Pediatric Endocrinology Expert Forum
Vaginal Bleeding/Enlarged Ovaries
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Questions in the Pediatric Endocrinology forum are answered by Dr. Deanna L Aftab Guy. Topics covered include adrenal problems, diabetes insipidus, menstrual irregularities, obesity, parathyroid abnormalities, pituitary abnormalities, puberty concerns, rapid growth, rickets and bone disease, short stature, and thyroid.

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Vaginal Bleeding/Enlarged Ovaries

In August, our eight year-old daughter had an incident of vaginally spotting.  She brought this to my attention in the early evening and I brought her to her primary care doctor the next day.  They did an physical exam, found nothing, and ordered lab work.  The lab work they ordered included the following: CBC - all within normal range, except WBC Count slightly low at 4.4,  Neutrophil low at 37, and Lymphocyte a little high at 48; Urinalysis was normal; TSH was normal at 1.19; FSH was 2.7; LH was 0.1.  No estrogen test was done.  The primary care referred us to a Pediatric Endocrinologist, whom we saw in September.  He reran some of the blood work, which he wanted done a couple of weeks later, at the beginning of October,  with the following findings:  Estradial was 9pg/ml; FSH was 0.79; LH was 0.04.  A pelvic ultrasound was also done, with the finding of enlarged ovaries.  Ovarian volume was 2.8 and 2.9, which were both more than two standard deviations from normal.  As you can imagine, the enlarged ovaries are of GREAT concern to us.  The endocrinologist recommended to wait three months (which brings us to now), and have the ultrasound repeated.  He also gave us the option of having an MRI or a Cat Scan done instead of the ultrasound.  (Our daughter didn't have a problem with the test procedure itself, but had a very difficult time holding her urine for the duration of the ultrasound, and only made it through by the skin of her teeth). I would like your opinion on the test results, as well as which test , MRI, ultrasound, or Cat Scan, would give the most definitive information.  Thank you.
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Vaginal bleeding in an 8 yo girl, does she have breast development? pubic hair?
Differential diagnosis-trauma or accident, a fissure in the vaginal area or rectal area or blood coming from rectum thought to be vaginal, foreign body, ruptured ovarian cyst or even menstruation.
I am so confused by the labs as is your endo hence the wait and repeat thing.
The labs show low hormones coming from the brain to the ovaries(lh and fsh were even lower when they rechecked them) and estradiol that is low (under 20 is prepubertal)
HOwever,,,,,,, you cannot rule out early signalling of puberty from the brain simply from random blood tests and honestly the ultrasound is very sensitive in giving us an idea, was there an "endometrial stripe" that is was the uterus starting to put down a layer as happens with estrogen influence in early cycling?
The definitive test is a leuprolide stimulation test-this is done by measuring lh, fsh and estradiol, then a dose of leuprolide is given as a subcut shot, then the hormones are measured a few times after and a day later as well
If the peak LH is over 6 or so and the estradiol is high on day 2 you have a brain that is signalling pubertal levels of hormones and this in an 8yo girl is relative early puberty-and then you and her endo can talk about treatment.
Sometimes the ovaries have a receptor to LH that is automatically turned on and is signalling without control from the brain and the brain hormones will be shut off all that they can in response and the ovaries will be in the ON mode-this is a basic description of McCune Albright Syndrome-usually though these girls will have the problems show early like age 1 or 2. This is early puberty that needs a different approach towards treatment and is rare but important.
The mri should be done of the brain, not the ovaries, the bilaterally enlarged ovaries makes me think of stimulation from the brain and perhaps the bleeding was a ruptured follicle or cyst.
I agree to repeat the ultrasound and glad that her bone age is not advance but I would not stop following her, I would take advantage of the bone age not being advanced and finish the workup so as to preserve her final height-that is treat her before her bones become older than she is due to influence of early puberty hormones.
So stick with your endo and be sure you get all the info and  your options, focus more on the big picture rather than the ultrasound bother. Keep us informed and good luck
10 Comments
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I forgot to include that a bone age xray of her left hand was done, and the radiologist interpreted the results to be about her age (he gave an age four months younger than her actual age).
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Thank you for your prompt and informative response.  I'm sorry, I was so focused on giving the test results that I forgot some other very important information.  The first two points are ones you asked about:

She does not have any breast development or pubic hair at all.

Endometrial stripe was 2 mm.

Blood was a pinkish red.

She is in the 97 percentile in height, and has been tall since birth.

She had a rash on her trunk in June, which was treated with Lidex cream.  I was cautioned about using too much as it could cause broken blood vessels, so used it very sparingly and on only one part of her rash at a time.  This was improving the rash, ever so slowly, when it starting coming back but with the addition of her knees and a little on neck.  This happenned at the end of July.  I used the other half of the tube of cream, and as I noticed no broken blood vessels, started to up the amount I was using.  I called in a refill at the first of August, and was continuing to use it more strongly and all over her trunk, front and back, but mainly in the abdominal area.  About a week after the refill, thus after much exposure to the Lidex, she had the bleeding.  In pondering all of this, I did go up to the manufacturer's site and saw listed side effects regarding pubertal effects.  Do you think that the spotting, since it hasn't happenned since (and we completely quit using the medicine right away), could have caused this?  Could it have bypassed the brain and caused the ovaries to enlarge and bleed?

Also, could you address the possiblity of this being a germ cell cancer?  This is a very big concern to my husband and me, with her ovaries being twice the size of what they should be.

Thank you, again.
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310293_tn?1274743373
Lidex is a strong steroid but it is not a male or female rather a antiinflammatory steroid, stop using that and work on the rash situation with a dermatologist, however it is unlikely related to her bleeding.
With no breast development and the presence of an endometrial stripe I worry about gonadotropin independent precocious puberty versus abnormal tempo to normal puberty.
If this were my patient I would be proceeding with an mri of the pituitary (which I get in every little girl that I am planning on treating with lupron) and I would also do a leuprolide stimulation test-not in that order.
If her ultrasound is bilateral a tumor is unlikely, large ovaries tells me stimulation from LH, either from the brain or from independent action at the LH receptor.
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Avatar_n_tn
Hello,
My 4.5 year old daughter started spotting on saturday with no fever. On sunday, looked like the first day of a period.  Still no fever and no infection in vagina (via urgent care doctor).   Her pediatrician seems to think that it is just a trauma to her vagina.  No abuse involved.  My question is if it was a trauma, wouldn't the bleeding have been bad and then better - not the other way around?  She is adopted from birth and african american.  I ran across a couple of medical pages online and got a little scared.  She does have two dark spots on her skin.  One on her buttocks and one on her calf.  Also, has just gone through a growth spurt.  She was almost a preemie and now has a thin build but is 48 pounds and 44.5 inches tall.  No signs of breast development or pubic hair.  We are going in tomorrow to get pelvic and abdomenal (abdominal) ultrasounds.  Any suggestions or questions that I should ask?
Thanks for any help or suggestions.  
laurie
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310293_tn?1274743373
You are getting the right workup, even an isolated incident needs workup, If the bleeding does not come back then just monitor her, if you see spotting again get her seen immediately by peds endocrine, a leuprolide stim test is needed to assess if she is having signalling and also they can test her thyroid and other hormones, it may be an isolated ovarian cyst rupture but needs monitored closely.
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Thank you so much for some extra insight.  We'll get her results from the ultrasounds tomorrow.  Do you know the average size of an ovary for a 4-year old?  I was trying to memorize the numbers as they were doing the procedure.  

One find that seems to be unrelated is that she has a pelvic kidney (left).  Hear of that much?  Also, are you familiar with McCune Albright Syndrome?  Forgive any spelling errors on that one.  Seems pretty rare, but when I punch in symptoms it comes up on many sites.  Thanks again for any help.  
Laurie
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310293_tn?1274743373
ok, average size of ovary of a prepubertal child, let the pediatric radiologist interpret, rather than size it is best to be assessed by volume(kind of like square footage)
But be sure that this is read by a pediatric radiologist, the adult folks may under or overinterpret depending if they see alot of pediatric ultrasounds. Also McCune Albright Syndrome, yes, have several patients, it is a pituitary independent cause of early puberty. That is what I talked about in my earlier post
Sometimes the ovaries have a receptor to LH that is automatically turned on and is signalling without control from the brain and the brain hormones will be shut off all that they can in response and the ovaries will be in the ON mode-this is a basic description of McCune Albright -these girls and boys have symptoms that also may lead to the diagnosis like a birth mark or several marks on their skin called cafe au lait marks- they usually do NOT cross the midline.
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Thank you so much for all of your help.  My daughter is still bleeding.  Today is day 6.  One quick question about your last comment-  What does cross the midline mean?  One mark on left buttocks and one on left calf.  

New info- the ultrasounds do not indicate that menstruation is occuring.  Our pediatrician said that the results do not show an unusual size of the uterus or endometrium lining.  Does this mean that we can cross off pre-puberty and not make an appt. with the endrocrinolgist?

The pediatrician seems to think that the bleeding is from trauma.  I told my sister-in-law my daughter's symptoms because she is a ob/gyn (not in peds).  I told her that it looks like there are little bloody "peas" in her vagina.  I just checked again, still there and not only is there blood and the "peas" but a little bloody tissue as well.  She was concerned about sarcoma botryoides.  I looked this up on-line and a picture of it looks just like the inside of her vagina.  Any other symptoms that I could look for?  Suggestions for a type of doctor to see?  Sorry, not a hypochondriac, just worried about my little girl.  Thanks
Laurie


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310293_tn?1274743373
She needs to see someone this week!!! I would demand for your pediatrician to refer her asap, I do not suspect tumor and it may just be foreign body but ultimately here are the folks that can help-pediatric surgery or pediatric urology.
Call them today please
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A related discussion, prolapsed urethra was started.
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Hello
My 4 year old has spotted in her panties this morning it reminded me of the first time I spotted ??? Any suggestions??!! Comments? Thank you
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