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Vaginal Bleeding

By

David H. Barad

, MD, MS, Center for Human Reproduction

Medically Reviewed May 2022 | Modified Sep 2022
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Abnormal vaginal bleeding includes any vaginal bleeding that occurs

  • Before puberty

  • Between menstrual periods

  • During pregnancy

  • After menopause (12 months or more after the last menstrual period)

During the childbearing years, vaginal bleeding occurs normally as menstrual periods. However, menstrual periods are considered abnormal if they

  • Become excessively heavy (saturating more than 1 or 2 tampons an hour)

  • Last too long (more than 7 days)

  • Occur too frequently (usually fewer than 21 days apart)

  • Occur too infrequently (usually more than 90 days apart)

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.

The Vagina
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Causes of Vaginal Bleeding

Vaginal bleeding may result from

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

Uterine bleeding due to ovulatory dysfunction occurs when the hormonal control of menstruation Overview of Menstrual Disorders Complex interactions among hormones control the start of menstruation during puberty, the rhythms and duration of menstrual cycles during the reproductive years, and the end of menstruation... read more changes and the lining of the uterus sheds irregularly. 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

  • Age-related thinning of the lining of the vagina (formerly called atrophic vaginitis) or uterus (part of the genitourinary syndrome of menopause)

Less common causes

Excessively heavy menstrual periods may be the first sign of a bleeding disorder Bleeding Due to Clotting Disorders .

Children may have hormonal abnormalities that cause puberty to begin too early—a disorder called precocious puberty Early Puberty Early (precocious) puberty is sexual maturation that begins before the average age. The cause of early puberty is often unknown, but it may be caused by structural abnormalities or tumors in... read more . 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 of Vaginal Bleeding

Doctors first focus on determining whether the cause of vaginal bleeding is a serious or life-threatening disorder (such as a ruptured ectopic pregnancy Ectopic Pregnancy Ectopic pregnancy is attachment (implantation) of a fertilized egg in an abnormal location, such as the fallopian tubes. In an ectopic pregnancy, the fetus cannot survive. When an ectopic pregnancy... read more ) 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 any of the following occur:

  • Women lose more than about a cup of blood.

  • More than 1 pad or tampon is saturated per hour for a few hours.

  • The blood contains large clots.

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 a few days, or is heavy or foul smelling, 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 Some Causes and Features of Vaginal Bleeding Some Causes and Features of Vaginal Bleeding ).

Doctors ask about the bleeding:

  • How many pads or tampons are used per day or hour

  • How long bleeding lasts

  • When it started

  • When it occurs in relation to menstrual periods and sexual activity

They also ask about the woman's menstrual history:

  • How old she was when menstrual periods started

  • How long they last

  • How heavy they are

  • How long the interval between periods is

  • Whether they are regular

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, other hormones, or other drugs that can cause excessive bleeding, (such as anticoagulants and nonsteroidal anti-inflammatory drugs (NSAIDs).

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 Pelvic Examination For gynecologic care, a woman should choose a health care practitioner with whom she can comfortably discuss sensitive topics, such as sex, birth control, pregnancy, and problems related to... read more . During the examination, doctors can identify disorders of the cervix, uterus, vagina, vulva, or urethra in women of all ages. In children, a general examination is done first to check for early (precocious) puberty Early Puberty Early (precocious) puberty is sexual maturation that begins before the average age. The cause of early puberty is often unknown, but it may be caused by structural abnormalities or tumors in... read more (based on the presence of pubic hair and breast development), and a pelvic examination is done only if necessary.

If no blood is present in the vagina, a rectal examination may be done to determine whether bleeding is coming from the digestive tract.

Table

Testing

If women are of childbearing age, doctors always do

  • A urine or blood test for pregnancy

If the urine pregnancy test is negative but doctors still suspect pregnancy, a blood test for pregnancy is done. It involves measuring a hormone produced by the placenta called human chorionic gonadotropin (hCG). 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

  • 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 Polycystic Ovary Syndrome (PCOS) Polycystic ovary syndrome is characterized by slight obesity, irregular or no menstrual periods, and symptoms caused by high levels of male hormones (androgens). It involves disruption of the... read more Polycystic Ovary Syndrome (PCOS) is suspected, blood tests to measure androgen hormone levels are done.

Ultrasonography is often used to look for abnormalities in the reproductive organs if women have risk factors for endometrial cancer or if doctors suspect problems such as fibroids, polyps, or a tumor. 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 Hysteroscopy Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic... read more Hysteroscopy , a viewing tube is inserted into the uterus through the vagina. For sonohysterography Saline Sonography Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic... read more Saline Sonography , 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, doctors may take a sample of tissue from the lining of the uterus for analysis in the following circumstances:

The sample may be obtained by suction (through a tube) or by scraping—a procedure called dilation and curettage Dilation and Curettage Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic... read more Dilation and Curettage (D and C). In postmenopausal women, the sample is usually obtained by hysteroscopy, which enables doctors to see inside the uterus and locate the abnormality.

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 of Vaginal Bleeding

If women are have extremely heavy bleeding and a very low blood pressure, they are immediately given fluids intravenously and blood transfusions as needed to restore blood pressure. Laparoscopy or laparotomy is often required if there is an emergency. For laparoscopy, doctors make a small incision just below the navel and insert a viewing tube (laparoscope). Laparotomy requires a large incision into the abdomen. Both procedures enable doctors to directly to directly view organs and look for abnormalities.

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 Drugs Drugs 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: Vaginal Bleeding

Postmenopausal bleeding (occurring more than 12 months after the last menstrual period) 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

  • Any vaginal bleeding

  • A vaginal discharge that is pink or brown, possibly containing small amounts of blood

However, postmenopausal bleeding has many other causes.

The most common cause is

  • Thinning of the lining of the uterus or vagina (genitourinary syndrome of menopause)

Other causes include

  • Use of estrogen or other hormone therapy, particularly when use is stopped

  • Polyps in the cervix or uterus

  • Fibroids

  • Infections

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

  • During the childbearing years, the most common cause of abnormal vaginal bleeding is pregnancy.

  • In women who are not pregnant, the most common cause is hormonal imbalance (ovulatory dysfunction), which can cause abnormal uterine bleeding.

  • Abnormal uterine bleeding is related to changes in the hormonal control of the menstrual cycle that prevent the ovaries from releasing an egg.

  • In children, the cause is usually a foreign object or an injury, but sometimes sexual abuse is the cause.

  • In women of childbearing age, a pregnancy test is done even when women do not think they could be pregnant.

  • If any vaginal bleeding occurs after menopause, an evaluation to rule out cancer is necessary.

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