The American College of Obstetrics and Gynecology has recommended replacing the phrase dysfunctional uterine bleeding (DUB) with the phrase abnormal uterine bleeding (AUB) when describing an adolescent with prolonged vaginal bleeding Abnormal bleeding may be characterized as menorrhagia, defined as bleeding that occurs at regular intervals but lasts more than consecutive days or in excess of 80 mL Metrorrhagia is defined as bleeding that occurs at irregular intervals Menometrorrhagia denotes heavy and irregular bleeding Evaluation and Decision in the Nonpregnant Adolescent A comprehensive history and physical examination, along with minimal ancillary testing, usually points to an etiology to guide management (see Fig 79.3 ) The detailed history includes a review of the patient’s menstrual history including age at menarche, usual cycle duration, a relative estimate of usual blood loss, and how the current symptoms may differ from baseline Heavy bleeding from the first period may indicate an underlying bleeding disorder, most commonly von Willebrand disease Abdominal cramping may occur at the time of ovulation due to progesterone secreted in the luteal phase Prostaglandins released from the endometrium at the time of menstruation may contribute to uterine cramping, nausea, vomiting, or diarrhea, which are all common features of dysmenorrhea NSAIDs may alleviate the discomfort of dysmenorrhea by inhibiting prostaglandin release The presence of dysmenorrhea is not usually a feature of anovulatory bleeding Other pertinent historical details include the presence or absence of trauma, fainting, dizziness, fever, easy bruising, and excessive bleeding at other sites Postural dizziness and other signs of anemia can be elicited Questions regarding sexual activity, the possibility of pregnancy, sexual abuse, and/or sexually transmitted infection should be asked with the teen alone An opportunity for private conversation between a teen and her physician without parent(s) is a routine and necessary part of the adolescent medical evaluation regardless of chief complaint The physical examination helps the clinician determine the severity of blood loss in order to narrow the differential diagnosis The ED physician begins with an assessment of vital signs and the patient’s hemodynamic status Tachycardia, hypotension, orthostatic changes, and/or signs of anemia may indicate more significant blood loss The mucous membranes, conjunctiva, and palms of the hands/feet should be assessed for pallor The skin should be examined for signs of androgen excess such as acne, hirsutism, or acanthosis nigricans as well as purpura or petechiae to suggest an underlying bleeding disorder The thyroid should be palpated for nodules or enlargement Presence of a soft systolic flow murmur may be noted during the cardiac examination in the setting of anemia