Differential Diagnosis for 11-year-old Female with 2 Weeks of Vaginal Bleeding

Single Most Likely Diagnosis

• Idiopathic heavy menstrual bleeding: This is a common condition in adolescents, especially in the first few years after menarche, due to anovulatory cycles. The fact that all labs are within normal limits (wnl) supports this diagnosis, as it suggests the absence of underlying conditions that could cause abnormal bleeding.

Other Likely Diagnoses

• Hormonal imbalance: Imbalances in estrogen and progesterone levels can lead to irregular menstrual bleeding. This is common in early adolescence due to the immaturity of the hypothalamic-pituitary-ovarian axis.
• Trauma or sexual abuse: Although sensitive and difficult to discuss, these are important considerations in any case of vaginal bleeding in a child. A thorough and compassionate history is essential.
• Foreign body: The presence of a foreign object in the vagina can cause bleeding and should be considered, especially if the bleeding is persistent or accompanied by other symptoms like discharge or odor.

Do Not Miss Diagnoses

• Sexual abuse or assault: As mentioned, this is a critical consideration due to its severe psychological and physical implications. It requires a sensitive and non-judgmental approach.
• Malignancy (e.g., rhabdomyosarcoma, cervical cancer): Although rare in this age group, any possibility of cancer must be thoroughly investigated due to its potential severity and the importance of early detection.
• Bleeding disorders (e.g., von Willebrand disease): These conditions can present with heavy menstrual bleeding and are crucial to diagnose to prevent future complications.
• Pregnancy: Although less likely in an 11-year-old, pregnancy should always be considered in the differential diagnosis of vaginal bleeding in females of reproductive age, regardless of age, due to its significant implications.

Rare Diagnoses

• Precocious puberty: This condition involves early onset of puberty, which can lead to menstrual bleeding before the expected age. It has various causes, including central (GnRH-dependent) and peripheral (GnRH-independent) precocity.
• Congenital anomalies of the reproductive system: Conditions like a double uterus or other anatomical abnormalities can sometimes present with abnormal vaginal bleeding.
• Infectious causes (e.g., pelvic inflammatory disease): Although less common in pre-teens, infections should be considered, especially if there are accompanying symptoms like fever, pelvic pain, or discharge.