of polycystic ovarian syndrome include hirsutism, acne, obesity, and acanthosis nigricans (an indication of insulin resistance) The clinician may choose to perform a speculum examination to note for the presence of bleeding from the cervical os, an incomplete abortion, cervicitis, a retained foreign body, and to rule out anomalies of the lower genital tract A bimanual examination may be performed to assess for uterine tenderness and adnexal masses If necessary, rectoabdominal palpation can be substituted for the standard vaginal bimanual examination A complete blood count should be ordered to assess the hemoglobin, hematocrit, and platelet count Iron studies should be considered A reticulocyte count may be helpful as an indicator of bone marrow response to the blood loss Screen sexually active adolescents with a pregnancy test as well as a vaginal swab or urine collection for a NAAT for N gonorrhoeae and C trachomatis Be aware that many adolescents may not be forthcoming about their sexual history; routine pregnancy testing can aid in narrowing the differential diagnosis Coagulation disorders—such as von Willebrand disease, thrombocytopenia, or platelet dysfunction—should be considered in adolescents who present with heavy bleeding at menarche or who bleed heavily with each menses Coagulation studies to send in addition to a complete blood count include prothrombin time, partial thromboplastin time, fibrinogen, and a von Willebrand panel—consisting of von Willebrand factor (antigen), von Willebrand multimers, ristocetin cofactor activity, factor VIII activity, and fibrinogen The von Willebrand panel should be drawn prior to the administration or days after discontinuing any hormonal medications, particularly those containing estrogen, as the estrogen may raise the von Willebrand factor into normal range Bleeding may also be related to liver disease (which affects production of coagulation factors), or use of medications, such as anticoagulants or platelet inhibitors TSH should also be sent, as hyperthyroidism and hypothyroidism may cause menstrual irregularities An evaluation for polycystic ovarian syndrome may include laboratory studies for FSH, LH, DHEAS, free and total testosterone, androstenedione, though these results will not be available to the emergency physician, but will likely be useful to the patient’s outpatient provider If there are concerns for a prolactinoma, including signs of visual field deficits, a prolactin level may be sent Adolescents with androgenic signs and clitoromegaly may be evaluated for congenital adrenal hyperplasia by sending 17-hydroxyprogesterone Management For patients with brisk hemorrhage or hemodynamic instability, hospitalization and prompt volume resuscitation are necessary as well as possible blood