Vaginal bleeding in very young patients has a broad range of causes – from minor injuries and foreign bodies to bleeding disorders and precocious puberty – so it’s essential to have a firm grasp of possible diagnoses, how to perform the physical exam and how to take a meaningful history. Gynecologist Sloane Berger-Chen, MD, whose focus is pediatric patients, explains her experience-based evaluation process as well as when lavage is appropriate, how to assess heavy bleeding and how to counsel on hygiene. Bonus: educational websites and other resources for patients.
um So I'm Sloan burger Chen, I am just going to talk a little bit about sort of um vaginal bleeding in younger patients in particular. The subject can get very large if we start moving into post cubicle bleeding but I'll sort of end the lecture a little bit on uh menstrual products, resources and just maybe a little bit about how to take a menstrual history. Um We haven't really had big access to pediatric gynecology as part of the UCSF system Until now and we're hoping to increase access over the next year or so in January, all my panels will move to pediatric only. We consider um up to age 26 as a pediatric patient. Um and I see patients at Mount Zion as well as the Berkeley outpatient. And my information will be um available to you at the end of this lecture like my email and everything to to reach me if you need to. Um If you're using Epic. Also you can we're gonna have an e consult function up and running and there is an ambulatory G. Y. N. Pizza adolescent referral if you want to use that as well. Um So I thought I would just start with just sort of a general approach to how I see a patient who is referred or how I'd recommend maybe um consider evaluating the patient as they present in your pediatric office. Um And I'm going to just move through those as a differential. Um This isn't like a huge evidence based study kind of lecture more just like practical tips and tricks for kind of how I see pediatric patients in my office? Um So my objectives as I've just stated are just to review some of the common causes of vaginal bleeding and pre maniacal patients. Um how I move about with diagnosis for pre maniacal patients and then option for management and then mental history taking and some resources. So I start as we've all been taught with history of present illness. So first just I generally get out of the way, any trauma history. So mechanisms of injury and I'll go a little bit more in depth on that when we get to the trauma section and try to get a little bit of child collaborative history, like separate from the parent if possible, but that's really dependent on age. Um if their complaint is also consistent with some discharge or some chronic bleeding or vulva vaginitis symptoms? I do my domestic characterized and quantified discharge. How much is in the pull up? How much is in the diaper? How long have they been seeing it? Do they have any pictures? Um What are the colors? Is it bright red, sort of a brown tinge to dirty or yellow color? Um Is it daily? Does it seem to be just once a month? That type of thing? Um And then general health history, like is anyone sick at home, are there any sore throats, upper respiratory infections? Diarrhea, um Travel any sick contacts and then a little bit about hygiene. Are they using any topical products regularly? Any scented products? Any essential oils are they showering taking baths? Um And then just symptom wise do they have itching accompanying it? Um And then again toilet id history. Are they potty trained? Are they learn um just learning to use the toilet? Are they diapers, pull ups, painful urination, painful defecation. Any problems with constipation. Does the teacher mentioned that they're having discomfort with like sitting in circle or unable to sit at the desk or constantly itching or wiggling in the chair? Or do they complain about sitting in the car? That type of thing And then any history of bleeding disorders. Um Any thermal sided pina symptoms, boutique easy bruising or bleeding nosebleeds, that type of thing. And then just a really brief review about vulvar anatomy. It might have been a while. So um on the right is a post puberty. It'll vulva. Um I just like it because it's a nice view of the anterior vaginal wall that's present which is well regulated. And a nice picture of a um hymen available. And it labels sort of the poster for ship very well perineum shows proximity to the anus although clearly not drawn to scale. Um And then just reference like this is the vestibule which we're talking about the pre pews and glands of the clitoris. So those types of things are helpful and sort of differentiating um where the issue is or where there is an issue that needs to be addressed. Um I think also just to address the difference between a pre puberty roll and a post puberty vagina where you have sort of thin poorly estrogen ized tissue, generally the labia Menorah are much smaller. Um But we'll have some rapid growth as puberty starts. And so I definitely have had consults for that to actually as a mass. But it was just a rapid growth of the Libya menorah, which is a normal finding but can be quite um shocking to patients, especially if one side it is growing faster or more significant in size than the other. Um But the poorly pre estrogen eyes vagina is also relevant to sort of the microbiome that's present and the risk for different types of infections and a pre pre versus post paper. It'll patient. Then when I'm doing sort of their physical exam and talking to them, I usually don't jump straight into a Volvo vaginal exam. I'm looking at their skin, talking to them. Do I see any evidence of breast budding either through their shirt and um or after they've changed? Um Do I see any cafe ole spots, any signs of eczema, vitiligo or hyperpigmentation and other areas of their skin? Any easy bruising or bleeding? Both for risk factors of um bleeding disorder but then also trauma history as well. So if they're coming in with bleeding related to a trauma, do I see bruising on the back, on the face, on the shoulders, arms, legs, those types of things for pattern of bruising. I should just give a caveat that I did 10 years of pediatrics, sex assault. So I sort of always have that vent in my head when I'm evaluating pre portal patients. But um that's just sort of the one overall give to patients as in this shading in their physical exam. It really depends on the patient. Obviously most patients are very anxious when they come in, especially to the gynecologist office. Um it's a little bit unfamiliar. Um It's not the office that they've been to and as all pediatricians, no kids have a hard time coming to the doctor anyways um sometimes I will have them change first before I come into the room um just to sort of allow for like um ease of transition, but it really just depends on the patient. Um I try not to have any paper gowns just for the crinkly stimulatory um discomfort for patients. So I keep like the cloth gowns and cloth sheets so it's a little bit softer and less bothersome like in a sensory way for them to change. And so I really just kind of do it on a case by case basis but certainly um we try to get them as comfortable as possible. Generally the parent is present. Um And then a nurse if they need like other support as well. So as far as the genital exam. I think we've all sort of been taught this. Um I really prefer the frog leg or as I call it to patients like the butterfly position or Leth autumn e either with autumn E in the stirrups themselves um or on a parent or care providers lap. Um I prefer the downward outward traction of the vulva which um generally gives a really good view of the vaginal canal. Like this one you can see the actually vaginal septum present just on the attraction part of the exam. You get a really good view of the hymen and the post here for shit. Um Some people try to kind of give some traction on the thighs but um either just with my gloved hands or with some gauze. I generally just will hold the labia majora and do that sort of down and out kind of motion which is really often is really reliable and a good evaluation. Um I know we're also all taught sort of the knee chest and the lateral position, the lateral position unless I really want sort of anus and perineum and they really are not holding still. I tend to not do this very often the knee chest is hard to the patient. Um It's kind of a vulnerable position. They can't see what's going on and but it does give me a good view of the anterior vaginal wall, especially if I'm looking for foreign bodies. Um It's also sometimes depending on the age I find difficult to explain to them how to get into the position. Um luckily yoga is so popular now, so everybody kind of knows like child's pose or downward dog. And so sometimes we can work with it this way but far and away. I'll do dorsal akademi or um butterfly feet um is kind of the easiest and most easy for me to visualize and do their exam. Um So just some pictures from the vault bar exam. So when we're talking about and I'll just do a brief overview of humans as well. But these are just some normal variance of a crescent eric Hyman with a little less anterior early and an annular Hyman, both totally normal variance. The absence of this upper part of the human does not indicate any um trauma necessarily. And they're just both normal variants. And here is some really good pictures of the hymen um in a pre puberty child, it's very thin and delicate appearing. Um This is um christian tara, Cayman and this is more of an annular presentation. These bulges here are the anterior vaginal wall that scene nicely. You can see that they're doing the downward outward attraction in this situation too, and that just contrasts in the post pupil. Well, estrogen eyes vagina that's a little bit more of like a ruffled edge or I like to explain it as sort of a scrunchie appearance that, you know, like that you put in your hair that it looks sort of like a scrunchie when it's not in your hair. But then when you stretch it to put in your hair then it gets a little bit flatter and goes back to that scrunchie shape. Now contrast this with a pre puberty. All Hyman with a laceration at six o'clock which is a sign of penetration can be um either as a result of trauma or abuse. Um We also look at lacerations at four and eight o'clock for the same sort of penetrative trauma which can be depending on the mechanism injury consistent with a penetrating trauma of some type. Um This is not a bleeding but because we're talking about him and I just threw a slide in here about him until variants, all of which are very normal. This is an imperfect Hyman, a micro perforated hymen um and accept eight Simon. This is sort of the visual appearance of tomato copos behind an imperfect human. You can see that was thin windows with the bluish bulge behind it. Um And this can also appear in a neo Nate um with um you coco post um with a similar appearance, this needs to be fixed in the operating room pretty straight forward, one of the most common presentations for an obstructive anomaly. I've had so many of these this year. I don't know what is happening in the bay area but this is a person sort of gets their tampon stuck or can't put the tampon in. You find the septum and these I can, depending on the patient most of the times take care of in the office. So I will just introduce this as a concept to you as well if you are comfortable and want to. So usually I'll just put some lidocaine there when they first come in, leave it there for about 10 15 minutes or 20 minutes. Come back in there. Pretty not give them about a couple of CCs of 1% lidocaine in the upper and lower portion hemostat across the top and bottom, tie it off cut it. That's it um takes really, it's really quick. The patients done within about a week there can go to tampons or intercourse whichever. Um and it's resolved quickly. They don't need O. R. Time. So not a bleeding thing but just thought I would run by that run that across. So differential for vaginal bleeding and the pre puberty child, I sort of break it down to sort of non hormonal and hormonal presentations infection is going to be the much the most common presentation to the pediatrician's office for vaginal bleeding or irritation, trauma is going to be high up there as well. Foreign bodies liken sclerosis can be quite common. Um Urethral prolapse the neonatal withdrawal bleeding as well. Um sexual abuse genital tumors pretty rare. Female genital cutting is very, very rare in general, but California is one of the states where it is more common. Um General awards also just wanted to give a little bit of a um comment on that and I have a slide later on and bleeding disorders more in the sort of perry pupil time. Um but can also be part of that neonatal withdraw bleeding syndrome, hormonal, we have the precocious puberty, hypothyroidism associated with proportional bleeding, estrogen exposure. Um and then isolated premature monarchy. So blunt trauma is the most common type of genital trauma, generally minor injuries to the thighs and groin, but occasionally can have a penetrating trauma um to the vulva and vagina. Water energetic Children and jumping are just the worst combinations. The pool ladder slipping on the side of the pool deck, slipping on the side of the bathtub. I've had some, like getting in the back of the boat injuries, jumping on the bed, hitting the edge of the bed. So this is where history really plays a role. Um but it's, you know, generally more of a groin slash full of our injury when you're examining them versus like a single penetrating injury. Um And then just to keep in mind also when you're getting the history um, for sexual abuse generally, um injuries are not traumatic in that sense. Unfortunately, the profile of abusers is that they wish to abuse sort of a prolonged period of time. So, acute painful trauma is generally not part of that, but that doesn't say that it can occur or isn't the source of the trauma when they're presenting, but just something to keep in mind um mechanism of injury and other patterns of bruising is another thing to observe when you're doing the exam. Um I just also want to point out how vascular even pre pube it'll vaginas and lower uteruses are, that the vaginal parties are branches of the internal iliac artery. So lacerations to the vagina and vulva are really can bleed a lot. Um And especially if it's a deep penetrating injury, the high pressure water jet, the water slide the water ski where they get sort of that huge pressure jet of high pressured water up into the vagina has in my experience causes like really some devastating injuries and they can become human dynamically unstable relatively quickly. Um But there but these patients are going to need to be examined under anesthesia and have some repair, especially if they're human dynamically unstable. If they're presenting to your office with active bleeding, I would just give the caution that if their vaginal vault is full of clots and they're bleeding but it's sort of not gushing, please just leave the clot. Um I've had a call to the er um recently where the president wanted to tell me about it and then they're like and I've cleaned all the clot out for you and I was like and I jumped in the car and was running and she had led almost 500 CCs by the time I got there and it took me like 18 minutes to get to the er So um if clot is present I would recommend leaving the clots because there's some self limiting Tampa not appropriate with it. If not you can try some vaginal packing. Um Well lubricated either time, re text or whatever you have in the office um and just pack the vagina as best as you can. It's not gonna be comfortable for them but it's going to keep them more stable on the way to the emergency room. Neo natal withdrawal bleeding is pretty self limited, usually occurs within the first week of life. It can be very anxiety inducing for parents. Um And it tends to trickle off. I have had cases where they were being evaluated for a bleeding disorder and there was actually some significant um withdraw bleeding associated with it but generally they'll have some bruising and trauma associated with the delivery and so that work up has already been started. But reassurances generally there if it's really occurring from past the first 4 to 6 weeks, sometimes I will initiate a little bit of a gentle work up to make sure everything else is um You know there's no nothing else that I would be concerned about because it's generally pretty over pretty quickly. Although literature does say it can last for a few months, even up to six. Um It's just something I keep in the back of my mind and follow the family's closely. So vaginal foreign bodies. Um, these are things I have pulled out myself, but another very common source of bloody foul smelling discharge and younger patients. So history is without trauma, They're not complaining of pain, but parents are noticing this sort of a bloody foul smelling discharge in the diapers, pull ups or underpants. Um It may be intermittent and not consistent um on office examination that this is where sometimes the knee chest is helpful because you get that anterior vaginal wall to fall away and you can get a pretty good view um into the vaginal canal. Sometimes with like the nasal or ear. Oh, disco polite. Um, can be really helpful in this situation. Most common finding a routine foreign body is going to be toilet paper. These are things I've personally pulled out of people. These polly pockets seem to be a very popular item, but I don't know if they're so popular to play with. Now management for them. It's going to be either vaginal lavage in the office and I'll go through some of that technique. Um or an easy way with a vaginal Oska P for removal of the object. Um so moving on, just because this might also require a vaginal copy or vaginal lavage. I just wanted to touch a little bit on the Volvo vaginitis that can induce bleeding and it's one of the most common complaints for pediatricians. Um, so most commonly vulva vaginitis in the pediatric patient, pre puberty early is not infectious but mostly related to hygiene and toilet ng. Um But the two types that are most common for bacterial infections of the vulva and vagina are strep a group A strep and shigella. Um Risk factors for these infections or lack of estrogen that's in vaginal mucosa, more alkaline ph and then very few protective microorganisms and then under underdeveloped microbiome. Um So shigella is often associated with diarrhea but some about half will actually present with Velvet is predominantly um with a bloody vaginal discharge or serious synchronous discharge diagnosed with vaginal cultures um And then treated with antibiotics. Um And just of note and some um if there getting the infection from travel or travel associated diarrhea, there are some areas where there is some resistance to antibiotics. This is super common. Especially common and sort of the abuse. Um Arena where they have this pure talent vaginal painful discharge with this bright red beefy vulva and perineum and peri anal um And it's very painful. They have pain with toilet ng or avoiding. Um and is consistent with the group a streptococcal infection. Um Often they will have throat cultures or an associated yu ri at some point in their history treatments. 10 to 14 days of antibiotics. I generally use Augmentin for them. But penicillin or amoxicillin is okay. Um And then pen allergy allergic cephalosporins, Michaelides, arc linda mason. Um And so vaginal lavage. This is sort of what I was talking about for like a foreign body or persistent vaginal discharge. Um Generally we're fortunate enough to have these G. Y. N. Beds and I tend to use this little tray bucket tray with an emphasis basin underneath and then do a lavage with either of these little pledge. It's sometimes work nicely. Um They give sort of a slow steady stream and then you catch the influence like in your nemesis basin. And then I just culture the influence. Um I also we have access to these are inter uterine insemination catheters but there's also a saline infusion. So no hissed a gram catheters which have this sort of rigid guide. And then this very very tiny flexible straw tip with an opening. And you can put like a three CCR five CC. Syringe on the end and hold the rigid portion really steady outside of the vulva. And then gently thread without touching the Hyman this little thin straw like portion and give a really good lavage and then collect the influence for culture. And so this works great. But I don't think most pediatricians have these types of catheters but I tend to use them in the office a little bit more or these pledge it's um some other things that sometimes we'll find with fashion. Ask api or an exam under anesthesia and bleeding that is otherwise unexplained um are hemangioma is is an external one. So you're going to be able to see that but they can have him. Angina is a little bit more in the enteritis that might be bleeding or leaking. Um These benign valerian papilloma, XyZ and then genital awards as well. Often these can be found and this is perry and I couldn't really find a good picture of Volvo vaginal. Um So these are all treated separately but essentially benign conditions um outside of sort of the 2 to 4 year range or younger, these concern for sexual abuse of course um needs to be made with any kind of vaginal awards. Um Also a maternal history should be obtained as well if they have had abnormal paths perhaps or history of general rewards themselves. Um But literature does document even actually up to five but kind of centering a little bit closer to two and under is more traditional in their teaching. So um just one of the things to keep in mind but they often don't bleed but more are noticeable of itching or irritation or noticed by the care provider. So genital tract malignancies is another one I think especially I live in fear of that the that I'm missing like a vaginal tract malignancy and that will pick up on a vaginal Oscar P or even sometimes on an exam. So you have sort of the yolk sac endo dermal tumors. This is one, this is another one and then the rabbit, oh my oh sarcoma. I try to put some maybe more non classic appearing of the rabbit. Oh my. Oh sarcoma. Because I think we're all taught that like big bunch of grapes that's coming out of the enjoy tous and that is definitely possible. And you see it a little bit more on the smaller younger patients but there are some more atypical presentations. Um even some that look a little bit like this one like that could be a urethral prolapse. So keeping it on your differential is also really important. This is just a benign papilloma, but all this is on these are all vaginal copy images. These are exams in the office. So another source of bleeding is going to be like in sclerosis. Your differential is like complaining vitiligo um and eczema. So on that initial exam I'm looking for signs of other hyperpigmentation. This is a vitiligo picture versus a lichen sclerosis. Um The margins are just much more distinct. They have a greater area um uh and then there will be other patches generally of vitiligo on the patient's um Other areas of their body. Um And like in sclerosis is um more you can see these schematic lesions there. Um and you have this sort of paper thin tissue. Um that can also have some areas of hyperpigmentation in them. Um 90% of all liken sclerosis going to present in females but it does present in male Children as well. But again classic with the opera and the is that our problem um prevalent. Um and a fair percent is gonna present in your pre puberty, little girls um often very early in life. Um So things you're also looking for fishers or cuts this creeping of the skin and these tell angie act Osias and bleeding and bruising. Um Treatment is pretty straightforward. Usually will use a and I have another side for treatment less commonly using things like the um to Kerala Miss and those types of things um Of note too, it's much less likely to progress to squamous cell carcinoma and presenting in a child than a new onset liken sclerosis presenting in an adult. Generally these patients are seen regularly every 3-6 months and an absence of regular maintenance therapy. They can develop fissures which can cause other issues of pain, bleeding and trauma to the vulva. Other things just to consider when diagnosing or evaluating for liken sclerosis, um, patients should be monitored for autoimmune conditions if you have any Turner syndrome patients very frequently. I also have like in sclerosis present, so an evaluation or at least questioning if they're having any itching or irritation or little cuts in the vulva or vagina or other important history portions um For treatment again I mentioned, so induction therapy generally I used appropriation it um point oh 5% for a 4 to 6 week course and then maintenance therapy about 1 to 2, two times weekly for at least the subsequent two years with a ball of every six months or so. Some people will do a step down to a less potent steroid. It really just depends on um you know the other presentation like if they're having very minimal symptoms, no thickening, no fissures or adhesions. And so it's sort of a case by case basis as a resource in as pack has put out now is not. North american Society for pediatric and adolescent gynecology. Super resource. They have some more links but they put out clinical opinions and they have a recently published one for like in sclerosis which is a really great overview label adhesion is not commonly at presenting um bleeding if ever. But I just put it in there since we're talking about um labial changes. Um So ideology is really unknown but probably again related to things like hygiene and hipaa estrogen anemia. Um treatment is either just gentle traction and um aliens versus traditionally topical estrogen cream. Um Adhesion licenses really reserved for a complete obstruction, um thick and tissue pain um but generally gentle traction and um aliens and waiting for puberty is what we're recommending. Currently, urethral prolapse is another on your differential for vaginal bleeding and a pre pube. It'll child again um more common and um african american patients. Vaginal bleeding is generally the presenting symptom versus urinary symptoms. You'll see this darkish purplish um kind of beefy red erythema tous area surrounding the urethra. Um And sometimes they can give a history of like having a recent cough or um some sort of abdominal um increase sudden increase in abdominal pressure um and really needs to be distinguished from something like a sarcoma associated with the vaginal wall. So generally it's a good exam. You can see a clear vaginal wall and you can clearly see the urethral. Me a tous surrounded by this tissue here, gentle support sits, baths and millions and estradiol cream. Very rarely would this be respected. And generally, if it's urethral um I would refer to pediatric urology. This is something we often see just because of the bleeding presentation, but if any extensive management generally have them see the pediatric urologists. So, just my tips and tricks for general hygiene. Um uh Often vulva vaginitis specifically will get better without treatment. Just some changes in hygiene. Um cotton underwear, loose fitting clothing. Um I think biggest offenders are the Children who are transitioning between diapers and using the toilet on their own or the Children who are just starting school and then um learning to just sort of take care of their own toilet. Ng at school, maybe not wiping as well. These pull ups are like the bane of the gynecology existence, their scratchy and loose fitting and patients don't change them as frequently. It's also that transitional toilet in time. So I feel like so often it has to do with just their toilet inhabits and making some gentle suggestions of either putting on a barrier cream or um going back to diapers if they're really not fitting properly, just so that they're not rubbing and irritating the skin. Um and then as they move on to toilet, ng, um talking about positioning on the toilet so many times, like the little people will lean back into the toilet and the, you know, their legs will be dangling and closed and the urine will actually run back and pull in the vagina. So they'll give a history of like standing up from the toilet and having a little bit of squirt of urine or that they always have urine in their underpants. And now they have like itchy smelly vaginal discharge, even some bleeding or bleeding when they wipe and that's many times can be fixed by some proper toilet ng positioning. Um I don't know how politically correct it is or not, but um often I'll recommend that they sit like a cowgirl, like leaning forward on the toilet with their feet up high with their elbows on their knees, which helps a little bit with the vaginal pooling. Um and doesn't allow that sort of cycle of vaginal pooling and infection and um, irritation of the Volvo vaginal area, bubble baths. Very irritating to vaginas for some people and some people not, but I usually get that as part of the history and if that's part of what is um, possibly contributing to their global vaginal symptoms. Talk to them about. Either fully showering and washing, making sure they're in the bath themselves. Not using bubbles but maybe just some warm water limiting the time that they are present, that type of thing. So back to sort of the bleeding track um Non trauma related postman Arkle um Human geologic conditions are going to be on your differential things like thrown beside a pina and von willow brands pregnancy like miscarriages, IQ topics, abnormal policing presentation back at General Awards Service, ItIS P. I. D. And endometriosis are all sort of your non trauma related postman Arkle Perriman Arkle um differentials. Those are all lectures in and of themselves but just things that you're thinking of as you're transitioning in and through puberty. Um I just put one slide about female genital cutting which can be a source of vaginal bleeding especially if they're having some trauma with active play or they have sutures or exposures. So if they've had the removal of the labia menorah and they have sort of exposure to the vestibule without protection they can get recurrent vaginal itis associated with it or irritation. Um And I just included this slide again this is a whole another talk because California is listed as one of the states that it's more commonly seen. Endocrine causes. I think this is something that we think about a lot too precocious puberty. Um So bleeding that's out of synchrony to their other pupil developments. Active bleeding and girls that are under eight depending on ethnicity, depending on um seven or 8 hypothyroidism is not an uncommon cause of endocrine related bleeding. Um And then you have sort of benign preview, portal bleeding. Once everything has been ruled out sort of this um premature larky or estrogen exposure. Either taking parents birth control pills or hormone replacement. There's a case series on sort of lavender oil and tea tree oil being risk factors for um breast budding and even vaginal bleeding in some rare cases. Um Endocrine is always gonna want the ultra sensitive lab sent. This is sort of the panel I'll send for the hypothalamic pituitary, ovarian access TSH free T four a bone age. Um And pelvic ultrasound is generally part of my work up for evaluation for endocrine causes. Here's those NASDAQ resources, these are patient handouts which are great resources for families. Either sending the links themselves or having them available to patients in the office. Um Just kind of going over like normal vaginal discharges. Volvo vaginal hygiene. Pre pupil Volvo vaginitis as well. All right, so just mentioned history taking. Um So I tried to get a general puberty evaluation. So age of filler key if they can remember when they first started wearing bras. Um or what greed. They think they were in a monarchy or puberty and their pubic hair. And then actual menstrual age of monarchy. When they first started bleeding. Very few Children are going to give a real thorough menstrual history, but some of the parents are keeping it on a calendar. I generally talk to them about some of the menstrual apps which are really helpful. Um This is one that is called flow. Um It's nice because they give some good summaries and they have some charts and graphs. So when they come to me they have all the information in one place. Um I'll also kind of get a history of duration of bleeding. So how many days are they bleeding? And then try to get an estimate of the volume of bleeding. So I usually do that with like what menstrual products are they using? Are they using tampons? Are they using pads? Are they using menstrual discs or cups? And then how many are they changing then also are they passing clots that are bigger than grape? Um And then try to get what size of plots they are passing? Are they leaking through their pads? And what period of time? Like are they leaking through within an hour? Are they changing their clothes every day because of leaking? Are is their bedding soaked when they take a shower? Do they have such heavy bleeding that it's running down their legs? Um And those are types of things like is it pooling in the bath or shower? Those types of things help me sort of differentiate. Is this a hygiene issue where they're just not changing their paths frequently? Or is this like somebody who's really having very heavy vaginal bleeding that I'm concerned for. Um like a bleeding disorder or an oval A Torrey bleeding, that type of thing. Regular menses are gonna last about 2-7 days um with a 21-45 day interval, the 1st 2-3 years. I think we all know they are not reliable or necessarily regular in that period of time. So I'm really trying to get like consistency and volume in those initial menstrual histories. They do make these pictorial blood assessment charts. Um they have them for pads as well as tampons. This is the National hemophilia Association, which has a great app called sisterhood where they actually have a p back chart in there. There's a place for putting how many pads you've used, What symptoms you've had. Have you had any blood clots? And this is a really good um app. They've even done studies on the brand of, you know, does it change whether or not like you're using a different brand? How often you're soaking. But it seems to be a pretty universal phenomenon if you're overflowing whatever pad you're using within an hour or two regularly that is high flow volume, You're passing clots, high volume flow. So just some stats about monarchy. So monarchy occurs on average about 2 to 2.5 years after the onset of puberty generally initiated by Theodore key um or breast development. Average age of monarchy was 12.1 is sort of shifting a little younger to 11.9. So many theories and papers written on is it socioeconomic dietary ethnic stressors? Um, endocrine disruptors and plastics and um but each of the Larky also is advancing. Um but uh faster rate than the age of monarchy. Um And cycle variability I alluded to that. Um There's a small amount of variability during the more the later reproductive years in the twenties to 40 range. But the greatest variability we're going to see is from the onset of puberty until your early twenties. Um And then both and then in the perimenopausal years, which is about 10 years before the cessation of your menstrual cycles. There's some really great sort of menstrual and pew Bertel and sexual resources that I often recommend to families. I love this amazed dot org, especially for the younger kids. Um it's sort of set to be sort of maybe the 10 to 13, 14 year old range. It's really geared more towards the younger teens. Um I generally caution parents to just take a look for us to make sure that that is in keeping with their values because there is, you know, stuff about masturbation and gender and sexuality. So sometimes um I just like to recommend that to parents that they kind of look through it first or maybe spot check versus giving free access. Um And a very neutral book for younger girls as well is going to be the care and keeping of you, which is put out by the american girl doll. They have a part one and part two. I think part two is geared towards older girls, but it's probably not appropriate. It's still just, I think best for the younger girls and just my opinion. This is another really healthy help, helpful and healthy I guess book that I recommend for families. Um, it does also give a lot of information about masturbation and gender and relationships and sexual activity. So I really caution parents that that's not the information that they're looking for. They should probably take a look, but again, most people are moving away from books and going to things like internet resources. Um, girl ology is another source. They have some in person classes depending on the area of the country that you're in. Um, and have some online resources as well. Dr jennifer Lincoln is an O. B two in in Oregon who put some helpful Tik toks out. This is just a screenshot, not an active one, but like how to insert a tampon in a really helpful way that is fact based. Um, she also has a book out that's appropriate sometimes for a little bit of an older child. Um, menstrual products that we talk about two that are sort of newer um, that families maybe don't know as much about our menstrual underwear. Really great for especially the younger girls or people who are having trouble with hygiene. Older girls to very eco friendly. Super easy to watch. They just rinse them out at the end of the day um Or in the morning after wearing them at night hang them to dry. And some are even machine washable since those brands also make bathing suits which are really great. Also if people aren't ready to use tampons but want to do swim team or go to the beach. Um They're pretty utilitarian style but really functional for um moderate bleeding. If they're really bleeding heavily again we need to redress. Um They also have all these new sort of recyclable menstrual pads similar to these. They have to be hand what were rinsed out and then many of them can be machine washed. These are I knew a lot of the older teens is very popular instead of tampons. And pads now are menstrual cups and caps. Um The caution I give when they're going to use them if they have an I. U. D. Section definitely needs to be broken so they don't pull out there I. U. D. With it. Um And then also they still are at risk and at first I I think a lot of um advertising was that you could not get toxic shock but we do um note that there have been some cases of toxic shock associated with the menstrual cups. So saying not really exceeding more than 4 to 6 hours without a cleaner a change. Um There have been some incidental reports as well for um some of the pads and menstrual products being a risk for Volvo vaginitis or evolve our dermatitis associated with some of the chemical components of menstrual products. Um there have been some associated relationships, if not concrete, um connection between some of those and things like labial adhesions and possibly liken sclerosis as well, not to say don't use them, but just if people are presenting, it's part of the history that I will get from them as well as to what kind of menstrual products they're using as a potential risk factor.