Menstrual disorders in adolescents — branching viva

Stem

The examiner tests whether you can classify and manage an adolescent's menstrual complaint, defend your work-up, and run the visit through confidential adolescent care. [1] [3]

Branch 1 — Normal thresholds and classification

Examiner: What is a normal menstrual cycle in an adolescent? [1]

Strong answer: Cycle 21 to 45 days, fewer than 8 days of flow, regular within 3 years of menarche, and menarche by age 15. The cycle is a vital sign — abnormal means investigate. [1]

Examiner: Classify the causes of abnormal uterine bleeding. [3]

Strong answer: FIGO PALM-COEIN — structural (Polyp, Adenomyosis, Leiomyoma, Malignancy) and non-structural (Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not yet classified). In adolescents most bleeding is non-structural, especially ovulatory dysfunction from HPO immaturity and coagulopathy (von Willebrand disease). [3] [4]

Branch 2 — Heavy menstrual bleeding work-up

Examiner: A 14-year-old has flooding, clots and a haemoglobin of 78. What is your work-up? [5]

Strong answer: Pregnancy test, full blood count, ferritin, TSH, prolactin, free testosterone, and a coagulation screen with a von Willebrand panel because about one in five adolescents referred for HMB has an underlying bleeding disorder. Pelvic ultrasound only if a structural cause is suspected. [5] [6]

Examiner: Why von Willebrand specifically? [6]

Strong answer: von Willebrand disease is the single most common inherited bleeding disorder causing HMB; heavy bleeding from menarche with bruising or family history is the clue. [6] [5]

Branch 3 — Refractory dysmenorrhoea

Examiner: A 15-year-old's dysmenorrhoea has not responded to an adequate NSAID trial and combined hormonal contraception. What now? [2]

Strong answer: Refractory dysmenorrhoea is a secondary cause until proven otherwise — endometriosis, outflow obstruction (imperforate hymen, vaginal septum), or pelvic infection. Take a focused pain history, examine including external genitalia, and refer to adolescent gynaecology. [2] [7]

Branch 4 — Secondary amenorrhoea

Examiner: A 16-year-old runner has been amenorrhoeic for six months with a BMI of 17. Approach? [1]

Strong answer: Exclude pregnancy first. The leading cause here is functional hypothalamic amenorrhoea from energy deficit; treatment is restoration of energy balance with the eating-disorder team, weight restoration, and bone-density monitoring — not hormones alone. [1] [8]

Examiner: Why not just start the oral contraceptive pill? [1]

Strong answer: Hormones may induce withdrawal bleeds and partially protect bone, but they mask the underlying energy deficit and do not restore the physiology; the definitive treatment is nutrition and reduced training. [1] [8]

Branch 5 — Confidentiality and systems

Examiner: She is sexually active and wants no parent involvement. How do you handle the visit? [1]

Strong answer: Confidential adolescent frame: time alone, conditional confidentiality with limits for serious harm, abuse and legal duties, a confidential pregnancy test and sexual health screen, and documentation that portals and billing will not leak. [1]

Examiner extras

• Always state the cycle is a vital sign in your opener. [1]
• Use FIGO objective terms, not menorrhagia/metrorrhagia. [4]
• Treat iron deficiency alongside the bleeding. [5]
• Do not diagnose PCOS on a single androgen level or ultrasound morphology in early adolescence. [8]