Clinical Expert Series

Abnormal Uterine Bleeding in the Adolescent

Angela Hernandez, MD, and Jennifer E. Dietrich, MD, MSc

Abnormal uterine bleeding is a common problem in adolescents. The differential diagnosis

varies from pregnancy and infection to anovulation and coagulopathy. Careful history and
examination can help elucidate the best next steps for workup and management. Heavy
menstrual bleeding is particularly worrisome in this group not only when it occurs at menarche,
but also anytime afterward when bleeding lasts longer than 7 days, blood loss is greater than 80
mL per cycle, or other warning signs that indicate a history of heavy bleeding such as anemia.
Once conditions of pregnancy, infection, structural abnormalities, and hormonal causes have
been ruled out, first-line treatment is medical management with hormonal therapy or
nonhormonal options. Invasive measures are a last resort in this patient population, because
maintenance of fertility is of critical importance.
(Obstet Gynecol 2020;00:1–7)
DOI: 10.1097/AOG.0000000000003693

A bnormal uterine bleeding (AUB) is a common

menstrual symptom among female adolescents.
The American College of Obstetricians and Gynecol-
ses. Additionally, blood loss affecting quality of life
and adolescent well-being warrants investigation.6
Because adolescents often do not quantify volume of
ogists has championed using the menstrual cycle as menstruation very well, changing a sanitary product
a vital sign, with abnormal menstruation patterns trig- every 1–2 hours has been deemed excessive, espe-
gering work-up of potential health concerns.1,2 The cially if menses is longer than 7 days.1
average age of menarche has remained stable at
approximately 12–13 years over the past 80 years in INCIDENCE
well-nourished populations in developed countries.3 Abnormal uterine bleeding affects 3–20% of
Irregular cycles occur most frequently within the first reproductive-aged females, with a higher incidence
2–3 years after menarche. Although this is normal in adolescence.7 Heavy menstrual bleeding is the
during this timeframe, cycle length still should be most frequent symptom. In a population-based study
approximately 21–45 days, with menses lasting 2–7 of 1,000 healthy Swedish adolescents, 73% reported
days. Normal blood loss is 30 mL per cycle or three menstrual problems and 37% reported heavy men-
to six pads or tampons per day (Box 1).1,4,5 Heavy strual bleeding.8 Other population-based studies have
menstrual bleeding refers to cycles lasting more than 7 reported that 12.1% and 17.9% of adolescents experi-
days or a blood loss of greater than 80 mL per men- enced heavy menstrual bleeding in Nigeria and Hong
Kong, respectively.9,10
From the Division of Pediatric and Adolescent Gynecology, Departments of PATHOPHYSIOLOGY
Obstetrics and Gynecology and Pediatrics, Baylor College of Medicine, Houston,
Texas; and the Department of Obstetrics and Gynecology, UCSF Fresno, Fresno, In an adolescent presenting with AUB, pregnancy, sexual
California. trauma, and infection must be reliably excluded regard-
Each author has confirmed compliance with the journal’s requirements for less of the sexual history the patient provides.11 A urine
authorship. pregnancy test and, if positive, serum b-hCG should be
Corresponding author: Jennifer E. Dietrich, MD, MSc, Department of Obstetrics obtained; if indicated, a sensitive pelvic examination and
and Gynecology, Baylor College of Medicine, Houston, TX; email: jedietri@ sexually transmitted infection testing should also be per-
bcm.edu.
formed. It is important to remember that pelvic inflam-
Financial Disclosure
The authors did not report any potential conflicts of interest. matory disease and ectopic pregnancy can present as
© 2020 by the American College of Obstetricians and Gynecologists. Published
AUB and abdominal pain, and only once these have
by Wolters Kluwer Health, Inc. All rights reserved. been reasonably eliminated can the AUB PALM-
ISSN: 0029-7844/20 COEIN (polyp; adenomyosis; leiomyoma; malignancy

VOL. 00, NO. 00, MONTH 2020 OBSTETRICS & GYNECOLOGY 1

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
and hyperplasia; coagulopathy; ovulatory dysfunction; cents may have heavier blood loss and may present
endometrial; iatrogenic; and not yet classified) system with acute anemia requiring emergency treatment and
be considered. hematologic evaluation. A patient presenting with
In 2011, the International Federation of Gyne- heavy menstrual bleeding should first be assessed
cology and Obstetrics published the PALM-COEIN for medical stability and triaged to emergency care
system for classifying AUB in hopes of eliminating the if necessary. Management of AUB–heavy menstrual
confusing and poorly defined terminology, including bleeding is detailed below.
dysfunctional uterine bleeding, menorrhagia, and A detailed history regarding menarche, intervals
metrorrhagia.12 In 2018, revisions to this system fur- between menses, duration of bleeding, amount of
ther clarified the parameters defining AUB.7 Abnor- bleeding, and signs and symptoms of anemia should
mal uterine bleeding describes any aberration of be obtained. Family history of bleeding disorders
menstrual volume, frequency, or duration in a non- should be obtained, in addition to assessing for easy
pregnant female. The system further separates the bruising or gum bleeding. Up to 20% of adolescents
causes of AUB into structural and nonstructural etiol- with heavy menstrual bleeding have subsequently
ogies. Structural causes (polyps, adenomyosis, leio- been found to have a bleeding disorder.17 Screening
myomas, malignancies [PALM]) are rare in tools such as the Pictorial Blood Assessment Chart
adolescents, constituting only about 1.3% of AUB in and questionnaires such as the one in Box 2 have been
this population.13 found to be useful in determining which adolescents
Nonstructural causes (coagulopathies, ovulatory to screen for bleeding disorders.2
disorders, endometrial disorders, iatrogenic, not yet Patients with obesity, hirsutism, and acanthosis
classified [COEIN]) are more prevalent in the adoles- nigricans should be evaluated for PCOS.6 The diag-
cent population, with ovulatory dysfunction being the nosis of PCOS in the adolescent can be challenging,
most prevalent. Ovulatory dysfunction due to an because irregular menses and acne are common in
immature hypothalamic-pituitary-ovarian axis occurs adolescence. Laboratory tests should include total or
in up to 95% of adolescents with AUB.14 Another free testosterone and a 17-OH-progesterone to rule
consideration is polycystic ovarian syndrome (PCOS); out nonclassical congenital adrenal hyperplasia, which
studies show that up to 59% of adolescents with AUB can present similarly to PCOS.18 Androstenedione,
when followed longitudinally will meet criteria for dehydroepiandrosterone sulfate, luteinizing hormone,
PCOS.15 follicle-stimulating hormone, and estradiol, can also
Among adolescents presenting with heavy men- be considered. In a patient found to be at risk for
strual bleeding, up to 20% may be found to have an PCOS, annual metabolic laboratory tests (complete
underlying bleeding disorder. Von Willebrand dis- metabolic panel, hemoglobin A1c) can be checked,
ease is the most common of bleeding disorders, given the risk of comorbidities.
occurring in 1% of the population, and heavy men- Thyroid dysfunction can be evaluated by asking
strual bleeding in adolescents is often the first about a history of heat or cold intolerance; palpita-
presenting symptom in otherwise healthy teens.2,6 In tions; fatigue; hair, skin, or nail changes; and weight
addition to a von Willebrand panel (von Willebrand– gain or loss. Thyroid-stimulating hormone levels
ristocetin cofactor activity, von Willebrand factor should be evaluated, because both hyperthyroidism
antigen, and factor VIII activity), a complete blood and hypothyroidism can cause AUB. Additionally,
cell count with platelets, prothrombin time, and par- a prolactin level should be checked to evaluate for
tial thromboplastin time should be performed in pa- hyperprolactinemia. Medications such as antipsy-
tients with a suspicious presentation.2,16 chotics can cause elevated prolactin levels. Prolacti-
Iatrogenic causes include anticoagulation medi- nomas are usually suggested by values greater than
cation, hormonal contraceptives, or any other medi- 100 ng/mL and can present with headaches, vision
cation known to interfere with ovulation, such as field obstructions, and galactorrhea.14 For the patient
antipsychotics. Abnormal uterine bleeding that does with slightly elevated prolactin levels, a fasting level
not fit into any of the other structural or nonstructural should be obtained to verify elevation.
causes is classified as AUB-N, or not yet classified. Although the incidence of endometrial cancer in
women younger than 20 years is low, in patients for
CLINICAL PRESENTATION whom medical treatments have failed and who have
Abnormal uterine bleeding in the adolescent often risk factors such as genetic conditions, morbid obesity,
presents with “skipped periods” or “too much bleed- and prolonged history of anovulatory cycles, evalua-
ing.” Because of frequent anovulatory cycles, adoles- tion of the endometrium may be warranted.11

2 Hernandez and Dietrich Abnormal Uterine Bleeding in the Adolescent OBSTETRICS & GYNECOLOGY

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
MEDICAL MANAGEMENT FOR ABNORMAL mentation agents may be considered, including tra-
UTERINE BLEEDING nexamic acid or aminocaproic acid (discussed in
It is important to understand the cause of AUB to more detail below).6
direct therapy. When pregnancy, infections, structural After immediate stabilization with intravenous
causes, and thyroid conditions have been ruled out, conjugated estrogen, patients can be transitioned to
tailored medical management can be discussed, taking an oral contraceptive taper with the goal to titrate down
into account the patient’s preferences and underlying eventually to one pill per day. For the patient who is
health conditions.7 Management of acute or chronic not a candidate for estrogen therapy, progesterone-
bleeding can be approached with either hormonal or only pills can be considered. High-dose progesterone
nonhormonal options. Among patients found to have can be delivered orally, with most pill tapers focusing
a bleeding disorder, management should be coordi- on norethindrone-acetate, medroxyprogesterone, or
nated with a hematologist in the event other factors or norethindrone alone (Table 1). For patients with lim-
blood products need to be administered concurrently. ited intestinal absorption, injectable depot medroxy-
For patients who are anticoagulated, working with progesterone acetate (150 mg intramuscularly or
a hematologist regarding the options for reversibility 104 mg subcutaneously) can be administered, with
of anticoagulant therapy to control AUB is also plans for additional backup use of antifibrinolytics or
important.19 oral progesterone-only pills.6 For patients who are
already anticoagulated but found to have super-
therapeutic international normalized ratio levels, acute
ACUTE ABNORMAL UTERINE BLEEDING heavy menstrual bleeding may be a concern. In one
Hormonal Options study at a single institution, 68 adolescent females were
In the acute setting of blood loss, the first priority is to receiving antithrombotic medications for indicated rea-
stabilize the patient. Determination for admission will sons. Nearly 20% of these individuals developed heavy
be based on whether the patient has symptomatic menses over time, with 43% ultimately being diag-
anemia requiring a blood transfusion. Should the nosed with anemia and 78% requiring a blood trans-
patient require admission, stabilizing with blood fusion, resulting in hospitalization.21 Reversal or
products is important, in addition to initiating medical halting of anticoagulants briefly in the acute setting to
therapy.6,20 When starting hormonal therapy, iron manage heavy bleeding may be necessary and should
therapy should also be administered, whether intrave- be discussed with a hematologist.
nously or orally. Depending on the patient’s medical
history and ability to tolerate oral intake, estrogen- Nonhormonal Options
containing options may be considered. The first-line Antifibrinolytics are an option as stand-alone therapy
options in this acute setting include intravenous con- or to augment hormonal therapy. These medications
jugated estrogen and oral contraceptive tapers. A can be delivered intravenously or orally to help
number of regimens have been studied previously reduce menstrual blood loss. One study examined
with the goal of bleeding cessation within the first the efficacy of tranexamic acid in adolescents with
24–48 hours (Table 1).6,20 In the event that bleeding heavy menstrual bleeding. The researchers conducted
does not cease within this timeframe, additional aug- an open-label prospective multicenter study involving

Table 1. Medical and Hormonal Therapies for Acute HMB

Therapy Dose Route Initial Frequency

Conjugated estrogen 25 mg IV Every 4–6 hours

50 mg ethinyl estradiol combined pill 1 tablet Oral Every 6 hours
30–35 mg ethinyl estradiol combined pill 1 tablet Oral Every 6 hours
Medroxyprogesterone 10–20 mg (maximum 80 mg/d) Oral Every 6–12 hours
Norethindrone acetate 5–10 mg Oral Every 6 hours
Tranexamic acid 10 mg/kg IV Every 6–8 hours
Aminocaproic acid 100–200 mg/kg (maximum 30 g/d IV or oral Every 4–6 hours
HMB, heavy menstrual bleeding; IV, intravenous.
Reprinted from Table 6 in Haamid F, Sass AE, Dietrich JE. Heavy menstrual bleeding in adolescents. J Pediatr Adolesc Gynecol 2017
Jun;30(3):335–340, Copyright 2017, with permission from Elsevier. Table 6 in Haamid et al also cites James AH, Kouides PA, Abdul-
Kadir R, Dietrich JE, Edlund M, Federici AB, et al. Evaluation and management of acute menorrhagia in women with and without
underlying bleeding disorders: consensus from an international expert panel. Eur J Obstet Gynecol Reprod Biol 2011;158(2):124–34.

VOL. 00, NO. 00, MONTH 2020 Hernandez and Dietrich Abnormal Uterine Bleeding in the Adolescent 3

© 2020 by the American College of Obstetricians

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Unauthorized reproduction of this article is prohibited.
32 girls and young women aged 10–19 years. The heavy menstrual bleeding using combined pills or
participants were treated with 1,300 mg of tranexamic combined rings compared with no treatment or pla-
acid orally three times daily during the first 5 days of cebo determined that, among eight randomized con-
the menstrual cycle and monitored over the course of trolled trials (RCTs), combined pills decreased
4 months from baseline. Throughout the study time- subjective mean menstrual blood loss through patient
frame, mean blood loss was reduced and quality of life satisfaction in having a reduced bleeding profile. The
scores improved.22 combined ring was shown to have similar benefits,
although evidence was limited.23 A review performed
CHRONIC ABNORMAL UTERINE BLEEDING in 2015 examined the benefits of continuous pill com-
AND MAINTENANCE THERAPY pared with other continuous combined hormonal
Hormonal Options methods such as the patch and ring. Over time, bleed-
Fortunately, a number of different hormones are good ing profiles were found to be favorable overall for
options for the control of chronic AUB (Table 2). extended cycling compared with monthly cycling. In
When anemia is present, iron therapy should be addition, extended cycling also offered a decrease in
administered concurrently. The choice of therapy is estrogen withdrawal symptoms, reliable ovulation
dependent on several factors, such as patient prefer- suppression, and a decrease in unscheduled bleeding
ence, compliance, cost, previous hormones tried, ease episodes.24 Another Cochrane Review examined the
of access to a particular therapy, and medical history.6 differences between extended cycling compared with
For patients desiring regulation of a cycle with pre- monthly cycling for combined hormonal contracep-
dictable menses each month, a combined hormonal tives. Twelve RCTs met criteria for the Review, and
method is the best option. For patients desiring fewer 11 of these found that bleeding patterns were either
cycles overall, progesterone-only methods and contin- equivalent to or improved with extended cycling over
uous combined hormonal methods with less frequent time and that compliance was similar.25
cycles are other options (Table 2). A Cochrane Progesterone-only methods for use in heavy men-
Review examining combined methods for managing strual bleeding are also well established. A retrospective

Table 2. Hormonal Management for Chronic Abnormal Uterine Bleeding

Therapy Route Dose Frequency Counseling

Combined OC Oral 10–50-microgram ethinyl E2 tablets Daily Requires compliance. Lowest dose options at 10
micrograms have a higher amenorrhea rate.
Breakthrough bleeding rates may be higher
with lower dose options. May be administered
cyclicly or continuously.
POP Oral 35 micrograms norethindrone Daily Requires compliance. No placebo week.
5–15 mg norethindrone acetate
Combined Transdermal 150 micrograms norelgestromin/35 Weekly May be administered cyclicly or continuously.
patch micrograms ethinyl E2/d
Combined Vaginal 0.12 mg etonogestrel/15 Monthly At lower dose, breakthrough bleeding rates may
ring micrograms ethinyl E2/d be higher. May be administered cyclicly or
continuously.
Injectable IM or SC 150 mg or 104 mg DMPA Every 3 mo High rates of amenorrhea. Can be administered
more frequently (monthly) for a few doses to
achieve amenorrhea earlier.
Implant SC 68 mg etonogestrel Every 3 y Gradual cessation of bleeding. High rates of
breakthrough bleeding. Studies beginning to
demonstrate use may be effective for up to 5 y.
IUD Intrauterine Levonorgestrel IUD (13.5–52 mg- 3–5 y Gradual cessation of bleeding. Heavy bleeding
formulations) episodes may predispose to expulsion of IUD.
Lowest dose formulations have higher rates of
breakthrough bleeding. Studies beginning to
demonstrate that, for highest dose formulations,
use may be effective for up to 7 y.
OC, oral contraceptive; E2, estradiol; POP, progesterone-only pill; IM, intramuscular; SC, subcutaneous; DMPA, depot medroxyprogester-
one acetate; IUD, intrauterine device.
Data from Haamid F, Sass AE, Dietrich JE. Heavy menstrual bleeding in adolescents. J Pediatr Adolesc Gynecol 2017;30:335–40.

4 Hernandez and Dietrich Abnormal Uterine Bleeding in the Adolescent OBSTETRICS & GYNECOLOGY

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
study involving 176 adolescent females taking noreth- with heavy menstrual bleeding, all participants diag-
indrone assessed bleeding profiles and discontinuations nosed with bleeding disorders who chose a nonhor-
rates. The mean age of the group was 14.862.3 years. monal method (tranexamic acid) had a decrease in
The most common indication for use was heavy men- their bleeding.29
strual bleeding in 32% of cases. Although 40 partici-
pants were lost to follow-up, 52% continued the
SURGICAL MANAGEMENT FOR ABNORMAL
method and 43% eventually discontinued secondary
UTERINE BLEEDING
to breakthrough bleeding. Only 20 patients in the
Medical therapy is, no question, the first line in the
cohort required a progesterone-only pill taper owing
adolescent population, because maintaining fertility is
to ongoing heavy menstrual bleeding, of whom 79%
paramount. When medical therapy fails, however,
had complete bleeding cessation within 7 days.26 A
Cochrane Review from 2015 focused on all more invasive measures must be considered. Revers-
ible options are applied first. Several studies have
progesterone-only methods to determine the effective-
pointed to the benefits of the Bakri balloon for use in
ness and acceptability of these methods to control
ceasing heavy postpartum bleeding. Such a balloon is
heavy menstrual bleeding. Twenty-one RCTs met cri-
too big for the purposes of controlling bleeding in an
teria, involving 2,082 women. The levonorgestrel intra-
adolescent. However, case reports have shown that
uterine device (IUD) was found to reduce mean
a 30-mL Foley balloon, after calculating the volume of
menstrual blood loss in 81% of 170 women in two
the uterus by ultrasound measurements, can be used
studies that were reviewed and in 79% among three
other studies reviewed, involving 335 women. The lev- for the same tamponade effect.30 In the event that
tamponade therapy fails and life-saving measures
onorgestrel IUD was ultimately not more effective in
become necessary, dilation and curettage, ablation,
reducing menstrual blood loss compared with hyster-
and hysterectomy become the absolute last resort in
ectomy, as pointed out by this particular study; how-
this patient population.6
ever, it was significantly more cost effective and far less
invasive.27
In 2019, an RCT was performed comparing CONCLUSIONS
combined contraceptive pills with norethindrone The most common reasons for AUB in the adolescent
acetate to control breakthrough bleeding or delay include anovulatory cycles and bleeding disorders.
menses when started late-cycle. No patients on First-line medical management may include either
norethindrone acetate had spotting; 10 of 25 patients hormonal or nonhormonal medications for acute or
randomized to the combined oral contraceptive group chronic heavy menstrual bleeding. Uterine tampo-
(control group) had spotting or irregular bleeding. nade is a reversible option for use in this population
Patient satisfaction was higher in the norethindrone when medical therapy needs to be augmented.
acetate group (80%).28 A prospective study involving Invasive and irreversible procedures are not recom-
73 adolescents noted common treatment modalities mend in this population unless absolutely necessary
among those presenting with heavy menses. They for life-saving measures, because maintenance of
were subcategorized on the basis of whether they fertility is the primary goal.
had a bleeding disorder that explained the heavy
menses. Forty-six percent were diagnosed with an
underlying bleeding disorder. Among those with
a bleeding disorder, the levonorgestrel IUD had the Box 1. Normal Menstrual Cycles in Adolescent
highest rate of success, followed by norethindrone Girls
acetate (89% and 83%, respectively). Among those
Menarche (median age): 12.43 years
without a bleeding disorder, the transdermal patch Mean cycle interval: 32.2 days in first gynecologic year
and the levonorgestrel IUD had the highest rates of Menstrual cycle interval: Typically 21–45 days
success (100% and 80%, respectively).29 Menstrual flow length: 7 days or less
Menstrual product use: Three to six pads or tampons
Nonhormonal Options per day
Some patients are not eager to be on hormonal Reprinted with permission from Menstruation in girls and
therapy. For patients desiring more local control of adolescents: using the menstrual cycle as a vital sign.
heavy bleeding episodes each month, episodic use of Committee Opinion No. 651. American College of
Obstetricians and Gynecologists. Obstet Gynecol
aminocaproic acid or tranexamic acid orally are other 2015;126:e143–6.
alternatives. In a prospective cohort of adolescents

VOL. 00, NO. 00, MONTH 2020 Hernandez and Dietrich Abnormal Uterine Bleeding in the Adolescent 5

© 2020 by the American College of Obstetricians

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Unauthorized reproduction of this article is prohibited.
 12. Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO clas-
Box 2. Recommended Screening Tool for sification system (PALM-COEIN) for causes of abnormal uter-
Adolescent Patients Who Report Heavy Menstrual ine bleeding in nongravid women of reproductive age. Int J
Gynaecol Obstet 2011;113:3–13.
Bleeding
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and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
29. Alaqzam TS, Stanley AC, Simpson PM, Flood VH, Menon S. AMA PRA Category 1 Credits. Physicians should claim only the
Treatment modalities in adolescents who present with heavy credit commensurate with the extent of their participation in the
menstrual bleeding. J Pediatr Adolesc Gynecol 2018;31:451–8. activity.
30. Stanley J, Adeyemi-Fowode O. Intrauterine Foley balloon cath- College Cognate Credit(s)
eter to manage acute heavy menstrual bleeding in a perimenar-
The American College of Obstetricians and Gynecologists
chal 10-year-old girl. Obstet Gynecol 2019;134:77–80.
designates this journal-based CME activity for a maximum
of 2 Category 1 College Cognate Credits. The College has
PEER REVIEW HISTORY a reciprocity agreement with the AMA that allows AMA PRA
Category 1 Credits to be equivalent to College Cognate
Received August 23, 2019. Received in revised form October 8, Credits.
2019. Accepted October 24, 2019. Peer reviews and author corre-
spondence are available at http://links.lww.com/AOG/B714. Disclosure of Faculty and Planning Committee
Industry Relationships
In accordance with the College policy, all faculty and planning
CME FOR THE CLINICAL EXPERT SERIES committee members have signed a conflict of interest statement in
which they have disclosed any financial interests or other relation-
Learning Objectives for “Abnormal Uterine Bleeding in ships with industry relative to article topics. Such disclosures allow
the Adolescent”
the participant to evaluate better the objectivity of the information
After completing this learning experience, the involved learner presented in the articles.
should be able to:
How to Earn CME Credit
• List the most common causes for abnormal uterine bleeding in
adolescents To earn CME credit, you must read the article in Obstetrics & Gyne-
•
cology and complete the quiz, answering at least 70 percent of the
Discuss the physiologic basis for normal and abnormal menstrual
function questions correctly. For more information on this CME educational
offering, visit the Lippincott CMEConnection portal at https://cme.
• Outline the role of history and physical examination in the
lww.com/browse/sources/196 to register and to complete the CME
diagnostic process
activity online. ACOG Fellows will receive 50% off by using cou-
• Implement treatment strategies appropriate for this age pon code, ONG50.
population
Hardware/software requirements are a desktop or laptop
Instructions for Obtaining AMA PRA Category 1 Credits computer (Mac or PC) and an Internet browser. This activity is
Continuing Medical Education credit is provided through joint available for credit through March 31, 2023. To receive proper
providership with The American College of Obstetricians credits for this activity, each participant will need to make sure
and Gynecologists. that the information on their profile for the CME platform (where
Obstetrics & Gynecology includes CME-certified content that is designed this activity is located) is updated with 1) their date of birth (month
to meet the educational needs of its readers. This article is certified for 2 and day only) and 2) their ACOG ID. In addition, participants
AMA PRA Category 1 Credits. This activity is available for credit should select that they are board-certified in obstetrics and
through March 31, 2023. gynecology.
Accreditation Statement The privacy policies for the Obstetrics & Gynecology website
ACCME Accreditation and the Lippincott CMEConnection portal are available
The American College of Obstetricians and Gynecologists is at http://www.greenjournal. org and https://cme.lww.com/
accredited by the Accreditation Council for Continuing Medical browse/sources/196, respectively.
Education (ACCME) to provide continuing medical education for Contact Information
physicians. Questions related to transcripts may be directed to educationc-
[email protected]. For other queries, please contact the Obstetrics &
AMA PRA Category 1 Credit(s) Gynecology Editorial Office, 202-314-2317 or [email protected].
The American College of Obstetricians and Gynecologists desig- For queries related to the CME test online, please contact
nates this journal-based CME activity for a maximum of 2 [email protected] or 1-800-787-8985.

VOL. 00, NO. 00, MONTH 2020 Hernandez and Dietrich Abnormal Uterine Bleeding in the Adolescent 7

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.