Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Puberty, menstrual and sexual-health concerns
Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Acute pelvic or testicular emergency
Sudden severe unilateral scrotal pain, acute pelvic pain with collapse, peritonism, shock, pregnancy or heavy bleeding may represent torsion, ectopic pregnancy, ovarian torsion or major haemorrhage.
Action: Use ABCDE, provide analgesia, obtain senior surgical or gynaecological assessment immediately, perform a pregnancy test when biologically possible without delaying resuscitation, and do not use reassuring screening tests to postpone time-critical intervention.
Overview
Assess normal and abnormal pubertal development, menstrual symptoms and sexual-health concerns without embarrassment, identify endocrine, pregnancy, infection, safeguarding and acute abdominal red flags, and choose proportionate examination, testing, referral and symptom support.
Begin with the young person's concern and language rather than assuming that the clinical goal is fertility or heterosexual activity. Offer time alone and explain confidentiality. Establish the sequence of growth, body hair, breast or genital development, voice change, menarche and cycle pattern. Ask what changes are welcome or distressing. Review prenatal history, smell, headache, visual symptoms, galactorrhoea, hot flushes, systemic illness, medicines, previous gonadotoxic treatment and family timing. Plot serial measurements because poor growth, weight loss or a falling growth centile may expose a systemic or energy-deficiency cause before laboratory testing.
Menstrual assessment records age at menarche, cycle interval, duration, flooding, clots, night changes, double protection, pain, intermenstrual or postcoital bleeding and effect on school and sleep. Ask about epistaxis, gum bleeding, easy bruising and surgical or family bleeding, particularly when heavy bleeding began at menarche. Symptoms of iron deficiency can be significant even when the young person has adapted to them. Sudden severe pain, shock or pregnancy possibility requires an acute pathway. Chronic cyclical pain with bowel, bladder or deep pelvic symptoms can suggest endometriosis and deserves review even when ultrasound is normal.
Practice
Two practice questions
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Question 1 of 2
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Paediatrics and child healthOriginal SBA
Heavy bleeding assessment
A 14-year-old reports flooding since menarche, bruises easily and is now tired and breathless on stairs. Which initial investigation pair best assesses the immediate common consequence?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE Heavy menstrual bleeding NG88Assessment, laboratory testing and treatment principles for heavy menstrual bleeding, adapted to adolescent context and specialist pathways.
BritSPAG Heavy menstrual bleeding in adolescentsUK paediatric and adolescent gynaecology guidance supporting full blood count, ferritin and targeted coagulation assessment in adolescents with heavy menstrual bleeding.
Sexual-health history is behaviour-based and non-judgemental. Ask about bodies and sites involved, barrier use, contraception, last exposure, symptoms, pregnancy intention, gender of partners, consent, power imbalance, exchanged goods, image sharing and safety. Explain why each sample or examination is offered. Self-taken vulvovaginal swabs and non-invasive urine testing can improve acceptability where clinically appropriate. Test anatomical sites according to exposure. A negative test does not settle pregnancy, safeguarding or non-infectious causes of symptoms.
Examination starts with observations, pallor, hydration, growth and general endocrine features. Assess thyroid, visual fields or neurological signs when indicated. Pubertal examination requires explicit permission, privacy, a chaperone offer, description before touch and the least exposure possible. Document objective findings and avoid photographs unless clinically essential under a governed process. Pelvic or scrotal ultrasound answers structural questions but does not replace emergency surgical assessment for torsion and should not be used as a shortcut to label normal variation.
Management combines explanation, symptom control and cause-specific referral. Offer iron for confirmed or likely deficiency, NSAID or hormonal options for menstrual symptoms after contraindication and pregnancy review, and STI care under current sexual-health protocols. Young people with delayed or arrested puberty, significant virilisation, primary amenorrhoea, suspected variation in sex development or systemic disease need paediatric endocrine or adolescent gynaecology input. Address school access, toilets, products, pain plans, emotional wellbeing and trusted-adult support rather than reducing care to test results.
Key points
Take a confidential history of growth, pubertal change, bleeding pattern, pain, discharge, medicines, nutrition, exercise, chronic disease, pregnancy possibility, sexual contact, coercion and safety.
Plot current and previous height, weight and growth velocity; pubertal stage and trajectory matter more than a single isolated examination label.
Consider specialist assessment when breast development is absent by 13 years, testicular enlargement is absent by 14 years, menstruation has not begun by 15 years or progress stalls, while applying the complete clinical context.
A pregnancy test is a relevant clinical investigation whenever pregnancy is biologically possible and should be discussed privately without assumptions based on identity, disability or family presence.
For heavy menstrual bleeding assess haemodynamic state and anaemia, ask about bleeding since menarche and personal or family bleeding history, and treat symptoms while investigating likely cause.
Do not diagnose polycystic ovary syndrome from irregular cycles and acne alone soon after menarche; assess time since menarche, biochemical or clinical hyperandrogenism and alternative causes.
Use external inspection and targeted examination only when it answers a clinical question, with consent, a chaperone offer and attention to trauma; internal examination is rarely a routine adolescent starting point.
Aetiology
01
Constitutional variation
Family pattern, nutrition and healthy individual timing create wide variation in puberty and early menstrual regularity, but trajectory should continue rather than arrest.
02
Endocrine or gonadal disorder
Hypogonadism, thyroid disease, hyperprolactinaemia, polycystic ovary syndrome, adrenal disease and variations in sex development can alter pubertal timing, bleeding or androgen effects.
03
Energy and chronic disease
Low energy availability, eating disorder, intensive exercise, inflammatory illness, malabsorption and organ disease can suppress hypothalamic signalling, growth and menstruation.
04
Pregnancy infection or trauma
Consensual sexual activity, coercion, assault and exploitation can lead to pregnancy, STI, pain, bleeding or genital injury and require confidential safeguarding-informed care.
Pathophysiology
1
Hypothalamic pituitary activation
Pulsatile gonadotrophin-releasing hormone stimulates LH and FSH, gonadal steroid production, secondary sexual characteristics, growth acceleration and eventual reproductive maturation.
2
Early anovulatory cycles
Immature hypothalamic-pituitary-ovarian coordination commonly produces variable cycle length after menarche; prolonged unopposed endometrial stimulation can nevertheless cause troublesome or heavy bleeding.
3
Androgen excess
Increased ovarian or adrenal androgen effect can cause hirsutism and acne; rapid progression, deep voice or clitoromegaly suggests a stronger virilising source.
4
Functional hypothalamic suppression
Energy deficit, psychological stress, illness or excessive training reduces pulsatile signalling, resulting in delayed progression or amenorrhoea with potential bone-health consequences.
Clinical features and red flags
Delayed pubertal progression
Secondary sexual characteristics are absent beyond the expected range, progress has stalled, or growth and pubertal sequence diverge from family pattern.
Heavy menstrual bleeding
Flooding, frequent product changes, double protection, night waking, clots, prolonged flow or iron-deficiency symptoms indicate burden beyond a simple cycle count.
Androgen excess
Progressive hirsutism, severe acne or scalp hair loss suggests hyperandrogenism; rapid virilisation requires urgent assessment for a potent ovarian or adrenal source.
Functional hypothalamic suppression
Weight loss, restricted intake, excessive exercise, stress injury, fatigue and amenorrhoea suggest low energy availability even at a non-low body mass index.
Sexual-health or safeguarding need
Discharge, dysuria, lesions, pregnancy concern, coercion, age or power imbalance, exchanged items or fear of disclosure requires private integrated assessment.
Red flags requiring action
No pubertal signs by the expected age range, pubertal regression or rapid virilisation requires targeted endocrine and specialist assessment rather than reassurance alone.
Vaginal bleeding before expected puberty, postcoital bleeding, genital injury, discharge with safeguarding concern or symptoms linked to coercion needs private assessment and a protection plan.
Investigations
01Growth and pubertal trajectoryFirst step
Why
Distinguish constitutional variation from stalled or pathological development.
Interpretation and limitations
Plot serial height, weight and growth velocity and document pubertal findings sensitively; poor growth or regression increases concern even when one hormone result is reassuring.
02Pregnancy test
Why
Identify pregnancy-related causes of amenorrhoea, pain or bleeding promptly.
Interpretation and limitations
Offer privately whenever biologically possible, consider timing since exposure, and escalate pain, bleeding or collapse because one early negative urine result may not exclude ectopic pregnancy.
03Full blood count and ferritin
Why
Detect anaemia and depleted iron associated with heavy bleeding.
Interpretation and limitations
Haemoglobin establishes current anaemia while ferritin supports iron-store assessment; inflammation can raise ferritin, so interpret it with the clinical setting and bleeding burden.
04Phenotype-directed endocrine tests
Why
Investigate delayed puberty, amenorrhoea or androgen excess without indiscriminate panels.
Interpretation and limitations
LH, FSH, oestradiol or testosterone, thyroid function, prolactin and androgen studies are selected by phenotype, timing and specialist pathway; patterns require age- and stage-appropriate ranges.
Differential diagnosis
01
Normal developmental variation
Familial timing, physiologic adolescent anovulation and benign asymmetry are common, but require documented growth and pubertal trajectory before reassurance.
02
Pregnancy-related condition
Intrauterine or ectopic pregnancy, miscarriage and gestational trophoblastic disease must be considered confidentially whenever pregnancy is biologically possible, regardless of stated identity.
03
Bleeding or structural disorder
Inherited coagulopathy, fibroid, polyp, genital tract lesion and ovarian pathology may present with heavy bleeding, bruising, pain or anaemia.
04
Infection or safeguarding harm
Pelvic inflammatory disease, urethritis, genital herpes, assault, female genital mutilation or exploitation may underlie pain, discharge, bleeding or avoidance.
Management
01UrgentExclude time-critical harmFirst stepThere is collapse, severe pain, heavy bleeding, pregnancy, testicular symptoms, sepsis or safeguarding danger.+
1Stabilise ABCDE, provide analgesia, check haemodynamic observations and obtain urgent senior specialty assessment.
2Perform pregnancy and focused laboratory testing when relevant without delaying surgery, resuscitation or protective action.
3Preserve confidentiality where possible while sharing proportionately with emergency, safeguarding or social-care teams when serious harm requires it.
4Document symptom onset, bleeding, examination, consent, chaperone, advice and the named team accepting ongoing care.
02AssessDefine development and symptom patternPuberty, bleeding, pain, discharge or body change is concerning but clinically stable.+
1Take private developmental, menstrual, sexual, nutritional, exercise, medicine, systemic and family histories using inclusive language.
Complications
01
Anaemia and functional loss
Heavy or prolonged bleeding can cause iron deficiency, fatigue, breathlessness, school absence and reduced participation even before haemodynamic instability appears.
02
Reduced bone accrual
Prolonged hypogonadism or low energy availability during adolescence can impair peak bone mass and increase stress-injury and later fracture risk.
03
Fertility or pregnancy harm
Untreated endocrine disease, pelvic infection or delayed pregnancy recognition can affect fertility and allow ectopic or obstetric complications to progress.
04
Psychosocial and safeguarding harm
Shame, dysphoria, bullying, coercion or inaccessible care may delay disclosure, worsen distress and leave abuse or exploitation unrecognised.
Monitoring and follow-up
Review growth velocity and pubertal progression at a defined interval rather than repeatedly reassuring without comparative measurements.
Use a bleeding and symptom record to assess cycle pattern, flooding, pain, school absence, product use and response to treatment.
Repeat full blood count and iron assessment according to initial severity and response, checking adherence, ongoing loss and alternative diagnoses when recovery is incomplete.
Track STI results, treatment completion, partner notification, window-period retesting, vaccination and safeguarding outcomes through the sexual-health pathway.
Ask about mood, body distress, eating, exercise, coercion and access to products or toilets at follow-up because these may change after the initial disclosure.
Escalate new severe pain, syncope, fever, pregnancy, neurological symptoms, rapidly progressive virilisation or pubertal regression without waiting for a routine review.
Special situations
Trajectory beats a snapshot
Serial growth and pubertal change distinguish many healthy variants from arrested progression more reliably than one isolated stage or hormone value.
Menstrual burden is functional
Flooding, fatigue, missed education and night waking matter even when the calendar pattern sounds superficially within a broad normal range.
Anatomy guides testing
Inclusive sexual histories identify exposed sites and pregnancy possibility without inferring behaviour from identity, appearance or partner labels.
Normal ultrasound has limits
It does not exclude endometriosis, early ectopic pregnancy, intermittent torsion or endocrine causes and cannot replace the appropriate clinical pathway.
Privacy improves diagnostic accuracy
Routine time alone permits disclosure of pregnancy risk, coercion, symptoms, medication and eating behaviours that may otherwise remain hidden.
Common pitfalls
01
Reassuring about late puberty without plotting growth, checking progression or agreeing a review date.
02
Calling irregular cycles polycystic ovary syndrome solely because acne is also present soon after menarche.
03
Omitting a confidential pregnancy test because a parent is present or the clinician assumes the young person is not sexually active.
04
Using a normal pelvic ultrasound to dismiss persistent cyclical pain or to delay urgent torsion assessment.
05
Performing an intimate examination automatically rather than explaining the clinical question, alternatives, consent and chaperone choice.
06
Treating iron deficiency while failing to control ongoing heavy bleeding or assess an inherited bleeding history.
Provide inclusive information about menstrual products, analgesia, contraception, STI testing, vaccination, consent and how to re-access confidential care.
Heavy menstrual bleeding with syncope, tachycardia, breathlessness, pallor or haemodynamic change requires urgent severity assessment, full blood count and active treatment.
Amenorrhoea with headache, visual change, galactorrhoea, severe weight change, excessive exercise or features of systemic disease should not be attributed automatically to stress.
Genital ulceration, lower abdominal pain, fever, testicular pain, pregnancy possibility or assault changes both urgency and the infection and safeguarding pathway.
05
Exposure-directed STI testing
Why
Identify treatable infection at every anatomical site potentially exposed.
Interpretation and limitations
Choose urine, self-taken swab, throat, rectal, blood or lesion samples by history and window period, arranging treatment, partner notification and repeat testing under current guidance.
2Plot growth and perform consented targeted examination, avoiding intimate examination that will not change the immediate plan.
3Order pregnancy, blood, endocrine, infection or imaging tests only where the history and examination establish a question.
4Explain normal variation and uncertainty while setting a definite review point for progression or results.
03TreatRelieve symptoms and address causeImmediate emergencies are excluded and a working formulation is established.+
1Treat iron deficiency, pain, bleeding or infection under age-appropriate current protocols after contraindication and interaction review.
2Refer delayed or arrested puberty, primary amenorrhoea, rapid virilisation, structural concern or persistent unexplained symptoms to the relevant specialist.
3Offer contraception, vaccination, partner notification and safeguarding support where relevant without making one service contingent on accepting another.
4Provide school and product access plans, safe contact details and explicit instructions for worsening pain, bleeding, faintness or distress.
Key medicines and prescribing safety2 treatments · regimens, roles and cautions+
Reduces prostaglandin-mediated dysmenorrhoea and can lessen menstrual blood loss in suitable patients.
Ibuprofen
For a young person aged 12 to 17 years, use 200 to 400 mg orally up to three times daily with food for the shortest useful period, following the product and local formulary maximum.
Avoid with NSAID hypersensitivity, active gastrointestinal bleeding, significant renal impairment or severe dehydration; review asthma history, interacting anticoagulants and pregnancy possibility and do not combine NSAIDs.
Treats iron-deficiency anaemia or depleted stores caused by heavy or prolonged menstrual loss.
Oral iron
Use an age-appropriate oral ferrous salt providing the locally recommended elemental iron dose once daily or on an agreed tolerable schedule, then continue after haemoglobin recovery long enough to replenish stores.
Confirm formulation and elemental dose, explain dark stools and gastrointestinal effects, keep securely away from younger children, and investigate ongoing loss or poor response rather than escalating indefinitely.