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Vaginal Bleeding

by David H. Barad, MD, MS

Abnormal vaginal bleeding includes any vaginal bleeding that occurs

  • Before puberty

  • During pregnancy

  • After menopause

  • 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 or late pregnancy (see Vaginal Bleeding During Early Pregnancy and see Vaginal Bleeding During Late Pregnancy) and may result from problems (complications) related to the pregnancy.

Prolonged or excessive bleeding can result in iron deficiency, anemia, and sometimes dangerously low blood pressure (shock).

Causes

Vaginal bleeding may result from a disorder of the vagina, uterus, cervix, or another reproductive organ. It may also result from malfunction of the complex hormonal system that regulates the menstrual cycle (see Absence of Menstrual Periods) or from bleeding disorders.

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 their 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 or an injury

During the childbearing years, the most common cause is

  • Dysfunctional uterine bleeding

Dysfunctional uterine bleeding results from changes in the hormonal control of the menstrual cycle that prevent the egg from being released. 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—see Dysfunctional Uterine Bleeding).

Other common causes during the childbearing years include

  • Complications of pregnancy in a woman who does not know she is pregnant

  • Fibroids

  • Bleeding when the egg is released (at ovulation) during the menstrual cycle

  • Use of birth control pills (oral contraceptives), which can cause spotting or bleeding between periods (called breakthrough bleeding)

After menopause, the most common cause is

  • Age-related thinning of the lining of the vagina (atrophic vaginitis) or uterus

Less common causes

Cancer of the cervix, vagina, or 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 (see Bleeding Due to Clotting Disorders).

Children may have hormonal abnormalities that cause puberty to begin too early—a disorder called precocious puberty (see Early 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

Doctors first focus on determining whether the cause is a serious disorder (such as an 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:

  • 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

  • Excessive bleeding

Bleeding is considered excessive if women lose more than about a cup of blood, if more than 1 pad or tampon is saturated per hour for a few hours, or if the blood contains large clots.

When to see a doctor

Women with 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. These symptoms 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 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 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. During the examination, doctors can identify precocious puberty in children (based on the presence of pubic hair and breasts) and can sometimes identify disorders of the cervix, uterus, or vagina.

Some Causes and Features of Vaginal Bleeding

Cause

Common Features*

Tests

During infancy

Exposure to the mother's estrogen before birth

A small amount of bleeding during the first 1–2 weeks of life

A doctor's examination

During childhood

A foreign object (body) in the vagina

Usually a foul-smelling discharge, often containing small amounts of blood

Sometimes a history of having inserted an object into the vagina

A doctor's examination, sometimes done after the girl is sedated or given a general anesthetic

Early (precocious) puberty

Development of breasts and appearance of pubic and underarm hair (as occurs during puberty) at a young age

X-rays of the hand and wrist

Blood tests to measure hormone levels

During the childbearing years

Dysfunctional uterine bleeding

Usually bleeding that occurs frequently or irregularly or that lasts longer or is heavier than typical menstrual periods

Tests to rule out other possible causes, including blood tests and ultrasonography, often using a handheld ultrasound device inserted in the vagina

Endometriosis (abnormally located patches of tissue that is normally located only in the lining of the uterus)

Sharp or crampy pain that occurs before and during the first days of menstrual periods

Often pain during sexual intercourse and/or bowel movements

May eventually cause pain unrelated to the menstrual cycle

Sometimes infertility

Insertion of a thin viewing tube (laparoscope) into the abdominal cavity to check for abnormal tissue and to obtain a sample for biopsy

Fibroids

Often no other symptoms

With large fibroids, sometimes pain, pressure, or a feeling of heaviness in the pelvic area

A doctor's examination

Often ultrasonography or sonohysterography (ultrasonography after fluid is infused into the uterus)

If results are unclear, MRI

Hormonal disorders, such as an underactive thyroid gland (hypothyroidism)

Hypothyroidism:

  • A slow heart rate

  • Weight gain

  • Intolerance of cold

  • Dry and coarse skin

  • Coarse facial features and dullness of facial expression

  • Sluggishness

Blood tests to measure thyroid hormone levels

Polycystic ovary syndrome

Excess body hair (hirsutism)

Irregular or no menstrual periods, acne, and excess fat in the torso

Darkened and thickened skin in the underarm, on the nape of the neck, and in skinfolds

A doctor’s examination

Blood tests to measure levels of hormones, such as testosterone (a male hormone) and follicle-stimulating hormone

Ultrasonography of the pelvis

Polyps in the cervix or uterus

Often no symptoms

Bleeding that occurs between menstrual periods or after sexual intercourse

A pelvic examination (see Gynecologic Examination)

Pregnancy complications (of an unrecognized pregnancy)

  • A miscarriage (spontaneous abortion) or one that may occur (threatened abortion)

  • Ectopic pregnancy (an abnormally located pregnancy—not in its usual place in the uterus)

Crampy pelvic pain (in the lowest part of the torso) or back pain

Sometimes passage of tissue through the vagina (usually occurs in a miscarriage)

If an ectopic pregnancy ruptures, constant pelvic pain and sometimes light-headedness, fainting, or dangerously low blood pressure (shock)

A doctor's examination

Ultrasonography of the pelvis

For a suspected ectopic pregnancy:

  • Urine and blood tests to measure a hormone produced by the placenta (called human chorionic gonadotropin, or hCG)

  • Sometimes for a suspected ectopic pregnancy, laparoscopy or laparotomy (a large incision into the abdomen enabling doctors to directly view organs)

Spotting or bleeding between periods (breakthrough bleeding) during the first months that oral or other hormonal contraceptives are used

Often no other symptoms

A doctor’s examination

After menopause

Thinning of the lining of the vagina (atrophic vaginitis)

A scant discharge

Pain during sexual intercourse

A doctor’s examination

Examination under a microscope and analysis of a sample of discharge

Thickening of the lining of the uterus (endometrial hyperplasia)

Often no other symptoms

Hysteroscopy (insertion of a viewing tube through the vagina to view the uterus) or sonohysterography

Biopsy of tissue taken from the lining of the uterus

Cancer of the cervix or lining of the uterus (endometrium), which can occur but is much less common among younger women

Often no other symptoms until the cancer is advanced

Sometimes vaginal bleeding or a bloody discharge

Pain that develops gradually

Sometimes weight loss

A Papanicolaou (Pap) test

A biopsy

Sometimes imaging of the pelvis such as ultrasonography, MRI, or CT

At any age

Bleeding disorders

Easy bruising

Excessive bleeding during toothbrushing or after minor cuts

A rash of tiny reddish purple dots (petechiae) or larger splotches (purpura), indicating bleeding in the skin

A complete blood cell count, including the number of platelets

Blood tests to assess the blood’s ability to clot (prothrombin time and partial thromboplastin time)

Examination of a sample of blood under a microscope

Injury (including that resulting from sexual abuse)

Sometimes a history of injuries

Often vaginal discharge

A doctor's examination

If sexual abuse is suspected:

  • Examination under a microscope and analysis of a sample of the discharge

  • Tests to detect sexually transmitted diseases using a sample of secretions taken from the cervix

*Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present.

CT = computed tomography; MRI = magnetic resonance imaging.

Testing

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 and, 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, a viewing tube is inserted into the uterus through the vagina. For sonohysterography, fluid is infused 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 (D and C).

Other tests may be done, depending on which disorders seem possible. For example, a Papanicolaou (Pap) test or a biopsy of the cervix may be done to check for cancer of the cervix.

Dysfunctional uterine bleeding may be diagnosed if the examination and tests do not detect another cause.

Treatment

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.

Birth control pills or other hormones may be used to treat dysfunctional uterine bleeding.

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 considered abnormal, even though it is relatively common. 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. Older women should see a doctor promptly if they have

  • Any vaginal bleeding

  • A 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

  • 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 dysfunctional uterine bleeding, which results from changes in the hormonal control of the menstrual cycle.

  • 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.

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