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Vaginal Bleeding

By David H. Barad, MD, MS, Albert Einstein College of Medicine, Bronx;Center for Human Reproduction

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Patient Education

Abnormal vaginal bleeding includes

  • Menses that are excessive (menorrhagia or hypermenorrhea) or too frequent (polymenorrhea)

  • Bleeding that is unrelated to menses, occurring irregularly between menses (metrorrhagia)

  • Bleeding that is excessive during menses and occurs irregularly between menses (menometrorrhagia)

  • Postmenopausal bleeding (ie, > 6 mo after the last normal menses)

Vaginal bleeding may also occur during early pregnancy (see Vaginal Bleeding During Early Pregnancy) or late pregnancy (see Vaginal Bleeding During Late Pregnancy).

Vaginal bleeding can originate anywhere in the genital tract, including the vulva, vagina, cervix, and uterus. When vaginal bleeding originates in the uterus, it is called abnormal uterine bleeding (AUB).

Pathophysiology

Most abnormal vaginal bleeding involves

  • Hormonal abnormalities in the hypothalamic-pituitary-ovarian axis (most common)

  • Structural, inflammatory, or other gynecologic disorders (eg, tumors)

  • Bleeding disorders (uncommon)

With hormonal causes, ovulation does not occur or occurs infrequently. During an anovulatory cycle, the corpus luteum does not form, and thus the normal cyclical secretion of progesterone does not occur. Without progesterone, estrogen causes the endometrium to continue to proliferate, eventually outgrowing its blood supply. The endometrium then sloughs and bleeds incompletely, irregularly, and sometimes profusely or for a long time.

Etiology

During the reproductive years, common causes of vaginal bleeding in women who are not known to be pregnant include

  • AUB, particularly anovulatory bleeding

  • Complications of an early, undiagnosed pregnancy

  • Submucous myoma

  • Midcycle bleeding associated with ovulation

  • Breakthrough bleeding while women are taking oral contraceptives

Anovulatory uterine bleeding is the most common cause of abnormal vaginal bleeding during the reproductive years.

Causes of AUB in nonpregnant women of reproductive age may be classified as structural or nonstructural as in the PALM-COEIN classification system (see Figure: PALM-COEIN classification system. [1, 2]). PALM-COEIN is a mnemonic for the structural causes (PALM) and the nonstructural (COEIN) causes.

Vaginitis, foreign bodies, trauma, and sexual abuse are common causes of vaginal bleeding before menarche.

PALM-COEIN classification system.

Some Causes of Abnormal Vaginal Bleeding in Adult Women

Category

Conditions

Early pregnancy* and related complications

Spontaneous abortion (patients may present immediately during the abortion or later because of bleeding due to retained products of conception)

Late pregnancy* and related complications

Placental polyps

Structural gynecologic disorders

Endometrial hyperplasia

Fibroids (submucosal or prolapsed)

Polyps of the cervix or endometrium

Other gynecologic disorders

Atrophic vaginitis

Foreign body in the vagina

Injury of the cervix, vagina, or vulva

Ovulatory disorders

Functional ovarian cysts (may be a sign of anovulation)

Endocrine disorders

Thyroid disorders (eg, hypothyroidism)

Bleeding disorders

Coagulation disorders (eg, due to drugs, liver disorders, or hereditary disorders)

Contraception and hormone therapy

Oral contraceptives, particularly when doses are missed or when long-cycle regimens or progestin only is used

*At presentation, patients may not suspect pregnancy of any stage (including recent spontaneous abortion).

Common Causes of Vaginal Bleeding in Children

Age Group

Causes

Infants

In utero endometrial stimulation by transplacental estrogens (causes minimal bleeding during the first 2 wk of life)

Older children

Precocious puberty with premature menses

Prolapse of the urethral meatus

Trauma (including sexual abuse)

Tumors (eg, sarcoma botryoides, cervical adenocarcinoma secondary to DES exposure)

Vaginal foreign body

Warts, cervical or vaginal

DES = diethylstilbestrol.

Etiology reference

  • 1. Practice bulletin no. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol 120(1):197-206, 2012. doi: 10.1097/AOG.0b013e318262e320.

  • 2. Practice bulletin no. 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol 122(1):176-85, 2013. doi: 10.1097/01.AOG.0000431815.52679.bb.

Evaluation

Unrecognized pregnancy must be suspected and diagnosed in women of childbearing age because some causes of bleeding during pregnancy (eg, ectopic pregnancy) are life threatening.

History

History of present illness should include quantity (eg, by number of pads used per day or hour) and duration of bleeding, as well as the relationship of bleeding to menses and intercourse. Clinicians should ask about the following:

  • Menstrual history, including date of last normal menstrual period, age at menarche and menopause (when appropriate), cycle length and regularity, and quantity and duration of typical menstrual bleeding

  • Previous episodes of abnormal bleeding, including frequency, duration, quantity, and pattern (cyclicity) of bleeding

  • Sexual history, including possible history of rape or sexual assault

Review of systems should seek symptoms of possible causes, including the following:

  • Missed menses, breast swelling, and nausea: Pregnancy-related bleeding

  • Abdominal pain, light-headedness, and syncope: Ectopic pregnancy or ruptured ovarian cyst

  • Chronic pain and weight loss: Cancer

  • Easy bruising and excessive bleeding due to toothbrushing, minor lacerations, or venipuncture: A bleeding disorder

Past medical history should identify disorders known to cause bleeding, including a recent spontaneous or therapeutic abortion and structural disorders (eg, uterine fibroids, ovarian cysts). Clinicians should identify risk factors for endometrial cancer, including obesity, diabetes, hypertension, prolonged unopposed estrogen use (ie, without progesterone), and polycystic ovary syndrome. Drug history should include specific questions about hormone use.

If sexual abuse of a child is suspected, a structured forensic interview based on the National Institute of Child Health and Human Development (NICHD) Protocol can be used. It helps the child report information about the experienced event and improves the quality of information obtained.

Physical examination

Vital signs are reviewed for signs of hypovolemia (eg, tachycardia, tachypnea, hypotension).

During the general examination, clinicians should look for signs of anemia (eg, conjunctival pallor) and evidence of possible causes of bleeding, including the following:

  • Warm and moist or dry skin, eye abnormalities, tremor, abnormal reflexes, or goiter: A thyroid disorder

  • Hepatomegaly, jaundice, asterixis (flapping tremor of the wrist), or splenomegaly: A liver disorder

  • Nipple discharge: Hyperprolactinemia

  • Low body mass index and loss of subcutaneous fat: Possibly anovulation

  • High body mass index and excess subcutaneous fat: Androgen or estrogen excess or polycystic ovary syndrome

  • Hirsutism, acne, obesity, and enlarged ovaries: Polycystic ovary syndrome

  • Easy bruising, petechiae, purpura, or mucosal (eg, gingival) bleeding: A bleeding disorder

  • In children, breast development and presence of pubic and axillary hair: Puberty

  • In children, difficulty walking or sitting; bruises or tears around the genitals, anus, or mouth; and/or vaginal discharge or pruritus: Sexual abuse

The abdomen is examined for distention, tenderness, and masses (particularly an enlarged uterus). If the uterus is enlarged, auscultation for fetal heart sounds is done.

A complete gynecologic examination is done unless abdominal examination suggests a late-stage pregnancy; then, digital pelvic examination is contraindicated until placental position is determined. In all other cases, speculum examination helps identify lesions of the urethra, vagina, and cervix. Bimanual examination is done to evaluate uterine size and ovarian enlargement. If no blood is present in the vagina, rectal examination is done to determine whether bleeding is GI in origin.

Red flags

The following findings are of particular concern:

  • Hemorrhagic shock (tachycardia, hypotension)

  • Premenarchal and postmenopausal vaginal bleeding

  • Vaginal bleeding in pregnant patients

  • Excessive bleeding

  • In children, difficulty walking or sitting; bruises or tears around the genitals, anus, or mouth; and /or vaginal discharge or pruritus

Interpretation of findings

Significant hypovolemia or hemorrhagic shock is unlikely except with ruptured ectopic pregnancy or, rarely, ovarian cyst (particularly when a tender pelvic mass is present).

In children, breast development and pubic or axillary hair suggest precocious puberty and premature menses. In those without such findings, the possibility of sexual abuse should be investigated unless an explanatory lesion or foreign body is obvious.

In women of reproductive age, examination may detect a causative gynecologic lesion or other findings suggesting a cause. If younger patients taking hormone therapy have no apparent abnormalities during examination and bleeding is spotty, bleeding is probably related to the hormone therapy. If the problem is excessive menstrual bleeding only, a uterine disorder or bleeding diathesis should be considered. Inherited bleeding disorders may initially manifest as heavy menstrual bleeding beginning at menarche or during adolescence.

In postmenopausal women, gynecologic cancer should be suspected.

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.

Testing

All women of reproductive age require

  • A urine pregnancy test

During early pregnancy (before 5 wk), a urine pregnancy test may not be sensitive enough. Urine contaminated with blood may lead to false results. A qualitative serum beta subunit of human chorionic gonadotropin (beta-hCG) test should be done if the urine test is negative and pregnancy is suspected. Vaginal bleeding during pregnancy requires a specific approach (see Vaginal Bleeding During Early Pregnancy and Professional.heading on page Vaginal Bleeding During Late Pregnancy).

Blood tests include CBC if bleeding is unusually heavy (eg, > 1 pad or tampon/h) or has lasted at least several days or if findings suggest anemia or hypovolemia. If anemia is identified and is not obviously due to iron deficiency (eg, based on microcytic, hypochromic RBC indices), iron studies are done.

Thyroid-stimulating hormone and prolactin levels are usually measured, even when galactorrhea is absent.

If a bleeding disorder is suspected, von Willebrand factor, platelet count, PT, and PTT are determined.

If polycystic ovary syndrome is suspected, testosterone and dehydroepiandrosterone sulfate (DHEAS) levels are measured.

Imaging includes transvaginal ultrasonography if women have any of the following:

  • Age > 35

  • Risk factors for endometrial cancer

  • Bleeding that continues despite use of empiric hormone therapy

Focal thickening of the endometrium that is detected during screening ultrasonography may require hysteroscopy or saline-infusion sonohysterography to identify small intrauterine masses (eg, endometrial polyps, submucous myomas).

Other testing includes endometrial sampling if examination and ultrasonography are inconclusive in women with any of the following:

  • Age > 35

  • Risk factors for cancer

  • Endometrial thickening > 4 mm

Sampling can be done by aspiration or, if the cervical canal requires dilation, by D & C. In postmenopausal women, hysteroscopy with D & C is recommended so that the entire uterine cavity can be assessed.

Treatment

Hemorrhagic shock is treated. Women with iron deficiency anemia may require supplemental oral iron.

Definitive treatment of vaginal bleeding is directed at the cause. Typically, hormones, usually oral contraceptives, are first-line treatment for anovulatory AUB.

Geriatrics Essentials

Postmenopausal bleeding (bleeding > 6 mo after menopause) is abnormal in most women and requires further evaluation to exclude cancer unless it clearly results from withdrawal of exogenous hormones.

In women not taking exogenous hormones, the most common cause of postmenopausal bleeding is endometrial and vaginal atrophy.

In some older women, physical examination of the vagina can be difficult because lack of estrogen leads to increased friability of the vaginal mucosa, vaginal stenosis, and sometimes adhesions in the vagina. For these patients, a pediatric speculum may be more comfortable.

Key Points

  • Pregnancy must be excluded in women of reproductive age even when history does not suggest it.

  • Anovulatory uterine bleeding is the most common cause of abnormal vaginal bleeding during the reproductive years.

  • Vaginitis, foreign bodies, trauma, and sexual abuse are common causes of vaginal bleeding before menarche.

  • Postmenopausal vaginal bleeding needs further evaluation to exclude cancer as the cause.

Resources In This Article

* This is the Professional Version. *