Abnormal vaginal bleeding includes any vaginal bleeding that occurs
Between menstrual periods
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 Vaginal Bleeding During Early Pregnancy During the first 20 weeks of pregnancy, 20 to 30% of women have vaginal bleeding. In about half of these women, the pregnancy ends in a miscarriage. If miscarriage does not occur immediately... read more or during late pregnancy Vaginal Bleeding During Late Pregnancy During late pregnancy (after 20 weeks), 3 to 4% of women have vaginal bleeding. Such women are at risk of losing the baby or of bleeding excessively (hemorrhaging). Sometimes so much blood is... read more 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 Shock Shock is a life-threatening condition in which blood flow to the organs is low, decreasing delivery of oxygen and thus causing organ damage and sometimes death. Blood pressure is usually low... read more ).
Causes of Vaginal Bleeding
Vaginal bleeding may result from
A disorder of the vagina, uterus, cervix, or another reproductive organ
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
During the childbearing years, the most common cause is
Abnormal uterine bleeding Abnormal Uterine Bleeding (AUB) Abnormal uterine bleeding is bleeding from the vagina that occurs frequently or irregularly or lasts longer or is heavier than normal menstrual periods. The most common type of abnormal bleeding... read more , especially uterine bleeding due to ovulatory dysfunction
Uterine bleeding due to ovulatory dysfunction occurs when the hormonal control of menstruation Overview of Menstrual Disorders Complex interactions among hormones control the start of menstruation during puberty, the rhythms and duration of menstrual cycles during the reproductive years, and the end of menstruation... read more changes. 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 in a woman who does not know she is pregnant
Bleeding when the egg is released (at ovulation) during the menstrual cycle
Use of birth control pills (oral contraceptives Oral Contraceptives Contraceptive hormones can be Taken by mouth (oral contraceptives) Inserted into the vagina (vaginal rings) Applied to the skin (patch) Implanted under the skin read more ), which can cause spotting or bleeding between periods (called breakthrough bleeding)
After menopause Menopause Menopause is the permanent end of menstrual periods and thus of fertility. For up to several years before and just after menopause, estrogen levels fluctuate widely, periods become irregular... read more , the most common cause is
Age-related thinning of the lining of the vagina (atrophic vaginitis) or uterus
Less common causes
Cervical cancer Cervical Cancer Cervical cancer develops in the cervix (the lower part of the uterus). Cervical cancer usually results from infection with the human papillomavirus (HPV), transmitted during sexual intercourse... read more , vaginal cancer Vaginal Cancer Cancer of the vagina, an uncommon cancer, usually develops in the cells lining the vagina, typically in women over 60. Vaginal cancer may cause abnormal vaginal bleeding, particularly after... read more , or cancer of the lining of the uterus Cancer of the Uterus Cancer of the uterus develops in the lining of the uterus (endometrium) and is thus also called endometrial cancer. Endometrial cancer usually affects women after menopause. It sometimes causes... read more (endometrial cancer) can cause bleeding, usually after menopause. Cancer is not a common cause during the childbearing years.
Certain hormonal disorders (such as hypothyroidism Hypothyroidism Hypothyroidism is underactivity of the thyroid gland that leads to inadequate production of thyroid hormones and a slowing of vital body functions. Facial expressions become dull, the voice... read more ) are a less common cause of bleeding.
Children may have hormonal abnormalities that cause puberty to begin too early—a disorder called precocious puberty Early Puberty Precocious puberty is sexual maturation that begins before age 9 in boys or before age 8 in girls. The cause of precocious puberty is often unknown, but it may be caused by structural abnormalities... read more . 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 check for pregnancy in all women of childbearing age.
Doctors first focus on determining whether the cause of vaginal bleeding is a serious or life-threatening disorder (such as a ruptured ectopic pregnancy Ectopic Pregnancy Ectopic pregnancy is attachment (implantation) of a fertilized egg in an abnormal location. In an ectopic pregnancy, the fetus cannot survive. When an ectopic pregnancy ruptures, women often... read more ) and whether the bleeding is excessive, possibly resulting in shock.
In women with vaginal bleeding, certain characteristics are cause for concern:
Loss of consciousness, weakness, light-headedness, cold and sweaty skin, difficulty breathing, and a weak and rapid pulse (which indicate shock Shock Shock is a life-threatening condition in which blood flow to the organs is low, decreasing delivery of oxygen and thus causing organ damage and sometimes death. Blood pressure is usually low... read more )
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 2 weeks, 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 Some Causes and Features of Vaginal Bleeding ).
Doctors ask about the bleeding:
How many pads are used per day or hour
How long bleeding lasts
When it started
When it occurs in relation to menstrual periods and sexual intercourse
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 or other hormones.
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 Pelvic Examination For gynecologic care, a woman should choose a health care practitioner with whom she can comfortably discuss sensitive topics, such as sex, birth control, pregnancy, and problems related to... read more . During the examination, doctors can identify precocious puberty in children (based on the presence of pubic hair and breasts). Sometimes they can identify disorders of the cervix, uterus, or vagina in women of all ages.
If women are of childbearing age, doctors always do
A urine test for pregnancy
If the urine pregnancy test is negative but doctors still suspect pregnancy, a blood test for pregnancy is done. 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 male hormone levels are done.
Ultrasonography is often used to look for abnormalities in the reproductive organs, particularly if women are over 35, if they have risk factors for endometrial cancer, or if bleeding continues despite treatment. 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 Hysteroscopy Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic... read more , a viewing tube is inserted into the uterus through the vagina. For sonohysterography Saline Sonography Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic... read more , 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 in women over 35 or with risk factors for cancer, doctors may take a sample of tissue from the lining of the uterus for analysis. The sample may be obtained by suction (through a tube) or by scraping—a procedure called dilation and curettage Dilation and Curettage Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic... read more (D and C).
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 in shock, they are given fluids intravenously and blood transfusions as needed to restore blood pressure.
When vaginal bleeding results from another disorder, that disorder is treated if possible. If bleeding has caused iron deficiency, women are given iron supplements.
Polyps, fibroids, cancers, and some benign tumors may be surgically removed from the uterus.
Essentials for Older Women
Postmenopausal bleeding (occurring more than 6 months after menopause) 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. They include
Thinning and drying of the lining of the uterus or vagina (the most common cause)
Use of estrogen or other hormone therapy, particularly when use is stopped
Polyps in the cervix or uterus
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 about Vaginal Bleeding
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 abnormal uterine bleeding, particularly uterine bleeding due to ovulatory dysfunction, which 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.