Thrombotic thrombocytopenic purpura (TTP) Immune thrombocytopenia purpura (ITP) Autoimmune hemolytic anemia Hemolytic uremic syndrome (HUS)

Pregnancy, eclampsia Disseminated intravascular coagulation (DIC) Septicemia with DIC Systemic lupus erythematosus (SLE) Scleroderma Paroxysmal nocturnal hemoglobinuria (PNH)

Coagulation Disorder
Blood loss in the normal menstrual cycle is self-limited due to the action of platelets and fibrin. Individuals with thrombocytopenia or coagulation deficiency may have excessive menstrual bleeding. Several studies of the incidence of coagulopathy in teenagers admitted or evaluated for menorrhagia found coagulopathies in 12 to 33% in all admissions for menorrhagia.[11-13] The most common coagulation disorders include thrombocytopenia, due to idiopathic thrombocytopenic purpura (ITP), von Willebrand's disease, which affects up to 1% of the population, and platelet function defects.[14] Of the adolescents presenting with severe menorrhagia or hemoglobin less than 10 g/dL, 25% were found to have a coagulation disorder. In those presenting with menorrhagia at the first menses, 50% were found to have a coagulation disorder.[13]

Pregnancy Complications
The possibility of pregnancy should be considered in any adolescent with abnormal bleeding, and a pregnancy test is mandatory even if the client denies sexual intercourse. Any bleeding in early pregnancy should lead to suspicion of miscarriage or ectopic pregnancy.[15]

Reproductive Tract Pathology

Any trauma, infection, or neoplasm can cause AUB. Infections, such as chlamydia[16] or pelvic inflammatory disease (PID), may present with abnormal bleeding. Vaginal trauma or a foreign body may cause bleeding that might be assumed by the adolescent to be uterine in origin. Women with a foreign body in the vagina generally present with a

bloody, odorous discharge. Cervical polyps, cervical carcinoma, and cervical inflammation can cause bleeding. Cervical cancer is fairly rare in adolescents but may be encountered in those who had sexual experiences at a very early age (including those with a history of sexual abuse). Ovarian estrogen-producing tumors need to be excluded in the adolescent with very heavy persistent bleeding. Finally, although rare, uterine pathology, such as polyps and fibroids, may lead to abnormal bleeding.

Endocrinopathies
The most common endocrine disorder to cause abnormal bleeding is thyroid disease.[17] In general, hypothyroidism presents with hypermenorrhea, and hyperthyroidism presents with hypomenorrhea. Hyperprolactinemia caused by a prolactinoma[18] or certain medications, such as neuroleptics, can also cause anovulation and AUB. PCOS is underdiagnosed in adolescents and should be suspected in obese teens with hirsutism, acne, and continued irregular cycles.[19] There is some recent evidence that PCOS is more common in women with epilepsy.[20] Other diseases to consider are congenital adrenal hyperplasia, Cushing syndrome, hepatic dysfunction, and adrenal insufficiency.

Others Causes of Aub in Adolescents

Other causes of AUB (most commonly amenorrhea) in adolescents are eating disorders, stress, excessive exercise, and weight loss. In addition, common medications, which increase the cytochrome P450 enzymatic processes in the liver, may induce the more rapid metabolism of steroid hormones, thereby decreasing their bioavailability and result in AUB that is secondary to a relative insufficiency of estrogen or progesterone (e.g., antiseizure medications).