Research Article| Volume 35, ISSUE 3, P288-293, June 2022

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Emergency Department Evaluation of Abnormal Uterine Bleeding in US Children's Hospitals

Published:January 06, 2022DOI:


      Study Objective

      To assess initial evaluation patterns of patients presenting to the Emergency Department (ED) with abnormal uterine bleeding (AUB) including differences by race


      Retrospective multicenter cohort study from October 2015 through September 2020


      Forty-seven children's hospitals submitting data to the Pediatric Health Information System


      Female patients aged 8-21 with an ED encounter with AUB as the primary diagnosis code

      Interventions and Main Outcome Measures

      Proportion of visits with at least 1 laboratory assessment for the evaluation of anemia, iron deficiency, and/or hemostatic disorders


      We identified 17,759 unique patients with AUB seen in the ED who met inclusion criteria. Median age was 16.3 years (IQR, 14.1-17.8 years). Most encounters (n = 11,576, 65.2%) included evaluation for anemia, but only 6.8% (n = 1,215) included assessment for iron deficiency and 26.2% (n = 4,654) for hemostatic disorders. Black patients accounted for 34.7% (n = 6,155) of AUB encounters yet constituted only 25% of all ED encounters (n = 198,192). Black patients with AUB were less likely to undergo bleeding disorder evaluation (OR = 0.76; 95% CI, 0.69-0.83) but more likely to receive evaluation for sexually transmitted infections (OR = 1.63; 95% CI, 1.48-1.80) compared with White patients, despite controlling for age and concomitant pain.


      In a national cohort of adolescents presenting to the ED with AUB, evaluations for anemia and hemostatic disorders were infrequently performed, and racial differences existed regarding initial assessment. Further studies are needed to understand the factors underlying racial differences in hematologic testing and the impact of this disparity on health outcomes for females with AUB.

      Key Words


      ED (emergency department), AUB (abnormal uterine bleeding), STI (sexually transmitted infection), CBC (complete blood count), PHIS (pediatric health information system), US (United States), IQR (interquartile range), OR (odds ratio), CI (confidence interval), PT (prothrombin time), PTT (partial thromboplastin time)
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      1. Gray SH, Emans SJ: Abnormal vaginal bleeding in adolescents. Pediatr Rev 2007; 28:175-182. doi:10.1542/pir.28-5-175

        • American Academy of Pediatrics Committee on Adolescence,
        American College of Obstetricians and Gynecologists Committee on Adolescent Health Care DA, Laufer MR, Breech LL: Menstruation in girls and adolescents: using the menstrual cycle as a vital sign.
        Pediatrics. 2006; 118: 2245-2250
        • Pitangui AC
        • Gomes MR
        • Lima AS
        • et al.
        Menstruation disturbances: prevalence, characteristics, and effects on the activities of daily living among adolescent girls from Brazil.
        J Pediatr Adolesc Gynecol. 2013; 26: 148-152
        • Johnson S
        • Lang A
        • Sturm M
        • et al.
        Iron deficiency without anemia: a common yet under-recognized diagnosis in young women with heavy menstrual bleeding.
        J Pediatr Adolesc Gynecol. 2016; 29: 628-631
        • Borzutzky C
        • Jaffray J
        Diagnosis and management of heavy menstrual bleeding and bleeding disorders in adolescents.
        JAMA Pediatr. 2020; 174: 186-194
        • Diaz R
        • Dietrich JE
        • Mahoney Jr, D
        • et al.
        Hemostatic abnormalities in young females with heavy menstrual bleeding.
        J Pediatr Adolesc Gynecol. 2014; 27: 324-329
        • Haamid F
        • Sass AE
        • Dietrich JE:
        Heavy menstrual bleeding in adolescents.
        J Pediatr Adolesc Gynecol. 2017; 30: 335-340
        • Powers JM
        • Stanek JR
        • Srivaths L
        • et al.
        Hematologic considerations and management of adolescent girls with heavy menstrual bleeding and anemia in US children's hospitals.
        J Pediatr Adolesc Gynecol. 2018; 31: 446-450
        • Cooke AG
        • McCavit TL
        • Buchanan GR
        • et al.
        Iron deficiency anemia in adolescents who present with heavy menstrual bleeding.
        J Pediatr Adolesc Gynecol. 2017; 30: 247-250
        • Rosen MW
        • Giuliani E
        • Marsh EE
        • et al.
        Trends in emergency department visits among adolescents with abnormal uterine bleeding.
        J Pediatr Adolesc Gynecol. 2020; 33: 484-488
        • Brown MC
        • White MH
        • Friedberg R
        • et al.
        Elevated von Willebrand factor levels during heavy menstrual bleeding episodes limit the diagnostic utility for von Willebrand disease.
        Res Pract Thromb Haemost. 2021; 5: e12513
        • Nicholson WK
        • Ellison SA
        • Grason H
        • et al.
        Patterns of ambulatory care use for gynecologic conditions: a national study.
        Am J Obstet Gynecol. 2001; 184: 523-530
        • Tang N
        • Stein J
        • Hsia RY
        • et al.
        Trends and characteristics of US emergency department visits, 1997-2007.
        JAMA. 2010; 304: 664-670
        • Hall WJ
        • Chapman MV
        • Lee KM
        • et al.
        Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review.
        Am J Public Health. 2015; 105: e60-e76
        • Marin JR
        • Rodean J
        • Hall M
        • et al.
        Racial and ethnic differences in emergency department diagnostic imaging at US children's hospitals, 2016-2019.
        JAMA Netw Open. 2021; 4e2033710
        • Raman J
        • Johnson TJ
        • Hayes K
        • et al.
        Racial differences in sepsis recognition in the emergency department.
        Pediatrics. 2019; 144: e20190348
        • Zook HG
        • Kharbanda AB
        • Flood A
        • et al.
        Racial differences in pediatric emergency department triage scores.
        J Emerg Med. 2016; 50: 720-727
        • Payne NR
        • Puumala SE:
        Racial disparities in ordering laboratory and radiology tests for pediatric patients in the emergency department.
        Pediatr Emerg Care. 2013; 29: 598-606
      2. Centers for Disease Control and Prevention: Health Disparities in HIV/AIDS, Viral hepatitis, STDs, and TB. Atlanta, GA. U.S. Department of Health and Human Services. 2018. Accessed October 6, 2021.

      3. Centers for Disease Control and Prevention: Von Willebrand disease. Atlanta, GA. U.S. Department of Health and Human Services. 2018. Accessed October 6, 2021.