do not wear panties to bed. Do not put any antiseptic such as Dettol in the water. Avoid baths if you can have a shower.

You can bath your bottom in a basin. Have a very clean basin on the toilet seat, fill it up with about 15 litres of cooled boiled water, add 2 tablespoons of salt, and sit in the water for 10 to 15 minutes.

It is very soothing. The swabs that where originally taken will show the infection and your GP, will prescribe the appropriate treatment. If the swab shows an infection called tricomonas or gonorrohea, beware. These are sexually transmitted infections. You as a mother will have to explore it further. Constiption should be avoided, as most of these vaginal infections come from the anus.  Threadworms are very common in young girls. When the children scratch the minute eggs of threadworms get transmitted to the vagina and irritate the child, but there no discharge. Please get the stool examined. It is easy to get rid of the threadworms. Always teach your child to wipe their bottom from front to back. Candidiasis is not such a common infection in children unless she has taken antibiotic or she is diabetic a taken bath with her mother who carries an infection.

I started the discussion about vaginal bleeding but got side tracked by vaginal discharge. One of the rare causes of blood stained discharge in children is a foreign body. In my time I have removed a few of these, such as, a safety pin, mother’s hairpin, and a lolly. If the discharge is bloody always try to look inside the vagina. A nasal speculum is a very good tool with a light. These may need to be removed under anaesthesia. I was able to remove a safety pin with a sterilized pair of tweezers.

One of the rare skin conditions that can affect very young girls is called Lichen sclerosis. This occurs at either end of a female’s life. We do not know what causes it, may be immunological. The girls present with intractable pain, itching and difficulty or pain on passing urine. Often there is some bleeding. On looking at it the skin appears dry shiny stretched and pigmented. It is a chronic condition and can last a long time. It has malignant potential.

The Above Picture is of a Normal Vagina

The Vulval Changes in Lichen Sclerosis

               

On looking the skin looks white and shine, pigmented and crinkly. In these cases we should try and exclude any sexual abuse. The diagnosis is confirmed by skin biopsy. The treatment should be started early. In asymptomatic or very mild cases soft emollient is enough. Local Corticosteroids are required in more well defined cases; in more severe cases stronger corticosteroids are used. Rarely immunological suppressants are used in combination with local high potency corticosteroids. Recently cell therapy is being tried by some plastic surgeons. The good news is, in most girls it resolves by puberty. Recurrences can happen; these cases should be followed up after 6 months and then yearly.

Other causes of vaginal bleeding can be due to injury; this can happen in school play grounds, bicycle riding or foreign bodies just being there or when they are sharp and big and sexual interference. If the injury is blunt not bleeding and the vulva is swollen it need reassurance, pain relief and cold compress. If bleeding it needs repair under anaesthesia. Sexual interference can be very traumatic. You have to work out who the offender is, look for sexually transmitted infections, and be very sympathetic to the family. I can never forget a case which I had to deal with of a 6 year old girl in 1968 when I was a very new gynaecologist with no experience in children. This girl was brought in with profuse bleeding on Sunday at midnight after being   assaulted by a big man by sexual intercourse. She was sleeping outside on the street with mum and dad in terrible heat. I called the theatre staff an anaesthetist, blood transfusion services, and the police, I got the terrible man arrested I took the child to the theatre tried to stop the bleeding. The whole area was so damaged could not make out what was what, however 3 hours I was able to stop the pouring of blood, it was still dribbling. I was unable to find a paediatric surgeon. We also gave her 2 units of o negative blood (o negative blood is a universal donor) as that was all I could get. I needed help from other specialists such as a internist or interventionist but these were just fancy words in those days. She ultimately died 2 days later. That was a very sad day in my very new profession. I can still remember her face.

The cause of bleeding can be paediatric malignancies and premature puberty.

Paediatric malignancies of the genital tract are extremely rare say about 5%of the total malignancies in children they are usually referred to tertiary centres where they have a paediatric gynaecologist. They happen both in girls and boys; they often arise in the left over remnants of embryonic tissue, use of diethylstilboestrol during pregnancy to prevent the miscarriage (this used to be practiced long time ago).

The discussion on paediatric malignancy and premature puberty is outside the scope of this blog. I will discuss premature puberty in the next