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 pregnancy or during late pregnancy and may result from problems (complications) related to the pregnancy.
Prolonged or excessive bleeding, regardless of cause, can result in iron deficiency, anemia, and sometimes dangerously low blood pressure (shock).
Causes
Vaginal bleeding may result from
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Malfunction of the complex hormonal system that regulates the menstrual cycle
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A disorder of the vagina, uterus, cervix, or another reproductive organ
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Bleeding disorders (uncommon)
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 the 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
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Abnormal uterine bleeding, especially uterine bleeding due to ovulatory dysfunction
Uterine bleeding due to ovulatory dysfunction occurs when the hormonal control of menstruation changes. 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).
Other common causes of vaginal bleeding during the childbearing years include
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Complications of pregnancy in a woman who does not know she is pregnant
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Fibroids inside the uterus
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Bleeding when the egg is released (at ovulation) during the menstrual cycle
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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
Less common causes
Cervical cancer, vaginal cancer, or cancer of the 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.
Children may have hormonal abnormalities that cause puberty to begin too early—a disorder called precocious 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 check for pregnancy in all women of childbearing age.
Doctors first focus on determining whether the cause of vaginal bleeding is a serious or life-threatening disorder (such as a ruptured ectopic pregnancy) and whether the bleeding is excessive, possibly resulting in shock.
Warning signs
In women with vaginal bleeding, certain characteristics are cause for concern:
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Loss of consciousness, weakness, light-headedness, cold and sweaty skin, difficulty breathing, and a weak and rapid pulse (which indicate shock)
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Bleeding that occurs before menstrual periods start (before puberty) or after they stop (after menopause)
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Bleeding during pregnancy
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Excessive bleeding
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In children, difficulty walking or sitting, bruises or tears around the genitals or anus or mouth, and/or vaginal discharge or itching (which may be signs of sexual abuse)
Bleeding is considered excessive if any of the following occur:
When to see a doctor
Women with most 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. Symptoms of a bleeding disorder 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 (or caregiver) 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:
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 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). Sometimes they can identify disorders of the cervix, uterus, or vagina in women of all ages.
Some Causes and Features of Vaginal Bleeding
Cause |
Common Features* |
Tests |
During infancy |
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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 |
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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 |
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Development of breasts and appearance of pubic and underarm hair (as occurs during puberty) at a young age |
A doctor's examination X-rays of the hand and wrist to check for speeded-up growth of bones Blood tests to measure hormone levels |
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Sexual abuse |
Difficulty walking or sitting and/or bruises or tears around the genitals, anus, or mouth Vaginal discharge or itching |
A doctor's examination |
During the childbearing years |
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Abnormal uterine bleeding, especially anovulatory 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 |
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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 |
A doctor's examination 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 (noncancerous tumors) in the uterus |
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 injected into the uterus) If results are unclear, MRI |
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Hormonal disorders, such as an underactive thyroid gland (hypothyroidism) |
Blood tests to measure thyroid hormone levels |
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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 |
A doctor’s examination Blood tests to measure levels of hormones, such as testosterone (a male hormone) and follicle-stimulating hormone (which helps stimulate the ovaries to produce estrogen and progesterone) Ultrasonography of the pelvis |
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Polyps in the cervix or uterus |
Often no symptoms Bleeding that occurs between menstrual periods or after sexual intercourse |
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Complications due to 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) |
A doctor's examination Ultrasonography of the pelvis For a suspected ectopic pregnancy:
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Spotting or bleeding between periods (breakthrough bleeding) usually during the first months that oral or other hormonal contraceptives are used |
Often no other symptoms |
A doctor’s examination |
After menopause |
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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 |
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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 |
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Cancer of the lining of the uterus (endometrium) |
Often no other symptoms until the cancer is advanced Sometimes vaginal bleeding or a brown or bloody vaginal discharge Pain that develops gradually Sometimes weight loss |
A biopsy Sometimes imaging of the pelvis such as ultrasonography, MRI, or CT |
At any age |
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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 |
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) |
Sometimes a history of injuries Often vaginal discharge |
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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† In anovulatory uterine bleeding, the ovaries do not release an egg (ovulate). This type of bleeding results from changes in the hormonal control of the menstrual cycle. |
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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
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 injected 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 biopsy of the cervix may be done to check for cancer of the cervix.
If abnormal bleeding does not result from any of the usual causes, it may be related to changes in the hormonal control of the menstrual cycle.
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 abnormal uterine bleeding related to changes in the hormonal control of the menstrual cycle.
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 relatively common but is always considered abnormal. 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 or be treated immediately.
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
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During the childbearing years, the most common cause of abnormal vaginal bleeding is pregnancy.
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In women who are not pregnant, the most common cause is abnormal uterine bleeding, particularly uterine bleeding due to ovulatory dysfunction, which is related to changes in the hormonal control of the menstrual cycle that prevent the ovaries from releasing an egg.
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In children, the cause is usually a foreign object or an injury, but sometimes sexual abuse is the cause.
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In women of childbearing age, a pregnancy test is done even when women do not think they could be pregnant.
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If any vaginal bleeding occurs after menopause, an evaluation to rule out cancer is necessary.
