CHAPTER 79 ■ VAGINAL BLEEDING MAMATA V SENTHIL, ALISON ROCKEY, LAUREN E ZINNS, JENNIFER H CHUANG, JILL C POSNER INTRODUCTION Vaginal bleeding can be either a normal event or a sign of disease Pathologic vaginal bleeding may indicate a local genital tract disorder, systemic endocrinologic or hematologic disease, or a complication of pregnancy During childhood, vaginal bleeding is abnormal after the first few weeks of life until menarche After menarche, abnormal vaginal bleeding must be differentiated from menstruation When evaluating patients with vaginal bleeding, it is important to distinguish between three types of bleeding: (1) prepubertal bleeding, (2) bleeding in nonpregnant adolescent females, and (3) bleeding associated with pregnancy VAGINAL BLEEDING IN THE PREPUBERTAL PATIENT Evaluation and Decision Important elements of the history include symptom onset, prior history of bleeding, associated abdominal pain, concern for foreign body, recent infections such as sore throat or diarrhea, rashes, masses, perineal skin changes, urinary and/or bowel symptoms, and estrogen-containing medications When trauma is suspected, questions pertaining to the mechanism of injury and concerns for sexual abuse guide management ( Fig 79.1 ) During the physical examination, the emergency clinician should note signs of hormonal stimulation (i.e., breast development, pubic hair growth, a dull pink vaginal mucosa, or physiologic leukorrhea), thyroid enlargement, and skin findings such as petechiae, excessive bruising, or café-au-lait spots Next, it is important to determine the source of bleeding For the initial examination of the genitalia, an infant or child should be placed in frog-leg position with heels near the buttocks while holding the legs flexed on the parent’s lap or examining table ( Fig 79.2A ) After inspecting the external genitalia, the left and right labia majora should be gently grasped by the examiner in an outward and downward direction to visualize the introitus and identify the source of bleeding If the vaginal tissues cannot be observed adequately, the knee-chest position is an alternative examination technique, allowing for relaxation of the abdominal