INTRODUCTION — The causes of vaginal bleeding in children differ substantially from the causes in adolescents. During childhood, vaginal bleeding after the first week or so of life but before menarche is always abnormal and warrants diagnostic evaluation. After menarche, pregnancy is a consideration; abnormal vaginal bleeding must be differentiated from menstruation; and menstrual bleeding must be categorized as either normal or excessive.

This topic offers an approach to the evaluation of vaginal bleeding in children and adolescents. The evaluation of the specific condition, abnormal uterine bleeding in adolescents, and the differential diagnosis of vaginal bleeding in adult women are discussed separately. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis" and "Differential diagnosis of genital tract bleeding in women".)

CAUSES — The causes of vaginal bleeding in children and adolescents organized by patients' menarcheal status are presented in the table (table 1).

Trauma is a cause of vaginal bleeding at any age (see 'Trauma' below). In non-injured children, the clinician should first consider the patient's chronological age and stage in puberty (Tanner or sexual maturity stage) (picture 1 and picture 2). When evaluating adolescents who have passed menarche, the clinician must first establish whether or not the patient is pregnant (see "Clinical manifestations and diagnosis of early pregnancy"). In adolescents who are not pregnant, the clinician will need to distinguish abnormal vaginal bleeding from normal menstruation. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis", section on 'Terminology'.)

Trauma

Blunt trauma — Most genital trauma in girls is blunt, nonpenetrating, and produces relatively minor injury. The home, and especially the bathroom, is a common location for blunt vaginal injuries in girls [1]. Bed frames, falls onto narrow objects and protruding bathtub fixtures can pose hazards to girls who slip on wet surfaces, jump, or fall. Although sexual assault is an important consideration in children and adolescents with genital trauma, most injuries that cause vaginal bleeding are unintentional. Conversely, most sexual assault of children does not produce any genital trauma [2]. Blunt or straddle injuries typically cause bruising of the labia majora or lacerations that are anterior or lateral to the hymen. Intravaginal bleeding, injury to the hymen or posterior fourchette, or perineal lacerations or tears raise suspicion for sexual abuse. (See "Straddle injuries in children: Evaluation and management", section on 'Findings suggesting child abuse' and "Evaluation of sexual abuse in children and adolescents", section on 'Differential diagnosis'.)

Evaluation and management of superficial vulvar and vaginal wounds are discussed in greater detail separately. (See "Straddle injuries in children: Evaluation and management", section on 'Girls'.)

Penetrating vaginal trauma — In children and adolescents, penetrating injuries from coitus [3-5], narrow sharp objects (eg, pencils), high-pressure water jets found in fountains or water slides [6], and recreational misadventures involving water or jet skiing [7,8] can lacerate the vaginal wall and may result in life-threatening hemorrhage, concomitant rectal injury, and/or peritonitis. In patients whose visible perineal injuries are minor, a history of impalement or water jet injury should alert the clinician to the possibility of inapparent but severe vaginorectal trauma [9].

Hemodynamically unstable patients with penetrating vaginal injuries require resuscitation according to Advanced Trauma Life Support (ATLS) guidance and emergency consultation with a surgeon with pediatric trauma expertise. Key actions include packing the vagina with sterile gauze to control bleeding and transfusion of blood products to maintain blood volume and coagulation factors. Patients should then rapidly proceed to the operating room for examination under anesthesia to fully characterize the vaginal injury, definitively control hemorrhage, and repair damage to adjacent structures (eg, urethra, bladder, or rectum). (See "Evaluation and management of female lower genital tract trauma", section on 'Vagina' and "Trauma management: Approach to the unstable child", section on 'Blood products'.)

Hemodynamically stable patients should undergo careful visual inspection of the perineum but also warrant prompt consultation with a surgeon who has the pediatric gynecologic expertise to perform an examination under anesthesia. In patients with a history of water jet injury or signs of significant injury, an upright abdominal film is warranted to identify free air under the diaphragm caused by penetration into the peritoneum.

Nontraumatic causes before normal menarche

Life-threatening conditions

Genital tract malignancies — Genital tract malignancy is a rare cause of vaginal bleeding in children [10,11]. Endodermal sinus tumors and rhabdomyosarcomas (including sarcoma botryoides) of the vagina are rare, accounting for about 8 percent of all pediatric germ cell tumors and about 0.3 percent of all childhood malignancies. They present almost exclusively in girls under the age of three years with vaginal bleeding [12] (see "Rhabdomyosarcoma in childhood and adolescence: Epidemiology, pathology, and molecular pathogenesis" and "Vaginal cancer", section on 'Sarcoma'). Benign papillomas can mimic this tumor [13]. (See 'Uncommon conditions' below.)

Common conditions — In the author's experience, the most common causes of actual or apparent vaginal bleeding in prepubertal girls are blunt trauma, foreign bodies, infections, lichen sclerosus, urethral prolapse, and neonatal withdrawal bleeding. Additionally, in some cases, a specific etiology cannot be identified despite complete evaluation [14-17]. Among prepubertal girls referred to subspecialists, the most commonly reported causes of vaginal bleeding have been precocious puberty, foreign bodies, sexual abuse, and genital tumors [14,15,18]. However, these series likely reflect referral bias. In primary care practice, precocious puberty is uncommon, and genital tumors are rare.

Neonatal withdrawal bleeding — During intrauterine life, maternal estrogen crosses the placenta and stimulates growth of the female fetus' endometrial lining. As this hormonal support wanes during the first few weeks after birth, some babies have an endometrial slough that results in a few days of bloody mucoid discharge or light vaginal bleeding. The bleeding is self-limited and requires no treatment. Although this phenomenon is widely considered a normal variant, some experts have suggested that retrograde menstruation during neonatal withdrawal bleeding might predispose patients to early-onset endometriosis [19].

Vaginal foreign bodies — Vaginal bleeding with or without associated discharge is the most common symptom in prepubertal girls who have vaginal foreign bodies [20]. Conversely, vaginal foreign body is a likely diagnosis in girls who present with vaginal bleeding but no history of trauma [21]. The bleeding is typically light, spotty, and/or intermittent, and may be associated with a foul odor. With the child in the knee-chest position (picture 3), examination of the vaginal vault frequently provides visualization of the foreign body. Occasionally, examination under anesthesia is required to establish the diagnosis. Management of vaginal foreign bodies is discussed separately. (See "Overview of vulvovaginal conditions in the prepubertal child", section on 'Vaginal foreign body'.)

Infection (vaginitis) — Of the bacteria that cause vaginitis in girls and women, two are particularly associated with bleeding: Streptococcus pyogenes (group A beta-hemolytic streptococci) and Shigella species. Infections with group A streptococci occur mainly in prepubertal girls. Similarly, Shigella vaginitis has not been reported in girls over the age of 10 years. Lack of estrogen, which results in a thin vaginal mucosa, an alkaline pH, and a relative paucity of protective microorganisms, is a risk factor for these and other vaginal infections [22]. All of these changes favor bacterial overgrowth.

●Group A streptococcal vaginitis – This infection is characterized by purulent vaginal discharge that is blood-tinged in about half of the cases [23]. A clinical hallmark of group A streptococcal perineal infection is a fiery or beefy red appearance of the perineal skin, often with a sharp margin (picture 4) [24]. Perineal streptococcal infection most often produces vulvar and/or perineal inflammation; true vaginitis with discharge is less common [25]. Most patients with perineal streptococcal infection do not have symptomatic pharyngitis, but throat cultures are positive in about 75 percent of cases [23]. Treatment with penicillin V; amoxicillin; or, in penicillin-allergic patients, cephalosporins, macrolides, or clindamycin for 10 days should result in rapid resolution of the infection (table 2). (See "Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment", section on 'Respiratory and enteric flora'.)

●Shigella vaginitis – Shigella infection produces vaginal discharge that is bloody or serosanguineous in about half of the cases and often produces concomitant vulvitis [26,27]. Only about one-third of patients have a history of recent or concurrent diarrhea. Nearly all reported cases of this uncommon infection have been caused by Shigella flexneri. Culture of vaginal secretions is necessary to establish the diagnosis; stool cultures are generally negative [26,28]. (See "Shigella infection: Clinical manifestations and diagnosis", section on 'Other manifestations'.)

Treatment of Shigella infection in children is discussed separately. (See "Shigella infection: Treatment and prevention in children", section on 'Oral therapy'.)

Lichen sclerosus — Although bleeding per se is not common, purpura, telangiectasias, and hematomas occur in 20 to 60 percent of girls with lichen sclerosus (picture 5 and picture 6) [29]. This condition (previously known as lichen sclerosus et atrophicus) is a chronic, mucocutaneous inflammatory disorder of unknown etiology that principally affects the vulva and perineum [30]. Ninety percent of cases are in females, and of those, about 7 to 15 percent are in prepubertal girls. Misdiagnosis of lichen sclerosus as sexual abuse is a recognized cause of intense distress to patients and families [31-33].

The most common presenting symptoms are vulvar and perineal itching, soreness, and pain with defecation. The perineal discomfort can lead to constipation in severe or undiagnosed cases [31]. On examination, the labia majora and minora, clitoris, introitus, and perineal skin show to varying extents the characteristic white, atrophic, "cigarette-paper" appearance (picture 7). Perineal hypopigmentation in a figure-of-eight pattern is a pathognomonic finding (picture 8).

Treatment consists of topical application of superpotent steroid ointments [34-36] or calcineurin inhibitors (eg, tacrolimus, pimecrolimus) [30,37].

Diagnosis and treatment of lichen sclerosus in adult women is discussed separately. (See "Vulvar lichen sclerosus".)

Urethral prolapse — Although this condition does not actually involve the vagina, the typical presentation is a Black girl 2 to 10 years old with a history of "vaginal" bleeding and with a dusky red or purplish annular mass between the labia majora upon examination. Some patients complain of dysuria or urinary frequency, but most have bleeding as their only symptom. Although the vaginal orifice can be obscured by the mass, and although clinicians often worry that it is malignant, gentle caudolateral retraction of the labia majora will generally reveal the diagnostic appearance of a prolapse: a smooth, doughnut shape with a central urethral dimple (figure 1 and picture 9).

Treatment of urethral prolapse is discussed in more detail separately.

Uncommon conditions — A variety of uncommon conditions can cause vaginal bleeding in children and premenarcheal adolescents:

●Precocious puberty – Experts differ on the precise age that should mark the separation between abnormally early puberty and early but physiologic puberty in girls. (See "Definition, etiology, and evaluation of precocious puberty", section on 'Threshold for evaluation'.)

In a girl who has already begun puberty, the clinician must assess whether bleeding that is presumed to be menstrual is in fact consistent with the patient's pubertal progression. On average, menarche occurs about two and a half years after the onset of breast development and most commonly when a girl is at sexual maturity rating stage 4 or 5 for breast development (picture 1). Bleeding out of synchrony with other signs of pubertal development (figure 2) or in a girl under the age of eight years warrants evaluation. The evaluation of girls with precocious puberty is discussed separately. (See "Definition, etiology, and evaluation of precocious puberty".)

●Hypothyroidism – Hypothyroidism can produce premature menstruation in association with growth delay, premature thelarche, galactorrhea, and ovarian cysts, in varying combinations (Van Wyk-Grumbach syndrome) [38]. Notably, in some cases, the massive size of the associated multicystic ovaries has distracted clinicians' attention away from the underlying, causal hypothyroidism [39]. (See "Definition, etiology, and evaluation of precocious puberty", section on 'Causes of central precocious puberty'.)

●Hemangiomas and papillomas – Intravaginal hemangiomas and Müllerian papillomas can produce vaginal bleeding in infancy or childhood [40,41] and should not be mistaken for sexual abuse [42]. Histopathology is required to differentiate benign Müllerian papilloma from malignant botryoid rhabdomyosarcoma [13,43]. (See "Infantile hemangiomas: Epidemiology, pathogenesis, clinical features, and complications".)

●Genital warts – Genital warts can produce bleeding in children when they are located on the mucosal surface of the introitus or just inside the hymenal ring (picture 10) [44]. Children acquire genital warts by vertical transmission (birth through an infected lower genital tract), autoinoculation of common warts, nonabusive contact, or sexual contact. (See "Condylomata acuminata (anogenital warts) in children", section on 'Transmission'.)

The diagnosis of condyloma acuminatum is usually made via clinical examination. Biopsies are rarely required and are usually reserved for patients in whom the diagnosis is uncertain or when the warts demonstrate atypical features, such as ulceration. (See "Condylomata acuminata (anogenital warts) in children", section on 'Diagnosis and evaluation'.)

Although it is likely that many children with condyloma acuminatum acquire the disorder through nonsexual means, the possibility of sexual abuse warrants serious consideration during patient evaluation. Children under four years of age with condyloma acuminatum are less likely to be victims of sexual abuse than older children, but the possibility of sexual abuse cannot be definitively excluded based upon age. (See "Condylomata acuminata (anogenital warts) in children", section on 'Assessment for sexual abuse'.)

Treatment of anogenital warts is discussed separately. (See "Condylomata acuminata (anogenital warts) in children", section on 'Treatment'.)

●Estrogen exposure – The possibility that a child with vaginal bleeding has been exposed chronically to exogenous estrogen in a cream, food, or alternative therapy should be explored. Evidence-based summaries of many dietary supplements and herbal remedies can be found on websites provided by the National Library of Medicine and the National Institutes of Health.

●Female genital cutting – Hemorrhage is a recognized complication of female genital cutting, which is practiced mainly by individuals from parts of East Africa, the Middle East, and Southeast Asia; it is less common in resource-rich countries. (See "Female genital cutting".)

●Benign prepubertal vaginal bleeding – Episodic vaginal bleeding that remains unexplained after thorough diagnostic investigation has been reported in girls who are either prepubertal or early in the pubertal progression [45,46]. This condition has also been termed "isolated menarche," but endometrial thickening has not been observed in the few affected patients who have undergone pelvic ultrasonographic examination. All other causes of bleeding, especially intravaginal foreign body and intravaginal tumor, should be excluded before settling on this diagnosis.

Nontraumatic causes after normal menarche — Because bleeding during pregnancy can indicate a life-threatening condition, the clinician's first task for the postmenarcheal adolescent with abnormal bleeding is to establish whether or not she is pregnant. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Detection of human chorionic gonadotropin'.)

In non-pregnant adolescents, menstrual bleeding that is prolonged or that does not follow a regular pattern usually indicates anovulation. In that case, the clinician's task is to identify the cause of the anovulation. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis", section on 'Causes of irregular bleeding'.)

Thrombocytopenia and von Willebrand disease are the most common hematologic causes of abnormal menstrual bleeding [47]. Patients with a bleeding disorder characteristically have menstrual bleeding that occurs monthly but with abnormally heavy or prolonged flow. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis", section on 'Bleeding disorders'.)

Life-threatening conditions — Life-threatening causes of vaginal bleeding during pregnancy include:

Ectopic pregnancy — Vaginal bleeding and abdominal pain preceded by an interval of amenorrhea are the classic symptoms of ectopic pregnancy. Although ectopic pregnancy is more common in adult women than in adolescents, the diagnosis should be considered in an adolescent who presents with vaginal bleeding and abdominal pain following a missed period and warrants urgent pregnancy testing and pelvic ultrasonography. (See "Ectopic pregnancy: Clinical manifestations and diagnosis", section on 'Clinical presentation'.)

Placenta previa — During the second or third trimester of pregnancy, vaginal bleeding can indicate placental tissue overlying the internal cervical os. This condition is diagnosed by ultrasound. This condition is uncommon in pregnant adolescents since they lack the interrelated risk factors of increasing age, increasing parity, and previous cesarean delivery. (See "Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality".)

Placental abruption — Placental abruption refers to a separation of the placenta from the uterine wall before normal delivery of the fetus. Abruption should be considered in pregnant patients who present during the second or third trimester with one or more of the following: vaginal bleeding, abdominal pain, preterm labor, and/or abdominal trauma. The diagnosis of abruption relies on clinical findings augmented by sonographic features as discussed separately. (See "Placental abruption: Pathophysiology, clinical features, diagnosis, and consequences".)

Common pregnancy-related conditions — Among clinically recognized pregnancies, approximately 8 to 20 percent end in spontaneous abortion, which nearly always occurs during the first trimester. Vaginal bleeding is also common during the second and third trimesters of pregnancy. The diagnostic evaluation for spontaneous abortion and the causes of vaginal bleeding during pregnancy are discussed separately. (See "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology" and "Overview of the etiology and evaluation of vaginal bleeding in pregnancy".)

Vaginal bleeding can also indicate a complication following spontaneous or therapeutic abortion. (See "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology" and "Retained products of conception in the first half of pregnancy".)

Common conditions not related to pregnancy — The currently preferred general term for abnormal bleeding in non-pregnant women of reproductive age is abnormal uterine bleeding. When the patient reports that her menstrual bleeding is excessive in quantity, frequency, duration or any combination of these, the currently preferred term for this symptom is heavy menstrual bleeding (HMB) [48].

The most common causes of HMB in adolescents are disorders of ovulation and side-effects of hormonal contraceptive methods. (See "Evaluation and management of unscheduled bleeding in individuals using hormonal contraception".)

In turn, the most common causes of ovulatory dysfunction in adolescence are delayed pubertal maturation and polycystic ovary syndrome. (See "Definition, clinical features, and differential diagnosis of polycystic ovary syndrome in adolescents".)

Uncommon conditions — A bleeding disorder, in particular thrombocytopenia, von Willebrand disease, or a factor deficiency, should be considered in the adolescent whose menstrual bleeding is cyclic but unusually heavy or prolonged, especially if the HMB had its onset close to the time of menarche, is associated with a past or family history of excessive bleeding, or produces anemia. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis", section on 'Bleeding disorders'.)

Vaginal foreign bodies, cervicitis, genital warts, and infections (eg, pelvic inflammatory disease [PID], endometritis), can uncommonly produce irregular or very light bleeding in adolescents [49]. Vulvar endometriosis is a rare cause of vaginal bleeding [50]. (See "Differential diagnosis of genital tract bleeding in women" and "Acute cervicitis" and "Desquamative inflammatory vaginitis" and "Condylomata acuminata (anogenital warts) in adults: Epidemiology, pathogenesis, clinical features, and diagnosis".)

EVALUATION

Trauma — With the exception of patients with penetrating trauma, most children and adolescents with vulvovaginal trauma are hemodynamically stable.

Initial evaluation and stabilization of penetrating vaginal injuries are discussed separately. (See 'Penetrating vaginal trauma' above and "Penetrating trauma of the upper and lower genitourinary tract: Initial evaluation and management", section on 'Initial assessment'.)

Premenarcheal patients

Approach — The algorithm summarizes an approach to diagnosis for patients with vaginal bleeding before menarche (algorithm 1). In many premenarcheal children, the physical examination findings will provide or suggest a diagnosis (see 'Physical examination' below). If the patient has a nondiagnostic examination and no signs of puberty, then vaginal culture for bacterial infection should be obtained followed by vaginoscopy if the culture is negative (see 'Diagnostic evaluation' below). Endocrinological evaluation is indicated for patients with early signs or an abnormal sequence of puberty (figure 2). (See "Definition, etiology, and evaluation of precocious puberty", section on 'Threshold for evaluation'.)

History — In prepubertal children, the history has low predictive value; diagnosis will depend primarily on the patient's physical examination findings [51,52]. However, it can be helpful to elicit a history of associated vaginal discharge, recent sore throat or streptococcal infection in a household member, diarrhea, pain with defecation, or previous vaginal foreign bodies.

Physical examination — The clinician will tend to focus on the external genital examination, but the skin, thyroid gland, and chest also require attention. Children's underwear should be removed completely to facilitate careful inspection of the external genitalia and perineum. Cafe-au-lait spots can suggest neurofibromatosis or McCune-Albright syndrome (picture 11), rare causes of precocious puberty. Thyroid enlargement can suggest hypothyroidism. The presence of breast or pubic hair development (picture 1 and picture 2) suggests either abnormal vaginal bleeding in a girl with normally progressing puberty, first menarche in a girl whose age and pubertal progression are appropriate, or, much less commonly, precocious puberty. Lichen sclerosus (picture 8 and picture 5) and urethral prolapse (picture 9 and figure 1) usually present pathognomonic appearances. A fiery or beefy red appearance of infected skin points to perineal group A streptococcal infection (picture 4).

If the general physical examination and inspection of the external genitalia do not permit a confident diagnosis, the vaginal vault should be inspected. Although speculum examination was recommended historically, this procedure is painful and should not be used in the awake premenarcheal patient. Most children over three years of age can cooperate for prone knee-chest examination (picture 3). The keys to successful visualization of the vaginal vault using this position are adequate lateral and cephalad retraction of the child's buttocks and labia majora (accomplished by a parent or assistant) and relaxation of the abdominal muscles sufficient to ensure that air enters the vaginal vault.

Diagnostic evaluation — The selection of diagnostic tests should be guided by findings from the child's history and physical examination (algorithm 1). (See 'Approach' above.)

If the physical examination was not diagnostic, vaginal secretions, if present, should be sampled and sent for culture. The clinician should alert the microbiology laboratory staff in advance to use culture media appropriate for the suspected pathogens, namely group A streptococcus and Shigella species. Otherwise a report of "Group B Strep not present" is likely to be obtained and will be useless to the clinician. (See "Gynecologic examination of the newborn and child", section on 'How to obtain cultures and other specimens from children'.)

Girls whose breast development is inappropriately advanced for their chronologic age (figure 2) warrant further evaluation for precocious puberty or potential exogenous estrogen exposure. The diagnostic evaluation of the child with precocious puberty is discussed separately. (See "Definition, etiology, and evaluation of precocious puberty", section on 'Evaluation'.)

In girls with no pubertal breast development, if the vaginal culture is negative and vaginal bleeding remains unexplained, then vaginoscopy by a pediatric surgeon or gynecologist should be undertaken [53]. Studies suggest that vaginoscopy has considerably better diagnostic sensitivity than does non-invasive imaging (ultrasound, computed tomography [CT], magnetic resonance imaging [MRI]), for the diagnoses of foreign body and malignancy [15]. (See "Vaginoscopy".)

Serum alpha-fetoprotein is a sensitive and specific marker for endodermal sinus tumors and should be obtained if there is any suspicion that a malignancy might be present. (See "Ovarian germ cell tumors: Pathology, epidemiology, clinical manifestations, and diagnosis", section on 'Tumor markers'.)

Differential diagnosis — The clinician should use history and physical examination to determine that the source of the bleeding is vaginal and not from the urinary or the gastrointestinal tract. In the author's experience, parents' assessments about the source are usually correct based upon observations at home during toileting or diaper changes. Asking about the location of the blood in the child’s underwear can also be revealing. For patients with rectal mucosal lesions (eg, anal fissures) or hematochezia caused by a juvenile polyp or a Meckel's diverticulum, bright red blood on the toilet paper is often reported. Physical examination, including examination in the knee-chest position, usually definitively demonstrates the bleeding site. However, if, after physical examination of the child, the bleeding source is still uncertain, urinalysis and/or stool guaiac testing is suggested.

Postmenarcheal patients — The evaluation of adolescents who could be pregnant is discussed in detail separately. (See "Clinical manifestations and diagnosis of early pregnancy" and "Approach to the adult with vaginal bleeding in the emergency department" and "Overview of the etiology and evaluation of vaginal bleeding in pregnancy".)

History-taking for non-pregnant, postmenarcheal adolescents with abnormal bleeding should focus on an estimate of how much blood has been lost (table 3), the menstrual history, and any use of contraceptive medications. Physical examination findings with potential diagnostic significance include pallor, abnormal bruising, severe acne, hirsutism, thyroid enlargement, and obesity. Laboratory testing should include a complete blood count to assess for anemia and thrombocytopenia and, in patients with no obvious diagnosis, evaluation for endocrinological causes of anovulation. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Evaluation and approach to diagnosis" and "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis", section on 'Initial evaluation'.)

Approach — Management of hemodynamically unstable postmenarcheal patients with vaginal bleeding is presented in detail separately (algorithm 2). (See "Approach to the adult with vaginal bleeding in the emergency department".)

For non-pregnant adolescents who are hemodynamically stable, a complete blood count should be obtained to assess for significant blood loss and for thrombocytopenia. Whether and which laboratory investigations should be undertaken next will depend upon the diagnoses suggested by the individual patient's clinical circumstances. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis", section on 'Initial evaluation'.)

SUMMARY AND RECOMMENDATIONS

●The causes of vaginal bleeding in children and adolescents are presented in the table (table 1). (See 'Causes' above.)

●The diagnostic approach to vulvovaginal bleeding in premenarcheal girls is provided above (algorithm 1). (See 'Premenarcheal patients' above.)

●The emergency management of postmenarcheal adolescents and women with vaginal bleeding is presented in detail separately (algorithm 2). (See "Approach to the adult with vaginal bleeding in the emergency department".)

●Penetrating vaginal injuries can cause life-threatening hemorrhage, rectal injury, or peritonitis. The possibility of intravaginal injury should be considered even if a patient's visible perineal injuries are minor. (See 'Penetrating vaginal trauma' above.)

●Although the possibility of sexual assault should be considered, most injuries that cause vaginal bleeding are unintentional. Conversely, most sexual abuse or assault of children does not produce genital trauma or bleeding. In particular, the clinician should be careful not to confuse lichen sclerosus (picture 8 and picture 5) with sexual abuse. (See 'Lichen sclerosus' above and 'Trauma' above and "Straddle injuries in children: Evaluation and management", section on 'Findings suggesting child abuse' and "Evaluation of sexual abuse in children and adolescents", section on 'Differential diagnosis'.)

●Foreign bodies, infectious vaginitis, and urethral prolapse (picture 9 and figure 1) are common causes of actual or apparent vaginal bleeding in premenarcheal children. Genital malignancies are rare. (See 'Common conditions' above and 'Life-threatening conditions' above.)

●For adolescents with vaginal bleeding, the most urgent issues are to establish whether the patient is pregnant and to manage hemorrhagic shock, if it is present. (See "Clinical manifestations and diagnosis of early pregnancy" and "Approach to the adult with vaginal bleeding in the emergency department", section on 'Diagnostic approach, initial management, and disposition'.)

●In adolescents who are not pregnant, the clinician needs to distinguish abnormal bleeding from normal menstruation. (See 'Common conditions not related to pregnancy' above and "Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis".)

ACKNOWLEDGMENT — We are saddened by the death of Jan Paradise, MD, who passed away in April 2021. UpToDate gratefully acknowledges Dr. Paradise's outstanding work as an author for this topic.