Vaginal Bleeding/Enlarged Ovaries

[Momma111]

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.

[Deanna L Aftab Guy, MD]

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

[Momma111]

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).

[Momma111]

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.

[Deanna L Aftab Guy, MD]

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