Merck Manual

Please confirm that you are not located inside the Russian Federation

honeypot link

Vaginal Bleeding

By

David H. Barad

, MD, MS, Center for Human Reproduction

Last full review/revision Apr 2020| Content last modified Apr 2020
Click here for the Professional Version
GET THE QUICK FACTS
Topic Resources

Abnormal vaginal bleeding includes any vaginal bleeding that occurs

  • Before puberty

  • During pregnancy

  • After menopause

  • Between menstrual periods

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.

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

  • A foreign object (body), such as toilet paper or a toy, in the vagina

  • An injury

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. 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 (atrophic vaginitis) or uterus

Less common causes

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

Children may have hormonal abnormalities that cause puberty to begin too early—a disorder called precocious puberty Early Puberty Precocious puberty is sexual maturation that begins before age 9 in boys or before age 8 in girls. The cause of precocious puberty is often unknown, but it may be caused by structural abnormalities... 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 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 Ectopic Pregnancy Ectopic pregnancy is attachment (implantation) of a fertilized egg in an abnormal location. In an ectopic pregnancy, the fetus cannot survive. When an ectopic pregnancy ruptures, women often... read more ) and whether the bleeding is excessive, possibly resulting in shock.

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 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 Some Causes and Features of Vaginal Bleeding Abnormal vaginal bleeding includes any vaginal bleeding that occurs Before puberty During pregnancy After menopause Between menstrual periods read more ).

Doctors ask about the bleeding:

  • How many pads are used per day or hour

  • How long bleeding lasts

  • When it started

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

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 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 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 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.

Table
icon

Testing

If women are of childbearing age, doctors always do

  • A urine test for pregnancy

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

  • 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 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 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 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).

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 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.

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

  • Any vaginal bleeding

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

However, postmenopausal bleeding has many other causes. They include

  • Thinning and drying of the lining of the uterus or vagina (the most common cause)

  • 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 about Vaginal Bleeding

  • 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 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.

  • 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.

NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
Click here for the Professional Version
OTHER TOPICS IN THIS CHAPTER
Others also read
Test your knowledge
Menopause
Menopause occurs in several stages. Which of the following is the stage that can last between 4 and 8 years, is characterized by changes in the pattern of menstrual periods, and leads up to the last menstrual period?
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID

Also of Interest

Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
TOP