Vaginal Bleeding

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 sexual activity. Clinicians should ask about the following:

Review of systems should seek symptoms of possible causes, including the following:

Past medical history should identify disorders known to cause vaginal bleeding, including a recent spontaneous or induced abortion or structural disorders (eg, uterine fibroids Uterine Fibroids Uterine fibroids (leiomyomas) are benign smooth muscle tumors of the uterus. Fibroids frequently cause abnormal uterine bleeding and pelvic pressure and sometimes urinary or intestinal symptoms... read more , cervical or endometrial polyps). Clinicians should identify risk factors for: endometrial cancer Endometrial Cancer Endometrial cancer is usually endometrioid adenocarcinoma. Typically, it manifests as postmenopausal uterine bleeding. Diagnosis is by biopsy. Staging is surgical. Treatment requires hysterectomy... read more (including obesity, diabetes, prolonged estrogen use without a progestin), cervical cancer Cervical Cancer Cervical cancer is usually squamous cell carcinoma; adenocarcinoma is less common. The cause of most cervical cancers is human papillomavirus (HPV) infection. Cervical neoplasia is often asymptomatic... read more (including abnormal or inadequate cervical cancer screening, immunosuppression), and polycystic ovary syndrome Polycystic Ovary Syndrome (PCOS) Polycystic ovary syndrome is a clinical syndrome typically characterized by anovulation or oligo-ovulation, signs of androgen excess (eg, hirsutism, acne), and multiple ovarian cysts in the... read more .

Drug history should include specific questions about use of hormonal contraceptives, other hormones, and other drugs that may cause AUB (eg, anticoagulants, nonsteroidal anti-inflammatory drugs).

Family history of bleeding problems or gynecologic cancers should be queried.

If sexual abuse of a child is suspected, a structured forensic interview based on the National Institute of Child Health and Human Development (NICHD) Protocol can be used. It helps the child report information about the experienced event and improves the quality of information obtained.

Vital signs are reviewed for signs of hypovolemia (eg, tachycardia, hypotension).

During the general examination, clinicians should look for signs of anemia (eg, conjunctival pallor) and evidence of possible causes of abnormal uterine bleeding, including the following:

The abdomen is examined for distention, tenderness, and masses (particularly an enlarged uterus).

A pelvic examination Physical Examination Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation. Gynecologic evaluation may be necessary... read more is done. External inspection and speculum examination help identify lesions of the vulva, vagina, cervix, and urethra. Bimanual examination is done to evaluate uterine size and ovarian enlargement. If abdominal examination suggests a late-stage pregnancy, digital cervical examination is contraindicated until placental position is determined. If no blood is present in the vagina, rectal examination is done to determine whether bleeding is gastrointestinal in origin.

If a child cannot tolerate a pelvic examination or if the source if the child's bleeding is undetermined, the child may be given an anesthetic before the examination; vaginoscopy is done if necessary to examine the vagina and cervix.

The following findings are of particular concern:

Significant hypovolemia or hemorrhagic shock is unlikely except with ruptured ectopic pregnancy or, rarely, a ruptured ovarian cyst.

In children, breast development and pubic or axillary hair before the typical age range for puberty 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 hormonal contraceptives have no apparent abnormalities during examination and bleeding is spotty, bleeding may be related to the hormones. 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.

All patients of reproductive age require

During early pregnancy (before 5 weeks), a urine pregnancy test may not be sensitive enough. A quantitative serum beta human chorionic gonadotropin (beta-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 Vaginal Bleeding During Early Pregnancy Vaginal bleeding occurs in approximately 20% of confirmed pregnancies during the first 20 weeks of gestation; about half of these cases end in spontaneous abortion ( 1). Vaginal bleeding is... read more and Vaginal Bleeding During Late Pregnancy Vaginal Bleeding During Late Pregnancy Bleeding during late pregnancy (≥ 20 weeks gestation, but before birth) occurs in 3 to 4% of pregnancies. It should be evaluated promptly, because it may be associated with complications that... read more ).

Blood tests include a complete blood count (CBC) if bleeding is unusually heavy (eg, > 1 pad or tampon/hour) or has lasted > 7 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 red blood cell [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, prothrombin time (PT), and partial thromboplastin time (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 uterine masses (eg, endometrial polyps, submucous myomas).

Other testing includes endometrial sampling if examination and ultrasonography are inconclusive in patients with any of the following:

Sampling can be done by endometrial biopsy or, if the cervical canal requires dilation, by dilation and curettage (D & C).