Vaginal Bleeding: A Merck Manual of Patient Symptoms podcast

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)

Vaginal bleeding may also occur during early pregnancy (see Symptoms During Pregnancy: Vaginal Bleeding During Early Pregnancy) or late pregnancy (see Symptoms During Pregnancy: Vaginal Bleeding During Late Pregnancy).

Pathophysiology

Most abnormal vaginal bleeding involves

• Hormonal abnormalities in the hypothalamic-pituitary-ovarian axis (most common)
• Structural, inflammatory, or other gynecologic disorders (eg, tumors)
• Bleeding disorders (uncommon)

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.

Etiology

Causes in adults (see Table 3: Symptoms of Gynecologic Disorders: Some Causes of Abnormal Vaginal Bleeding in Adult Women) and children (see Table 4: Symptoms of Gynecologic Disorders: Common Causes of Vaginal Bleeding in Children) vary.

Overall, the most common specific causes in adult women who are not known to be pregnant are

• Complications of an early, undiagnosed pregnancy
• Anovulatory bleeding
• Submucous myoma
• Midcycle bleeding associated with ovulation
• Breakthrough bleeding while women are taking oral contraceptives

Table 3
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Some Causes of Abnormal Vaginal Bleeding in Adult Women Category Conditions Early pregnancy* and related complications Spontaneous abortion (patients may present immediately during the abortion or later because of bleeding due to retained products of conception) Ectopic pregnancy Late pregnancy* and related complications Abruptio placentae Gestational trophoblastic disease Placental polyps Placenta previa Structural gynecologic disorders Adenomyosis Cancer of the vagina, cervix, or uterus Endometrial hyperplasia Endometriosis Fibroids (submucosal or prolapsed) Polyps of the cervix or endometrium Other gynecologic disorders Atrophic vaginitis Cervicitis Foreign body in the vagina Injury of the cervix, vagina, or vulva Vaginitis Ovulatory disorders Dysfunctional uterine bleeding Functional ovarian cysts (may be a sign of anovulation) Polycystic ovary syndrome Endocrine disorders Hyperprolactinemia Thyroid disorders (eg, hypothyroidism) Bleeding disorders Coagulation disorders (eg, due to drugs, liver disorders, or hereditary disorders) Platelet disorders Contraception and hormone therapy Depot medroxyprogesterone injections Hormone replacement therapy Intrauterine devices Levonorgestrel implants Oral contraceptives, particularly when doses are missed or when long-cycle regimens or progestin only is used *At presentation, patients may not suspect pregnancy of any stage (including recent spontaneous abortion).

Table 4
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Common Causes of Vaginal Bleeding in Children Age Group Causes Infants In utero endometrial stimulation by transplacental estrogens (causes minimal bleeding during the first 2 wk of life) Older children Precocious puberty with premature menses Prolapse of the urethral meatus Trauma (including sexual abuse) Tumors (eg, sarcoma botryoides, cervical adenocarcinoma secondary to DES exposure) Vaginal foreign body Warts, cervical or vaginal DES = diethylstilbestrol.

Evaluation

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

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, 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.

Physical examination

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.

Red flags

The following findings are of particular concern:

• Hemorrhagic shock (tachycardia, hypotension)
• Premenarchal and postmenopausal vaginal bleeding
• Vaginal bleeding in pregnant patients

Interpretation of findings

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, the most common cause during reproductive years, is a diagnosis of exclusion after other causes are ruled out; testing is usually required.

Testing

All women of reproductive age require

• A urine pregnancy test

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 Symptoms During Pregnancy: Vaginal Bleeding During Early Pregnancy and see Symptoms During Pregnancy: 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's 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:

• Age > 35
• Risk factors for endometrial cancer
• Bleeding that continues despite use of empiric hormone therapy

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.

Treatment

Hemorrhagic shock is treated. Women with iron deficiency anemia may require supplemental oral iron.

Definitive treatment of vaginal bleeding is directed at the cause. Hormones, usually oral contraceptives, are used to treat dysfunctional uterine bleeding.

Geriatrics Essentials

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.

Key Points

• 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.

Last full review/revision July 2012 by David H. Barad, MD, MS