Abnormal vaginal bleeding includes any vaginal bleeding that occurs
During the childbearing years, vaginal bleeding occurs normally as menstrual periods. However, menstrual periods are considered abnormal if they
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).
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.
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
During the childbearing years, the most common cause is
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
After menopause, the most common cause is
Less common causes:
Cancer of the cervix, vagina, or lining of the uterus (endometrial cancer) can cause bleeding, usually after menopause. Cancer is an uncommon cause during the childbearing years. 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.
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.
In women with vaginal bleeding, certain characteristics are cause for concern:
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 see Table 2: Some Causes and Features of Vaginal Bleeding ).
Doctors ask about the bleeding:
They also ask about the woman's menstrual history:
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 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.
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If women are of childbearing age, doctors always do
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.
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
However, postmenopausal bleeding has many other causes. They include
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.
Last full review/revision May 2012 by David H. Barad, MD, MS