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Original Study

Polycystic Ovary Syndrome: An Under-recognized Cause of


Abnormal Uterine Bleeding in Adolescents Admitted to a
Children's Hospital
Sofya Maslyanskaya MD 1,2,*, Hina J. Talib MD 1,2, Jennifer L. Northridge MD 1,2, Amanda M. Jacobs MD 1,2,
Chanelle Coble MD 1,2, Susan M. Coupey MD 1,2
1
Pediatrics, Albert Einstein College of Medicine, Bronx, New York
2
Division of Adolescent Medicine, Children's Hospital at Monteore, Bronx, New York

a b s t r a c t
Study Objective: To evaluate whether ovulatory dysfunction due to polycystic ovary syndrome (PCOS) is a common underlying etiology of
abnormal uterine bleeding (AUB) in adolescents who require hospitalization and to explore etiology, treatment, and complications of AUB
with severe anemia in adolescents.
Design, Setting, Participants, Interventions, and Main Outcome Measures: We identied female patients aged 8-20 years admitted to a
children's hospital for treatment of AUB from January 2000 to December 2014. Our hospital protocol advises hormonal testing for PCOS
and other disorders before treatment for AUB. We reviewed medical records and recorded laboratory evaluations, treatments, and nal
underlying diagnoses as well as recurrences of AUB and readmissions in the subsequent year.
Results: Of the 125 subjects, the mean age was 16.5  2.9 years; mean hemoglobin level was 7.0  1.8 g/dL; 54% were overweight/obese;
and 41% sexually active. PCOS accounted for 33% of admissions; hypothalamic pituitary ovarian axis immaturity 31%; endometritis 13%;
bleeding disorders 10%. Girls with PCOS were more likely to be overweight/obese (74% vs 46%; P ! .01) and girls with hypothalamic
pituitary ovarian axis immaturity had lower hemoglobin levels (6.4 g/dL vs 7.4 g/dL; P ! .05), than girls with all other etiologies of AUB.
Treating physicians failed to diagnose endometritis as the etiology for AUB in 4 of 8 girls with positive tests for sexually transmitted
infection and no other etiology.
Conclusion: PCOS was the most common underlying etiology in adolescents hospitalized with AUB. Screening for hyperandrogenemia is
important for early diagnosis of PCOS to allow ongoing management and prevention of comorbidities. Endometritis was frequently
underestimated as an etiology for AUB.
Key Words: Abnormal uterine bleeding, Menorrhagia, Anemia, Polycystic Ovary Syndrome, Adolescent, Endometritis

Introduction the 2 most common causes of AUB requiring hospitalization


in this age group, with thyroid dysfunction and sexually
Abnormal uterine bleeding (AUB) is a frequent reason for transmitted infections (STIs) being less common reasons.3e8
physician visits by adolescent girls and this menstrual dis- As a result, experts suggest that adolescents with AUB with
order has been shown to adversely affect adolescents' severe anemia should be evaluated for bleeding disorders,
quality of life.1,2 Most often adolescent girls with AUB can be thyroid dysfunction, and STIs.9
evaluated and managed in the outpatient setting but they AUB is dened as uterine bleeding lasting longer than
might develop severe symptomatic anemia and/or hemo- 7 days, occurring more frequently than every 21 days and/or
dynamic instability and require urgent management in an requiring tampon or pad changes every 1-2 hours.10 A
inpatient setting. Over the past 25 years, several small chart classication system supported by the American Congress
review studies of adolescents hospitalized with AUB and of Obstetricians and Gynecologists divides the causes of
severe anemia indicate that ovulatory dysfunction due to AUB into 2 groups: those with structural abnormalities
immaturity of the hypothalamic pituitary ovarian (HPO) including polyps, adenomyosis, leiomyoma, and malig-
axis as well as congenital or acquired bleeding disorders are nancy, and those with nonstructural abnormalities
including bleeding disorders, ovulatory dysfunction, endo-
metrial, iatrogenic, and not classied causes of bleeding.11
The authors indicate no conicts of interest. Structural causes of AUB are less frequently seen in ado-
Current address: Jennifer L. Northridge, MD, Adolescent Medicine, Hackensack
University Medical Center, Hackensack, New Jersey. lescents than in adult women and the etiology of most AUB
Current address: Amanda M. Jacobs, MD, Health Services, Sheltering Arms Chil- episodes in adolescents is nonstructural.11
dren and Family Services, New York, New York. At our children's hospital, we have had a protocol for
Current address: Chanelle Coble, MD, Pediatrics, New York University School of
Medicine, New York, New York. evaluation and management of adolescents with AUB with
* Address correspondence to: Sofya Maslyanskaya, MD, Division of Adolescent severe anemia for the past 15 years. The protocol was
Medicine, Children's Hospital at Monteore, 3415 Bainbridge Ave, Bronx, NY 10467; developed and is periodically updated by the Division of
Phone: (718) 920-5098
E-mail address: smaslyan@monteore.org (S. Maslyanskaya). Adolescent Medicine. This protocol is followed by our
1083-3188/$ - see front matter 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jpag.2016.11.009
2 S. Maslyanskaya et al. / J Pediatr Adolesc Gynecol xxx (2016) 1e7

emergency department physicians, in consultation with acute menorrhagia and anemia from January 1, 2000 to
adolescent medicine specialists who manage the patients December 31, 2014. CLG integrates demographic, clinical,
during their hospitalization (Fig. 1). In addition to recom- and administrative data sets from the electronic medical
mending appropriate assessment and treatment regimens, records (EMRs) of all patients seen in inpatient hospitals
the protocol advises that certain blood tests to assess for and ambulatory clinics in our extensive health system and
bleeding disorders, and hormonal dysfunction including allows them to be reproduced in a programmable format for
polycystic ovary syndrome (PCOS) should be sent to the statistical access.13 Specically, we queried CLG for all fe-
laboratory before beginning treatment with any hormonal male patients aged 8-20 years discharged from the hospital
medication or blood transfusion. Thus, for our cohort of ad- with primary or secondary International Classication of
olescents, we have the opportunity to differentiate ovulatory Diseases, Ninth Revision diagnosis codes for menorrhagia,
dysfunction secondary to PCOS from that due to other causes. menstrual disorders, acute and chronic anemia, thrombo-
In this study, we aimed to describe the underlying eti- cytopenia and other bleeding disorders, and who were
ologies, treatments, and complications of AUB in a large treated with estrogens, progestins, or antibrinolytics dur-
sample of adolescents admitted to a single quaternary care ing the hospital admission.
children's hospital. We hypothesized that ovulatory
dysfunction related to PCOS would be a common underly- Subjects
ing etiology because we frequently diagnose PCOS in ado-
lescents in the outpatient setting.12 The CLG search produced a total of 335 patient records
that we screened for inclusion in the cohort. We excluded a
Materials and Methods total of 210 adolescents; most with pregnancy-related
uterine bleeding admitted to a hospital other than the
The study was approved by the institutional review children's hospital in our health system. In addition, we
board of the Albert Einstein College of Medicine/Children's excluded a few adolescents admitted to the children's
Hospital at Monteore. hospital who did not meet inclusion criteria because they
did not have active uterine bleeding during the hospitali-
Procedure zation. A total of 125 subjects were included in the study.

Using Clinical Looking Glass (http://exploreclg. Measures


monteore.org; CLG) an interactive software application,
we identied all female patients aged 8-20 years admitted EMRs of the 125 subjects were reviewed by 5 physicians
to the Children's Hospital at Monteore for treatment of (authors S.M., H.J.T., J.L.N., A.M.J., and C.C.) using a detailed

Fig. 1. Children's Hospital at Monteore Abnormal Uterine Bleeding Protocol.


S. Maslyanskaya et al. / J Pediatr Adolesc Gynecol xxx (2016) 1e7 3

data extraction tool created for this study. The 5 physicians Table 1
Characteristics of Adolescents Admitted to a Children's Hospital with AUB (N 5 125)
met in person after reviewing 3-5 medical records each to
discuss and resolve areas of confusion and amend the data Characteristic Value

extraction tool as necessary to allow uniform recording of Mean


data. In addition, a medical student trained and supervised Age, years 16.5  2.9
by S.M. also reviewed some records. Reviewers recorded Age at menarche, years 11.6  1.6
Gynecologic agez 4.9  2.9
demographic characteristics, menstrual history, laboratory Admission hemoglobin, g/dL 7.0  1.8
evaluations, etiologies, and treatments from the index Length of stay, days* 2.7  1.0
hospital admission for AUB with anemia. We dened gy- Percentage
necologic age as chronologic age at the time of the hospi- Race/ethnicity
talization minus age at menarche. To characterize weight Hispanic 44
categories, we dened obesity as a body mass index (BMI) Black 37
Asian 6
greater than the 95th percentile for age and sex, overweight White 3
as a BMI between the 85th and 95th percentiles, and normal Other/mixed 10
weight as a BMI less than the 85th percentile for age and Weight statusy
Normal weight (BMI ! 85th percentile) 46
sex. In addition, the reviewers recorded the nal underlying Overweight (BMI 85th-95th percentile) 19
diagnosis for the AUB as documented in the EMR by the Obese (BMI O 95th percentile) 35
treating physician (either during or after the hospitaliza- Gynecologic age #2 years 29
Ever had sex 41
tion) as well as the number of recurrences of AUB and History of STI 8
readmissions for severe anemia up to 1 year after the index
AUB, abnormal uterine bleeding; BMI, body mass index; STI, sexually transmitted
admission. Because of short hospital stays, the underlying infection
diagnosis for the AUB was often not made until after hos- * N 5 120.
y
pital discharge when results of the bleeding disorder, hor- N 5 111.
z
Gynecologic age indicates chronologic age minus age at menarche.
monal, and STI testing became available. Most subjects were
followed after hospitalization by the adolescent medicine
service whose physicians used Rotterdam criteria for diag- was used for all analyses and a P value of ! .05 was
nosis of PCOS, including oligomenorrhea or secondary considered to be statistically signicant.
amenorrhea and hyperandrogenemia.14
For the 41 subjects for whom the underlying etiology of Results
AUB was not documented by the treating physician, S.M.
reviewed the medical records a second time to attempt to Characteristics of Subjects
determine the etiology for some subjects on the basis of the
history, physical examination, and laboratory results docu- The mean age of the 125 subjects was 16.5  2.9 years
mented in the EMR. For this second chart review, we and mean hemoglobin level at hospital admission was
dened HPO axis immaturity as the etiology of the AUB if 7.0  1.8 g/dL (Table 1). More than half were overweight or
the subject had a gynecologic age of 2 years or less at the obese, 51 out of 125 (41%) were sexually active, and less
time of hospitalization without identication of any other than one-third had a gynecologic age of 2 years or less. Of
causes of AUB. We classied subjects as having PCOS if their the 125 subjects, 120 were admitted to the children's hos-
gynecologic age at the time of hospitalization was greater pital specically for the treatment of AUB with severe
than 2 years and they met Rotterdam criteria for diagnosis anemia and their hospital length of stay was 2.7  1.0 days.
with hyperandrogenemia (elevated free and/or total Five subjects were admitted for treatment of other medical
testosterone levels) as well as evidence of anovulation with conditions but also had uterine bleeding that required
a history of oligomenorrhea or secondary amenorrhea.14 treatment at some time during the admission including 1
Ultrasonographic criteria were not used for PCOS diag- subject each with sepsis-related thrombocytopenia,
nosis because they are difcult to apply to adolescents.15,16 chemotherapy-related thrombocytopenia, prolonged pro-
We dened endometritis as the etiology of AUB in sub- thrombin time related to anticoagulant medication, and
jects with a positive nucleic acid amplication test for either thrombotic thrombocytopenic purpura. Their length of stay
Chlamydia trachomatis or Neisseria gonorrhea without was longer and ranged from 16 to 89 days.
identication of any other cause of AUB.
Etiology of AUB

Statistical Analyses For our 125 adolescent subjects we determined the un-
derlying etiology of AUB for a total of 102 (Fig. 2). For 84
Descriptive statistics were used to characterize de- subjects the treating physician documented the etiology in
mographic characteristics, age at menarche, gynecologic the medical record. For 18 subjects the etiology was deter-
age, etiology of AUB, and types of treatment. To compare mined in our medical record review. Ovulatory dysfunction
etiologies, hemoglobin measurement at the time of related to PCOS accounted for 33% (34 out of 102) of the
admission and patient characteristics we used the Student t admissions and was the most common underlying etiology
test for continuous variables and c2 for categorical vari- of AUB. Ovulatory dysfunction related to HPO axis imma-
ables. STATA version 11.0 (StataCorp, College Station, TX) turity accounted for 31% (32 out of 102) of admissions,
4 S. Maslyanskaya et al. / J Pediatr Adolesc Gynecol xxx (2016) 1e7

Structural results. Four of the 13 subjects were diagnosed with endo-


Other abnormalities metritis in EMR review: 3 with positive tests for chlamydia
Endocrinopathies 5%
8%
and 1 with a positive test for gonorrhea. Thus 4 of 8 subjects
(50%) with positive tests for either chlamydia or gonorrhea
had no underlying etiology for the AUB documented in the
EMR and were diagnosed with endometritis in medical
record review. Structural abnormalities including 2 subjects
Polycystic Ovary with high vaginal lacerations and 1 subject each with
Bleeding Disorder Syndrome uterine arteriovenous malformation and adenomyosis,
10% 33%
accounted for only 5% (5 out of 102) of the admissions.

Endometritis
13% Treatment of AUB and Anemia during the Index Hospital Admission

Most subjects were treated with intravenous uids and/


Hypothalamic Pituitary
Axis Immaturity or packed red blood cells to provide hemodynamic stability
31% as well as a combination of estrogens, progestins, and
antibrinolytic medications to control uterine bleeding
(Fig. 3). Almost all, 114 of 125 (91%), were treated with
combination (estrogen/progestin) oral contraceptive pills,
Fig. 2. Etiology of abnormal uterine bleeding (AUB) in adolescents admitted to a
children's hospital (N 5 102). nearly 60% received packed red blood cell transfusions, and
more than 75% received intravenous conjugated estrogens.
Only 2 subjects had a surgical intervention; 1 had dilatation
whereas bleeding disorders (primarily thrombocytopenia
and curettage with no nal etiology of AUB determined and
and von Willebrand disease) and endocrinopathies other
the other required sutures for a high vaginal laceration.
than PCOS (including thyroid disease and primary ovarian
insufciency due to mosaic Turner syndrome), each
accounted for approximately 10%. In a comparison of the 34 Associations of Etiology of AUB with Weight Category and Initial
subjects diagnosed with PCOS with the 32 subjects diag- Hemoglobin Level
nosed with HPO axis immaturity, we found a mean gyne-
cologic age of 62  29.6 months vs 15  14.7 months Comparisons of the 6 etiologies of AUB shown in Figure 2
(P ! .001), respectively. Interestingly, endometritis was the according to weight categories of overweight/obese vs
third most common underlying etiology for AUB, account- normal weight showed that girls with PCOS were signi-
ing for 13% of admissions. For the 13 subjects diagnosed cantly more likely to be overweight/obese and those with
with endometritis, 9 were diagnosed by treating physicians HPO axis immaturity were more likely to be normal weight
during the hospitalization: 3 of 9 had a positive nucleic acid than girls with all other etiologies of AUB (Table 2). Com-
amplication test for chlamydia; 1 of 9 had positive chla- parisons of the etiologies of AUB according to initial he-
mydia and gonorrhea tests; 4 of 9 had negative tests for moglobin level at hospital admission showed that the
chlamydia as well as gonorrhea, and 1 of 9 had no test hemoglobin level was signicantly lower for adolescent

anfibrinolycs

anbiocs

progesn only pills

intravenous estrogens

combined oral contracepves

packed red blood cells

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Fig. 3. Inpatient management of abnormal uterine bleeding (AUB) with severe anemia according to frequency of therapeutic use (N 5 125).
Individual patients may have been treated with more than 1 therapeutic agent.
S. Maslyanskaya et al. / J Pediatr Adolesc Gynecol xxx (2016) 1e7 5

Table 2 etiology of AUB, accounting for one-third of the cases


Probability of Etiology of AUB According to Weight Category (N 5 89*)
whereas bleeding disorders accounted for only 10% of cases.
Overweight/Obese Normal Weight P This nding is in contrast to the ndings in most published
(BMI $85th (BMI !85th
Percentile), % Percentile), %
studies of adolescents admitted to hospital for AUB and
severe anemia in whom PCOS is not reported as an etiology
PCOS (n 5 30) 74 26 !.01
All other 46 54 and bleeding disorders account for 20% or more of the
HPO axis immaturity (n 5 28) 39 61 !.05 cases.4e7 Our disparate nding is likely explained by the
All other 64 36
changing ethnic composition of the adolescent popula-
Bleeding disorder (n 5 10) 70 30 ns
All other 54 46 tion,17 the evolving childhood obesity epidemic, and the fact
Endometritis (n 5 10) 50 50 ns that our protocol allowed for testing for hyper-
All other 57 43
androgenemia before hormonal treatment of AUB.18 Our
Other endocrinopathies (n 5 8) 25 75 ns
All other 60 40 subjects with PCOS had a mean gynecologic age of just older
Structural abnormalities (n 5 3) 67 33 ns than 5 years, well beyond the time frame associated with
All other 56 44
physiologic ovulatory dysfunction, whereas subjects diag-
AUB, abnormal uterine bleeding; BMI, body mass index; HPO, hypothalamic pitui- nosed with HPO axis immaturity were well within the 2- to
tary ovarian; ns, not signicant; PCOS, polycystic ovary syndrome
* Number is !102 because 13 subjects had no height documented in the medical
3-year accepted time frame with a mean gynecologic age of
record so no calculation of BMI was possible. just older than 1 year. Fifty percent of our sample was
Hispanic or Asian and both ethnicities have a high preva-
subjects with HPO axis immaturity (6.4 g/dL) vs all other lence of PCOS and metabolic syndrome,19 especially in
etiologies (7.4 g/dL; P ! .05; Table 3). conjunction with excess body weight. In a recent study of 48
South Asian adolescents admitted to hospital in India with
Outcomes Documented up to 1 Year after Hospital Admission AUB and severe anemia, 35% of the teens had a BMI greater
than 25 and 10 of 48 (21%) were reported to have PCOS.20
Of the 125 subjects, 27 (21%) had no outpatient notes We found that nearly three-quarters of our adolescent
documented in the EMR after the index hospital admission. subjects with PCOS were overweight or obese, a signi-
For the 98 subjects with some documentation during the cantly greater proportion than our subjects with all other
year after hospital admission, 92 of 98 (94%) were seen by etiologies of AUB. Because of the serious comorbidities of
an adolescent medicine specialist afliated with the chil- PCOS, including type 2 diabetes mellitus and cardiovascular
dren's hospital. No severe adverse effects of treatment, disease,21,22 early diagnosis and treatment of this common
including venous thromboembolism or vascular events endocrine disorder is important.18 However, a barrier to
were documented for any subject. Of 88 subjects with at early diagnosis of PCOS in adolescents is the absence of
least 1 full year of documentation after the index hospital specic diagnostic criteria for this age group, because of
admission, 10 (11%) had recurrence of signicant AUB with physiologic ovulatory dysfunction in the perimenarchal
anemia, dened as a decrease of hemoglobin to less than period and the observation that many adolescents have
10 g/dL in the year after the admission and 6 (7%) were multifollicular ovaries as a normal nding. Recommenda-
readmitted for treatment of AUB with severe anemia. These tions in the 2010 Consensus Statement from the American
recurrences and readmissions were primarily due to poor Society for Reproductive Medicine/European Society of
adherence to prescribed medication. Human Reproduction and Embryology for diagnosis of PCOS
in adolescents include using biochemical markers of
Discussion hyperandrogenemia as we did in this study, instead of the
nonspecic clinical markers of hyperandrogenism such as
In this sample of adolescent girls admitted to a children's acne, hirsutism, and alopecia.23,24 A controversial recom-
hospital with AUB and severe anemia, we found that mendation is to require that all 3 Rotterdam criteria be
ovulatory dysfunction due to PCOS was the most common present for a PCOS diagnosis in adolescents, rather than 2 of
the 3 criteria as we used in this study. However, there is a
Table 3 lack of evidence on which to base ultrasonographic criteria
Probability of Etiology of AUB According to Initial Hemoglobin Level at the Time of for PCOS that were developed in adults for diagnosis in
the Index Hospital Admission (N 5 102)
adolescents. A study from our group in which we compared
Initial Hemoglobin Level, g/dL P ultrasonography (U/S) with magnetic resonance imaging for
PCOS (n 5 34) 7.2  0.3 ns diagnosis of PCOS in adolescent girls, we found that using
Other etiologies 7.0  0.2
HPO axis immaturity (n 5 32) 6.4  0.2 !.05
Rotterdam cutoffs for ovarian volume, 91% of adolescent
Other etiologies 7.4  0.2 girls with PCOS met criteria using magnetic resonance im-
Endometritis (n 5 13) 7.0  0.4 Ns aging but only 52% met criteria using U/S. In that study we
Other etiologies 7.1  0.2
Bleeding disorder (n 5 10) 7.2  0.5 Ns
could not accurately assess the follicle number using U/S in
Other etiologies 7.1  0.2 the adolescent girls.15
Other endocrinopathies (n 5 8) 7.0  0.4 Ns Treatment of PCOS consists of lifestyle changes leading to
Other etiologies 7.1  0.2
Structural abnormalities (n 5 5) 10.4  1.6 !.001
weight loss and increased exercise as well as medications to
Other etiologies 6.9  0.2 lower levels of serum androgens, regulate menses, and
AUB, abnormal uterine bleeding; HPO, hypothalamic pituitary ovarian; ns, not sig- improve insulin sensitivity.25 A prompt diagnosis of PCOS
nicant; PCOS, polycystic ovary syndrome provides adolescents and their parents with knowledge
6 S. Maslyanskaya et al. / J Pediatr Adolesc Gynecol xxx (2016) 1e7

about the etiology of AUB, risk of recurrence of AUB if index hospitalization. This highlights the importance of
treatment is discontinued, and prevention of comorbidities. determining the etiology of AUB and providing anticipatory
Thus, making a diagnosis of PCOS as the etiology for AUB guidance for adolescent girls and their families regarding
allows for intensive intervention to assist in improving the the need for ongoing monitoring and adherence to treat-
lifetime health of these adolescents. ment after the initial episode. Many adolescents and their
We found that adolescent girls in our sample whose AUB parents are ambivalent about taking birth control pills,
with severe anemia was related to ovulatory dysfunction the treatment most often used to prevent recurrences of
due to HPO axis immaturity had a signicantly lower he- AUB, and poor adherence is common. Cost utility analysis of
moglobin level on admission to hospital than girls admitted screening for von Willebrand disease in women with
with all other etiologies of AUB. This is a surprising nding menorrhagia was found to be cost-effective,29 and we pro-
and suggests to us that for perimenarchal girls whose pose that screening adolescent girls with AUB for PCOS as
relative inexperience in judging normal quantities of men- our protocol suggests might also be cost-effective. Finally
strual blood loss coupled with embarrassment and reluc- our ndings reafrm the importance of having a clinical
tance to bring attention to their menstrual bleeding likely protocol or guideline to standardize practice and ensure
delays their presentation for needed health care and puts that girls with AUB and severe anemia are tested for
them at risk for life-threatening anemia.26 We suggest that hyperandrogenemia before treatment with hormones is
pediatricians and other clinicians caring for perimenarchal begun and that those who are sexually active are examined
girls document detailed menstrual histories and monitor and tested for STIs.30
hemoglobin levels if prolonged or frequent uterine bleeding A limitation of this study is that it was performed in a
is uncovered so that treatment can be instituted before the single center and the subjects were a diverse ethnic/racial
development of severe anemia and the necessity for hos- mix with very few white adolescents. Our results might not
pital admission.10 be generalizable to primarily Caucasian or other pop-
Another nding of this study that is different from ulations of adolescents. In addition, because of the medical
ndings reported in older published studies of adolescents record review study design, there were missing data and we
admitted to hospital for AUB and severe anemia is that more were limited in obtaining long-term follow up data on all
than 10% of the AUB episodes that required hospitalization subjects. Despite these limitations, the ndings of this study
in our subjects were related to sexually transmitted endo- highlight the importance of considering gynecologic age,
metritis. Studies of adult women suggest that AUB sec- ethnicity, weight status, and sexual activity when deter-
ondary to infectious endometritis is frequently mining the etiology of AUB with severe anemia in the
underestimated.27,28 Toth et al examined endometrial bi- adolescent population. For populations similar to ours, we
opsies from premenopausal women hospitalized with AUB recommend screening for biochemical markers of hyper-
to nd antibodies against Chlamydia trachomatis as well as androgenemia to aid in the diagnosis of PCOS before
histopathology associated with inammation.27 They found beginning treatment with estrogens and/or progestins that
that Chlamydia trachomatis was detected in 48% of speci- suppress ovarian androgens and preclude making the
mens and was signicantly associated with endometrial diagnosis. In addition, all adolescents with AUB and signif-
inammation, suggesting that chlamydia infection of the icant anemia should have a condential sexual history
endometrium might result in chronic inammation causing taken and STIs should be considered in the etiology of AUB
AUB. In our sample of adolescents, more than 40% were at in adolescents.
risk for STIs because they were sexually active and 8% had a
history of a previous STI. Infectious endometritis is a known Acknowledgments
cause of AUB but unless a condential sexual history, pelvic
examination, and tests for STIs are obtained the diagnosis The authors thank Tamara Freiden, MD, 2016 graduate of
might be missed in adolescent girls and appropriate anti- the Albert Einstein College of Medicine, for her assistance
biotic treatment might not be given. Indeed, in our cohort, with review of medical records.
cases of endometritis might have been missed because we
found several adolescents who tested positive for STIs
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