Synopsis
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.
- 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.
- Provide inclusive information about menstrual products, analgesia, contraception, STI testing, vaccination, consent and how to re-access confidential care.
Key red flags
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.
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.
Investigation priorities
Distinguish constitutional variation from stalled or pathological development.
Management branches
There is collapse, severe pain, heavy bleeding, pregnancy, testicular symptoms, sepsis or safeguarding danger.
- Stabilise ABCDE, provide analgesia, check haemodynamic observations and obtain urgent senior specialty assessment.
- Perform pregnancy and focused laboratory testing when relevant without delaying surgery, resuscitation or protective action.
- Preserve confidentiality where possible while sharing proportionately with emergency, safeguarding or social-care teams when serious harm requires it.
- Document symptom onset, bleeding, examination, consent, chaperone, advice and the named team accepting ongoing care.
Puberty, bleeding, pain, discharge or body change is concerning but clinically stable.
- Take private developmental, menstrual, sexual, nutritional, exercise, medicine, systemic and family histories using inclusive language.
- Plot growth and perform consented targeted examination, avoiding intimate examination that will not change the immediate plan.
- Order pregnancy, blood, endocrine, infection or imaging tests only where the history and examination establish a question.
- Explain normal variation and uncertainty while setting a definite review point for progression or results.