title: Tampon use in patients with anorexia nervosa can cause persistent vaginal bleeding: a case series.
abstract: OBJECTIVE
  To describe the phenomenon of persistent vaginal bleeding in two patients with severe anorexia nervosa.
  
  
  METHODS
  We report two cases of young women with severe anorexia nervosa reporting vaginal bleeding that persisted for months despite trials of topical and systemic conjugated estrogen therapy.
  
  
  RESULTS
  A speculum exam by a gynecologist ultimately revealed the source of the bleeding to be tampon-induced vaginal ulcers. These resolved, along with the vaginal bleeding, with vaginal estrogen cream and cessation of tampon use.
  
  
  CONCLUSIONS
  Most patients with anorexia nervosa are amenorrheic due to reversion of the hypothalamic-pituitary-ovarian axis to a prepubertal state. Vaginal bleeding in patients with anorexia nervosa may trigger needless systemic hormonal treatments, radiographic studies, and multiple physician visits. A careful exam is warranted to evaluate for the presence of tampon-induced vaginal ulcer in patients with anorexia nervosa who have persistent vaginal bleeding.
authors.affiliation: Department of Medicine, University of Colorado Health Sciences Center, Denver, Colorado, USA. jennifer.gaudiani@dhha.org
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Gaudiani
authors.forename: Gretchen
authors.initials: G
authors.lastname: Heinrichs
authors.forename: Vignesh
authors.initials: V
authors.lastname: Narayanan
authors.forename: Philip S
authors.initials: PS
authors.lastname: Mehler
mesh_terms: D000328:Adult; D000856:Anorexia Nervosa / Q000150:complications*; D005260:Female; D006801:Humans; D052576:Menstrual Hygiene Products / Q000009:adverse effects*; D014592:Uterine Hemorrhage / Q000209:etiology*