EC Gynaecology

Objective: To synthesise evidence for the evaluation and management of abnormal uterine bleeding (AUB) in non-sexually active patients, emphasising minimally invasive, hymen-sparing diagnostic pathways and culturally informed care relevant to Middle East and North Africa (MENA) settings.

Data Sources: Guidelines from ACOG, FIGO, NICE, and ACR, along with peer-reviewed literature on minimally invasive hysteroscopy, imaging alternatives to transvaginal ultrasound, and sociocultural and bioethical considerations.

Methods: Structured narrative review of literature (2005-2025), prioritising guideline-level evidence and minimally invasive gynaecology studies. Evidence was synthesised into a clinically applicable diagnostic and management pathway.

Results: Most AUB in adolescents results from ovulatory dysfunction, with bleeding disorders as a prominent secondary cause. A hymen-sparing diagnostic approach-using transabdominal ultrasound, MRI or transrectal ultrasound, and vaginoscopic hysteroscopy-maintains diagnostic accuracy while enhancing acceptability. Minimally invasive hysteroscopy allows for diagnosis and treatment with high tolerability. Virginity testing is not medically valid and should be avoided.

Conclusion: A structured, minimally invasive, culturally sensitive approach improves diagnostic access, patient experience, and clinical outcomes in non-sexually active patients with AUB.

Keywords: Abnormal Uterine Bleeding; Heavy Menstrual Bleeding; Non-Sexually Active Patients; Vaginoscopic Hysteroscopy; Minimally Invasive Gynaecology; Islamic Bioethics

1. Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding-ACOG.
2. “Screening and management of bleeding disorders in adolescents with heavy menstrual bleeding: ACOG COMMITTEE OPINION, Number 785”. Obstetrics and Gynecology 134.3 (2019): E71-E83.
3. “ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women”. Obstetrics and Gynecology4 (2013): 891-896.
4. Munro MG., et al. “FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age”. International Journal of Gynecology and Obstetrics1 (2011): 3-13.
5. “Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women”. Obstetrics and Gynecology 121 (2013): 891-896.
6. Hoan K and Ascher-Walsh C. “Abnormal uterine bleeding”. Obstetrics and Gynecology (2025): 152-159.
7. Robbins JB., et al. “ACR appropriateness criteria^® abnormal uterine bleeding”. Journal of the American College of Radiology 11S (2020): S336-S345.
8. Cavus Y and Aegean J. “Effective use of office hysteroscopy in virgin patients: A series of 22 cases: Virginity and hysteroscopy”. Aegean Journal of Obstetrics and Gynecology2 (2022): 45-48.
9. Gupta N., et al. “Comparative evaluation of vaginoscopic vs traditional hysteroscopy”. World Journal of Laparoscopic Surgery 2 (2021): 98-102.
10. Munro MG., et al. “The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions”. International Journal of Gynecology and Obstetrics 3 (2018): 393-408.
11. “Heavy menstrual bleeding: assessment and management NICE guideline 2018”.
12. De Silva PM., et al. “Outpatient hysteroscopy: (Green-top Guideline no. 59)”. BJOG: An International Journal of Obstetrics and Gynaecology 13 (2024): e86-e110.
13. Islamic Bioethics: Guide To Treating Patients - IMANA n.d (2026).
14. AlBuhairan F., et al. “Adolescent health in the Middle East and North Africa region: leaving no one behind”. Eastern Mediterranean Health Journal2 (2023): 89-90.
15. O’Brien SH. “Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist”. Blood20 (2018): 2134-2142.
16. Crosby SS., et al. “Virginity testing: recommendations for primary care physicians in Europe and North America”. BMJ Global Health1 (2020): e002057.
17. Organization WH. “WHO recommendations on adolescent sexual and reproductive health and rights 2018”.
18. “Caring for patients who have experienced trauma: ACOG Committee Opinion, Number 825”. Obstetrics and Gynecology 137.4 (2021): E94-E99.
19. Tuğba Kontbay Çetin and Zuhal Keskin Sarılar. “Evaluation of heavy menstrual bleeding in adolescents”. Journal of Clinical Research in Pediatric Endocrinology 4 (2025): 402-409.
20. Tamer Farouk Bourg. “Transrectal ultrasound and 3D transabdominal ultrasound in comparison to vaginoscopy in virgins with suspected genital tract lesions: A comparative diagnostic accuracy study”. Ginekologia i Poloznictwo 1 (2023): 001-005.
21. Timor-Tritsch IE., et al. “Transrectal scanning: An alternative when transvaginal scanning is not feasible”. Ultrasound in Obstetrics and Gynecology5 (2003): 473-479.
22. Güdücü N., et al. “The utility of transrectal ultrasound in adolescents when transabdominal or transvaginal ultrasound is not feasible”. Journal of Pediatric and Adolescent Gynecology 5 (2013): 265-268.
23. Aderibigbe AS., et al. “Unpopular yet invaluable: the role of transrectal ultrasonography in evaluating gynecological pathologies”. Journal of Radiation Medicine in the Tropics2 (2024): 64-69.
24. Güdücü N., et al. “The utility of transrectal ultrasound in adolescents when transabdominal or transvaginal ultrasound is not feasible”. Journal of Pediatric and Adolescent Gynecology 5 (2013): 265-268.
25. Küçük T. “When virginity does matter: Rigid hysteroscopy for diagnostic and operative vaginoscopy-A series of 26 cases”. Journal of Minimally Invasive Gynecology 5 (2007): 651-653.
26. Moiety FS., et al. “Studying hysteroscopic procedures in virgins in terms of feasibility and task completion with intact hymen: a series of 44 cases”. Journal of Gynecologic Surgery 4 (2025): 160-163.
27. Liang Lee Y. “The office vaginoscopic hysteroscopy in management of virginal women with recurrent abnormal uterine bleeding”. World Journal of Gynecology and Womens Health 2 (2019).
28. Lacy B., et al. “NASPAG clinical consensus: use of tranexamic acid in the treatment of heavy menstrual bleeding”. Journal of Pediatric and Adolescent Gynecology 4 (2025): 452-457.
29. Abder Rahman HA. “Hymen care for unmarried Muslim females: role of the forensic consultant in gynaecology interventions”. EMHJ - Eastern Mediterranean Health Journal4 (2009): 861-867.
30. Moussaoui D., et al. “Hymen and virginity: What every paediatrician should know”. Journal of Paediatrics and Child Health 3 (2022): 382-387.
31. Saharso S. “Hymen ‘repair’: Views from feminists, medical professionals and the women involved in the middle east, North Africa and Europe”. Ethnicities 22 (2022): 196-214.
32. Cheong ML. “Minihysteroscopy for examination and management of pathologic lesions of virginal reproductive tracts: Can we preserve the hymen intact?” Archives of Gynecology and Obstetrics 2 (2010): 375-376.