Toddler Has Menstrual Cycle at 17 Months

A 17-month-old girl experienced vaginal bleeding each month for 3 months before a clinical team uncovered an unusual diagnosis.

The patient was diagnosed with isolated premature menarche, “a rare and benign condition characterized by vaginal bleeding without other signs of pubertal activation” in girls younger than 8 years — a diagnosis of exclusion, wrote Dewi Rani Pelitawati, MD, of the Universitas Padjadjaran in Bandung, Indonesia, and co-authors in the American Journal of Case Reports.

“Children with menstrual-like vaginal bleeding in the prepubertal period should always undergo a systematic and comprehensive evaluation to differentiate isolated premature menarche from other pathological causes,” the authors wrote. “Recognizing findings indicative of this benign condition is important to avoid unnecessary interventions and to ensure appropriate follow-up.”

The clinical team noted that multiple occurrences of vaginal bleeding had occurred without any breast development or pubic or axillary (underarm) hair growth, and the child’s overall growth appeared appropriate to her age. She’d been born full-term with no complications, and at the time of the physical exam weighed 13.5 kg and was 87 cm tall, putting her higher than the 97th percentile of weight-for-age.

An external genital examination found normal, age-appropriate female genitalia. She had no dysmorphic features and had a non-palpable thyroid gland.

The team considered a diagnosis of precocious puberty, “defined as the early onset of secondary sexual characteristics, occurring before the age of 8 years in girls and 9 years in boys.” This condition is more common in girls, with an estimated incidence rate of 1 in 5,000-10,000. Central precocious puberty — the most common form — stems from premature activation of the hypothalamic-pituitary-gonadal axis.

However, they found no evidence that the hypothalamic-pituitary-gonadal axis had been activated. On the Tanner Staging system, or the Sexual Maturity Rating, her development was rated as stage 1, or prepubertal.

An ultrasound of the pelvis also showed a prepubertal uterus and ovaries, with a fundus-to-cervix ratio of 2:1, indicating an “age-appropriate prepubertal uterus.” She had no cysts, masses, or other abnormalities, and the team ruled out local causes of vaginal bleeding, such as vulvovaginitis and neoplastic processes.

They did not find any foreign bodies, and an abdominal exam did not find any palpable masses in the lower abdomen or pelvis.

“The vulva and vaginal introitus were clean and non-erythematous, with no signs of inflammation, discharge, trauma, bruising, or bleeding at the time of examination,” noted Pelitawati and team. She had no abrasions, lacerations, or other signs of sexual abuse, they confirmed.

The team also assessed the child’s bone age by taking bilateral x-rays of her hands and wrists. Based on the x-rays and measurements of various hormones — follicle-stimulating hormone, basal serum luteinizing hormone, and thyroid function — bone age was found to be consistent with her chronological age, and hormonal values were found to be within prepubertal or normal ranges.

The girl had no history of surgery, seizure, encephalitis, or radiation or pesticide exposure, nor had she had abdominal pain, headache, blurred vision, changes in behavior, or neurological deficits.

She showed no signs of infection, blood clots, or fever, and lab tests suggested that her inflammatory markers fell in the normal range. The clinical team could find no underlying infectious, hematologic, or inflammatory disorders.

After diagnosis of isolated premature menarche, the girl was treated with tranexamic acid 200 mg, given three times daily, which helped to control the bleeding and correct the hormonal imbalance.

“The patient showed a good clinical response and the prognosis was favorable,” Pelitawati and colleagues noted.