* This is the Professional Version. *
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)
Most abnormal vaginal bleeding involves
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.
Causes in adults (see Table: Some Causes of Abnormal Vaginal Bleeding in Adult Women) and children (see Table: Common Causes of Vaginal Bleeding in Children) vary.
During the reproductive years, the most common cause of vaginal bleeding is
Dysfunctional uterine bleeding (see Dysfunctional Uterine Bleeding (DUB)), including anovulatory bleeding
The most common specific causes in adult women who are not known to be pregnant are
Some Causes of Abnormal Vaginal Bleeding in Adult Women
Common Causes of Vaginal Bleeding in Children
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 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. Menstrual history should be obtained; it should include 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, should be identified.
Review of systems should seek symptoms of possible causes, including 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); and 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.
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)
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.
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.
Dysfunctional uterine bleeding is a diagnosis of exclusion after other causes are ruled out; testing is usually required.
All women of reproductive age require
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 β subunit of human chorionic gonadotropin (β-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 see 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:
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 who are > 35, who have risk factors for cancer, or who have endometrial thickening > 4 mm. Sampling can be done by aspiration or, if the cervical canal requires dilation, by D & C.
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.
Pregnancy must be excluded in women of reproductive age even when history does not suggest it.
Dysfunctional 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.
* This is the Professional Version. *