RESEARCH 70 | REPRINTED FROM AJGP VOL. 49, NO. 1–2, JAN–FEB 2020 © The Royal Australian College of General Practitioners 2020 Mikhaila Lazanyi, Sonia R Grover Background and objective Heavy menstrual bleeding (HMB) in adolecents is predominantly related to an immature hypothalamic–pituitary–ovarian axis. Structural causes in this population are extremely rare; therefore, pelvic ultrasonography is not required as a first- line investigation. Anecdotally, it has been observed that pelvic ultrasounds of adolescents with HMB are normal and do not change clinical care. The aim of this study was to analyse all female patients aged ≤18 years who were referred to a tertiary paediatric hospital for HMB over a 12-month period. Method Medical records were reviewed to determine if pelvic ultrasonography was ordered during the diagnostic process and whether the imaging altered management. Results No pelvic ultrasounds ordered for adolescents with HMB altered clinical management. General practitioners (GP) were the most likely to refer patients to the tertiary paediatric hospital and to order pelvic ultrasonography, likely reflecting that most female adolescents are seen by a GP within the community. Discussion Providing clinical updates and ongoing education to health professionals managing female adolescent patients is recommended. THE COMPLEXITY OF tests, treatments and procedures in modern medicine is at an unprecedented level. Unnecessary practices and frequent and invasive investigations are potentially costly to the healthcare system, may divert away from effective care and can potentially expose the patient to undue risk of harm, emotional stress or personal financial costs. 1 Paediatric and adolescent gynaecology is a unique sub-speciality that falls under the domain of general practitioners (GPs), gynaecologists, paediatricians and emergency physicians. During medical training, this sub-speciality is frequently not covered in depth, and exposure to this area can be limited post-fellowship. It has been shown that history taking and diagnostic ordering for adolescent females presenting with heavy menstrual bleeding (HMB) is inconsistent and inadequate. 2 This has been suggested to contribute to clinicians ordering investigations overcautiously. The resultant increase in patient (and parental) anxiety, which is not uncommon in this patient demographic, is considerable. Abnormal uterine bleeding (AUB) refers to any variation from a normal menstrual cycle. It includes HMB and irregular bleeding, which together account for up to half of adolescent gynaecology visits. 3 HMB in this age group is almost invariably due to an immature hypothalamic–pituitary–ovarian axis, which is reflective of the pubertal transition. The physiological maturation of this axis can persist for up to 5–8 years post-menarche. 4,5 This differs from the causes and management of HMB in older women of reproductive age, which are more likely to be related to structural causes. A retrospective review of 230 adolescents at a paediatric hospital in Canada showed that 67.8% of all patients referred with AUB had pelvic ultrasonography performed as part of their initial workup, and ‘no patient had a change in her AUB management due to ultrasound findings’. 6 Unfortunately, unnecessary ordering of pelvic ultrasonography for AUB in adolescent females is common. In Australia, 14.9% of GP encounters with female patients aged <25 years are for women’s health problems, compared with 12% for women of any age. 7 The majority of these patients are managed solely by GPs, with referral to a gynaecologist occurring at a rate of 0.8 per 100 GP–female patient encounters. 8 In Victoria, Tasmania and southern New South Wales, a significant proportion of adolescent females referred to a gynaecologist are seen at the Royal Children’s Hospital (RCH). This study was designed to review all new referrals to gynaecology for female adolescents with HMB from 1 January 2017 to 31 December 2017, to identify whether or not pelvic ultrasonography had been arranged prior to a referral. It was hypothesised that pelvic ultrasonography was frequently being ordered in the Reducing unnecessary investigations in adolescent gynaecology The utility of pelvic ultrasonography for adolescents presenting with heavy menstrual bleeding