Newborn girls sometimes spot for a few days after birth because of placental estrogenic stimulation of the endometrium in utero. Any other bleeding before puberty demands evaluation. Accidental trauma to the vulva or vagina is the most common cause of bleeding during childhood. Sexual abuse also must be considered. Vaginitis with spotting, most often because of irritation from a foreign body, may also occur. Prolapse of the urethral meatus and tumors of the genital tract must also be considered in the differential diagnosis of genital bleeding before puberty. For example, bleeding and vaginal discharge are the initial symptoms of most girls who have benign vaginal adenosis or clear cell adenocarcinoma of the vagina or cervix. These disorders have been linked to maternal ingestion of diethylstilbestrol during pregnancy and are diagnosed by Papanicolaou smear and colposcopically directed biopsy of suspicious areas.189 Precocious puberty is a rare but real cause of bleeding in childhood and is generally recognized by the development of secondary sexual characteristics. If the bleeding is caused by ingestion of estrogen-containing drugs, there is rarely significant pubertal development.190

All cases of abnormal genital bleeding demand evaluation, but treatment is not always necessary. A thorough history with emphasis on the pattern and quantity of bleeding is important, but most women are poor at estimating blood loss. All patients should be asked to keep a prospective menstrual calendar in which they record days and severity of bleeding. The normal volume of blood lost at each menses is ˜30 mL; loss of more than 80 mL is abnormal.192,193 Menses typically last 4 to 6 days, but normal menstrual flow may be as brief as 2 days or as long as 8 days. However, menses that commonly last 7 or more days warrant investigation. A pelvic examination is needed to rule out obvious organic causes.