Abnormal vaginal bleeding includes any vaginal bleeding that occurs
Before puberty
Between menstrual periods
During pregnancy
After menopause (12 months or more after the last menstrual period)
During the childbearing years, vaginal bleeding occurs normally as menstrual periods. However, menstrual periods are considered abnormal if they
Become excessively heavy (saturating more than 1 or 2 tampons an hour)
Last too long (more than 7 days)
Occur too frequently (usually fewer than 21 days apart)
Occur too infrequently (usually more than 90 days apart)
Typically, menstrual periods last from 3 to 7 days and occur every 21 to 35 days. In adolescents, the interval between periods varies more and may be as long as 45 days.
Vaginal bleeding may occur during early pregnancy or during late pregnancy and may result from problems (complications) related to the pregnancy.
Prolonged or excessive bleeding, regardless of cause, can result in iron deficiency, anemia, and sometimes dangerously low blood pressure (shock).
Causes of Vaginal Bleeding
Vaginal bleeding may result from
Malfunction of the complex hormonal system that regulates the menstrual cycle
A disorder of the vagina, uterus, cervix, or another reproductive organ, such as fibroids, infection, or cancer
Disorders that cause excessive bleeding (uncommon)
Common causes
Likely causes of vaginal bleeding depend on the woman’s age.
Newborn girls may have a small amount of vaginal bleeding. Before birth, they absorb estrogen through the placenta from the mother. After birth, these high levels of estrogen decrease rapidly, sometimes causing a little bleeding during the first 1 to 2 weeks of life.
During childhood, vaginal bleeding is abnormal and uncommon. When it occurs, it is most often caused by
A foreign object (body), such as toilet paper or a toy, in the vagina
An injury, or possible sexual abuse
Infections in the vagina (vaginitis)
During the childbearing years, the most common cause is
Hormonal imbalance that causes ovulation to be delayed or not happen (ovulatory dysfunction), which can cause abnormal uterine bleeding
Uterine bleeding due to ovulatory dysfunction occurs when the hormonal control of menstruation changes and the lining of the uterus sheds irregularly. It is more likely to occur in adolescents (when menstrual periods are just starting) or in women in their late 40s (when periods are nearing an end).
Other common causes of vaginal bleeding during the childbearing years include
Complications of pregnancy (sometimes when a woman who does not know she is pregnant)
Fibroids (muscle masses) inside the uterus
Polyps in the cervix or uterus
Bleeding when the egg is released (at ovulation) during the menstrual cycle
Use of birth control pills (oral contraceptives), if there is spotting or bleeding between periods (called breakthrough bleeding)
After menopause, the most common cause is
Age-related thinning of the lining of the vagina (formerly called atrophic vaginitis) or uterus (part of the genitourinary syndrome of menopause)
Less common causes
Cervical cancer, vaginal cancer, or cancer of the lining of the uterus (endometrial cancer) can cause bleeding, usually after menopause. Cancer is not a common cause during the childbearing years.
Certain hormonal disorders (such as hypothyroidism) are a less common cause of bleeding.
Excessively heavy menstrual periods may be the first sign of a bleeding disorder.
Children may have hormonal abnormalities that cause puberty to begin too early—a disorder called precocious puberty. In these children, menstrual periods start, breasts develop, and pubic and underarm hair appears too soon.
Rarely, bleeding is caused by a tumor or an injury resulting from unsuspected child abuse.
Evaluation of Vaginal Bleeding
Doctors first focus on determining whether the cause of vaginal bleeding is a serious or life-threatening disorder (such as a ruptured ectopic pregnancy) and whether the bleeding is excessive, possibly resulting in shock.
Doctors check for pregnancy in all women of childbearing age.
Warning signs
In women with vaginal bleeding, certain characteristics are cause for concern:
Excessive bleeding
Loss of consciousness, weakness, light-headedness, cold and sweaty skin, difficulty breathing, and a weak and rapid pulse (which indicate shock)
Bleeding that occurs before menstrual periods start (before puberty) or after they stop (after menopause)
Bleeding during pregnancy
In children, difficulty walking or sitting, bruises or tears around the genitals or anus or mouth, and/or vaginal discharge or itching (which may be signs of sexual abuse)
Bleeding is considered excessive if any of the following occur:
Women lose more than about a cup of blood.
More than 1 pad or tampon is saturated per hour for a few hours.
The blood contains large clots.
When to see a doctor
Women with most warning signs should see a doctor immediately, as should those with large clots or clumps of tissue in the blood or with symptoms suggesting a bleeding disorder. Symptoms of a bleeding disorder include easy bruising, excessive bleeding during toothbrushing or after minor cuts, and rashes of tiny reddish purple dots or larger splotches (indicating bleeding in the skin). However, if the only warning sign is vaginal bleeding before puberty or after menopause, a delay of a week or so is not harmful.
Women without warning signs should schedule a visit when practical, but a delay of several days is not likely to be harmful.
If vaginal bleeding continues in newborns for more than a few days, or is heavy or foul smelling, they should be seen by a doctor.
What the doctor does
Doctors first ask the woman (or caregiver) questions about her symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the bleeding and the tests that may need to be done (see table Some Causes and Features of Vaginal Bleeding).
Doctors ask about the bleeding:
How many pads or tampons are used per day or hour
How long bleeding lasts
When it started
When it occurs in relation to menstrual periods and sexual activity
They also ask about the woman's menstrual history:
How old she was when menstrual periods started
How long they last
How heavy they are
How long the interval between periods is
Whether they are regular
The woman is asked whether she has had previous episodes of abnormal bleeding, has had a disorder that can cause bleeding (such as a recent miscarriage), or takes birth control pills, other hormones, or other drugs that can cause excessive bleeding, (such as anticoagulants and nonsteroidal anti-inflammatory drugs (NSAIDs).
The woman is asked about other symptoms, such as light-headedness, abdominal pain, and excessive bleeding after toothbrushing or a minor cut.
The physical examination includes a pelvic examination. During the examination, doctors can identify disorders of the cervix, uterus, vagina, vulva, or urethra in women of all ages. In children, a general examination is done first to check for early (precocious) puberty (based on the presence of pubic hair and breast development), and a pelvic examination is done only if necessary.
If no blood is present in the vagina, a rectal examination may be done to determine whether bleeding is coming from the digestive tract.
Testing
If women are of childbearing age, doctors always do
A urine or blood test for pregnancy
If the urine pregnancy test is negative but doctors still suspect pregnancy, a blood test for pregnancy is done. It involves measuring a hormone produced by the placenta called human chorionic gonadotropin (hCG). The blood test is more accurate than the urine test when a pregnancy is very early (less than 5 weeks).
Tests commonly done include
Blood tests to measure thyroid hormone levels
If bleeding has been heavy or lasted a long time, a complete blood cell count to check for anemia
Other blood tests are done depending on the disorder doctors suspect. For example, if a bleeding disorder is suspected, the blood's ability to clot is assessed. If polycystic ovary syndrome is suspected, blood tests to measure androgen hormone levels are done.
Ultrasonography is often used to look for abnormalities in the reproductive organs if women have risk factors for endometrial cancer or if doctors suspect problems such as fibroids, polyps, or a tumor. For ultrasonography, a handheld ultrasound device is usually inserted into the vagina, but it may be placed on the abdomen.
If ultrasonography detects thickening of the uterine lining (endometrial hyperplasia), hysteroscopy or sonohysterography may be done to look for small growths in the uterus. For hysteroscopy, a viewing tube is inserted into the uterus through the vagina. For sonohysterography, fluid is injected into the uterus during ultrasonography to make abnormalities easier to identity.
If results of these tests are abnormal or if they are inconclusive, doctors may take a sample of tissue from the lining of the uterus for analysis in the following circumstances:
Women are over age 45.
Women have risk factors for cancer of the reproductive tract, including cancers of the lining of the uterus (endometrial cancer) and ovaries.
Too much estrogen is being produced, as occurs in women with polycystic ovary syndrome or a high body mass index.
In postmenopausal women, the lining of the uterus (endometrium) is thickened (seen on an ultrasound).
The sample may be obtained by suction (through a tube) or by scraping—a procedure called dilation and curettage (D and C). In postmenopausal women, the sample is usually obtained by hysteroscopy, which enables doctors to see inside the uterus and locate the abnormality.
Other tests may be done, depending on which disorders seem possible. For example, a biopsy of the cervix may be done to check for cancer of the cervix.
If abnormal bleeding does not result from any of the usual causes, it may be related to changes in the hormonal control of the menstrual cycle.
Treatment of Vaginal Bleeding
If women are have extremely heavy bleeding and a very low blood pressure, they are immediately given fluids intravenously and blood transfusions as needed to restore blood pressure. Laparoscopy or laparotomy is often required if there is an emergency. For laparoscopy, doctors make a small incision just below the navel and insert a viewing tube (laparoscope). Laparotomy requires a large incision into the abdomen. Both procedures enable doctors to directly to directly view organs and look for abnormalities.
When vaginal bleeding results from another disorder, that disorder is treated if possible. If bleeding has caused iron deficiency, women are given iron supplements.
Birth control pills or other hormones may be used to treat abnormal uterine bleeding related to changes in the hormonal control of the menstrual cycle.
Polyps, fibroids, cancers, and some benign tumors may be surgically removed from the uterus.
Essentials for Older Women: Vaginal Bleeding
Postmenopausal bleeding (occurring more than 12 months after the last menstrual period) is relatively common but is always considered abnormal. Such bleeding can indicate a precancerous disorder (such as thickening of the lining of the uterus) or cancer. Thus, if such bleeding occurs, older women should see a doctor promptly so that cancer can be ruled out or be treated immediately.
Older women should see a doctor promptly if they have
Any vaginal bleeding
A vaginal discharge that is pink or brown, possibly containing small amounts of blood
However, postmenopausal bleeding has many other causes.
The most common cause is
Thinning of the lining of the uterus or vagina (genitourinary syndrome of menopause)
Other causes include
Use of estrogen or other hormone therapy, particularly when use is stopped
Polyps in the cervix or uterus
Fibroids
Infections
Because the tissues of the vagina may be thin and dry, examination of the vagina may be uncomfortable. Doctors may try using a smaller instrument (speculum) to make the examination less uncomfortable.
Key Points
During the childbearing years, the most common cause of abnormal vaginal bleeding is pregnancy.
In women who are not pregnant, the most common cause is hormonal imbalance (ovulatory dysfunction), which can cause abnormal uterine bleeding.
Abnormal uterine bleeding is related to changes in the hormonal control of the menstrual cycle that prevent the ovaries from releasing an egg.
In children, the cause is usually a foreign object or an injury, but sometimes sexual abuse is the cause.
In women of childbearing age, a pregnancy test is done even when women do not think they could be pregnant.
If any vaginal bleeding occurs after menopause, an evaluation to rule out cancer is necessary.
