Vaginal bleeding in girls before periods start

Premenarche is the time before a girl has her first period (menarche). Before puberty, the lining of the womb has not yet started its monthly cycle, so any blood on underwear, toilet paper or in the nappy needs an explanation. The commonest sources are not the womb at all.

The Devon guide says presentations of genital bleeding in premenarcheal girls are rare. The Scottish national child protection guideline says bleeding reported by a child or parents as vaginal may be vaginal, or may come from the skin, urinary tract or anus, and that the clinician's task is to work out which. It also asks the first question to be whether it is blood at all, since urate crystals in a baby's nappy can look like pink staining.

The Scottish guideline groups causes by how often they occur. Common causes include constipation or an anal fissure, vulvovaginitis, lichen sclerosus, accidental trauma such as a straddle injury (usually with external bruising), threadworms, infections that can spread through hygiene or follow a sore throat, and sometimes no cause being found.

Vulvovaginitis means inflammation or infection of the genital area. Leicester's Hospitals explain it is very common in young girls because they lack the female hormone oestrogen until puberty, which makes redness, swelling and infection more likely. The discharge may be coloured, smelly and sometimes blood-stained, with itching and soreness when passing urine.

The Devon guide says the commonest skin change of the vulva is lichen sclerosus, a pearly, translucent appearance around the vulva and anus with possible itching, soreness and bleeding, treated with topical steroid ointment over a period of weeks.

Less common causes in the Scottish guideline include a foreign body in the vagina, isolated menarche with no other signs of puberty, separation of labial adhesions and urethral prolapse. Rare causes include tumours, recent female genital mutilation, a bleeding disorder, sexually transmitted infection and fabricated or induced illness.

Hormonal causes are on the list too. The Devon guide names precocious puberty and exposure to oestrogen from outside the body. Genital tract tumours are described as something to suspect in girls under 3 years, and any such concern is referred urgently.

Because the range is wide, doctors do not guess. They take a history, look at the area and decide what further tests are needed.

The Scottish guideline recommends a detailed history from parents and carers, and an examination of the child, and if possible of the underwear. Important questions cover how much blood there has been, how long and how often, itching especially at night, any injury and exactly how it happened, bowel habit, urinary symptoms, any signs of puberty, smelly or bloody discharge and any family history of bleeding disorders.

The examination considers signs of puberty, redness, eczema, skin changes of lichen sclerosus, visible threadworms, discharge, signs of injury, a visible foreign body and labial adhesions. The guideline says the genital area should be looked at in every case. Tests may include a urine test, blood tests, an ultrasound of the pelvis and abdomen, hormone tests discussed with an endocrinology team, and a swab if there is discharge or redness.

Parents are often anxious about what the doctor is looking for. A careful, gentle approach, explanations for the child in simple terms and a parent staying alongside are usual.

The Scottish guideline is open about something many parents find upsetting: it says vaginal bleeding can be an alarming presentation for children, parents and professionals as child sexual abuse is often considered, but that it is NOT a common presentation of abuse, and other more common skin, injury or medical conditions should be part of the assessment.

It also asks clinicians to document that safeguarding has been considered, and says the process involves discussing cases with senior colleagues. Being asked about this does not mean that anyone suspects the family. Parents and carers can help by answering openly and by telling the doctor if the child has said anything that worries them or if behaviour has changed.

Any disclosure by a child is handled by child protection services, who work alongside the medical team.

For vulvovaginitis, Leicester's Hospitals say there is no standard treatment and it improves as puberty starts. If soreness and discharge are very bad, they suggest a salt or white vinegar bath for 10 to 15 minutes, drying thoroughly afterwards and applying a soothing barrier cream. A doctor may prescribe a single course of antibiotics if there is a lot of smelly discharge, though repeated courses, steroid creams and antifungal creams are not helpful.

Prevention advice includes cotton underwear changed daily, washing with mild non-scented soap, wiping front to back, avoiding bubble bath and scented products, avoiding tight or synthetic clothing and encouraging fruit, vegetables and regular bowel habits because constipation raises risk. The Devon guide says labial adhesions are common in young girls and most do not need treatment, since they usually resolve by themselves.

Lichen sclerosus, injuries, foreign bodies, threadworms and constipation each have their own treatments, and a GP or paediatrician can explain them. A tumour or an unexplained pattern needs specialist referral.

If a girl has breast development, pubic hair or a growth spurt along with bleeding, early puberty may be the reason. The NHS says signs of puberty before 8 could be early puberty and a GP can arrange tests to see whether a condition is causing it. Isolated menarche, a first period without other pubertal signs, is also listed by the Scottish guideline as a less common cause.

Doctors may arrange hormone tests, a wrist X-ray for bone age and a scan, as in any assessment for early puberty. Management then follows the paediatric endocrine route, which can include monitoring or treatment to pause puberty if it is likely to cause problems.

Make a GP appointment for any unexplained blood in a girl who has not started periods, and mention any discharge, itching, constipation or a recent fall. Seek urgent help through NHS 111 or A&E if bleeding is heavy or continuing, if there has been a significant injury, if she cannot pass urine, or if she is pale, drowsy or in severe pain. Call 999 if she collapses.

The usual route is the GP, who may refer to a paediatric or paediatric gynaecology clinic or to endocrinology if puberty is a possibility. The Scottish guideline says active bleeding may need admission to hospital and surgical review, and that further episodes should lead to a follow-up plan from the responsible clinician. Anyone seeking a private paediatric opinion should ask for results to be shared with the GP and NHS team.