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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 Symptoms During Pregnancy: Vaginal Bleeding During Early Pregnancy and see Symptoms During Pregnancy: 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 Menstrual Disorders and Abnormal Vaginal Bleeding: 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
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 Menstrual Disorders and Abnormal Vaginal Bleeding: 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 and Clotting Disorders).
Children may have hormonal abnormalities that cause puberty to begin too early—a disorder called precocious puberty (see Problems in Adolescents: 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:
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 Symptoms of Gynecologic Disorders: 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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Some Causes and Features of Vaginal Bleeding |
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Cause
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Common Features*
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Tests
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During infancy
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Exposure to the mother's estrogen before birth
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A small amount of bleeding during the first 1–2 weeks of life
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A doctor's examination
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During childhood
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A foreign body in the vagina
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Usually a foul-smelling discharge, often containing small amounts of blood
Sometimes a history of having inserted an object into the vagina
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A doctor's examination, sometimes done after the girl is sedated or given a general anesthetic
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Early (precocious) puberty
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Development of breasts and appearance of pubic and underarm hair (as occurs during puberty) at a young age
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X-rays of the hand and wrist
Blood tests to measure hormone levels
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During the childbearing years
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Dysfunctional uterine bleeding
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Usually bleeding that occurs frequently or irregularly or that lasts longer or is heavier than typical menstrual periods
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Tests to rule out other possible causes, including blood tests and ultrasonography, often using a handheld ultrasound device inserted in the vagina
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Endometriosis (abnormally located patches of tissue that is normally located only in the lining of the uterus)
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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
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Insertion of a thin viewing tube (laparoscope) into the abdominal cavity to check for abnormal tissue and to obtain a sample for biopsy
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Fibroids
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Often no other symptoms
With large fibroids, sometimes pain, pressure, or a feeling of heaviness in the pelvic area
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A doctor's examination
Often ultrasonography or sonohysterography (ultrasonography after fluid is infused into the uterus)
If results are unclear, MRI
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Polycystic ovary syndrome
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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
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A doctor's examination
Blood tests to measure levels of hormones, such as testosterone, luteinizing hormone, and follicle-stimulating hormone
Ultrasonography of the pelvis
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Pregnancy complications (of an unrecognized pregnancy)
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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)
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A doctor's examination
Ultrasonography of the pelvis
For a suspected ectopic pregnancy:
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Urine and blood tests to measure a hormone produced by the placenta (called human chorionic gonadotropin, or hCG)
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Sometimes for a suspected ectopic pregnancy, laparoscopy or laparotomy (a large incision into the abdomen enabling doctors to directly view organs)
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Spotting or bleeding between periods (breakthrough bleeding) during the first months that oral contraceptives are used
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Often no other symptoms
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A doctor's examination
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After menopause
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Thinning of the lining of the vagina (atrophic vaginitis)
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A scant discharge
Pain during sexual intercourse
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A doctor's examination
Examination under a microscope and analysis of a sample of discharge
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Thickening of the lining of the uterus (endometrial hyperplasia)
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Often no other symptoms
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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
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Cancer of the cervix or lining of the uterus (endometrium), which can occur but is much less common among younger women
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Often no other symptoms until the cancer is advanced
Sometimes vaginal bleeding or a bloody discharge
Pain that develops gradually
Sometimes weight loss
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A Papanicolaou (Pap) test
A biopsy
Sometimes imaging tests of the pelvis such as ultrasonography, MRI, or CT of the pelvis
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At any age
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Bleeding disorders
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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
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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
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Injury (including that resulting from sexual abuse)
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Sometimes a history of injuries
Often vaginal discharge
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A doctor's examination
If sexual abuse is suspected:
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*Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present.
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CT = computed tomography; MRI = magnetic resonance imaging.
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Testing:
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 (see Menstrual Disorders and Abnormal Vaginal Bleeding: Diagnosis).
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
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.
Key Points
Last full review/revision May 2012 by David H. Barad, MD, MS
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