 |
Abnormal vaginal bleeding includes menses that are prolonged (menorrhagia), excessive (menorrhagia or hypermenorrhea), or too frequent (polymenorrhea) or that is unrelated to menses, occurring frequently and irregularly between menses (metrorrhagia) or postmenopausally. In women > 50, postmenopausal bleeding > 6 mo after the last normal menses should be evaluated. Total menstrual blood loss is usually < 80 mL. Prolonged or excessive bleeding, regardless of cause, may result in iron deficiency and anemia (see Anemias Caused by Deficient Erythropoiesis: Iron Deficiency Anemia). For bleeding during pregnancy, see Approach to the Pregnant Woman and Prenatal Care: Vaginal Bleeding During Early Pregnancy; see Approach to the Pregnant Woman and Prenatal Care: Vaginal Bleeding During Early Pregnancy.
Etiology
Most abnormal vaginal bleeding results from hormonal abnormalities in the hypothalamic-pituitary-ovarian axis, but bleeding may also result from structural gynecologic disorders. Rarely, the cause is a bleeding disorder. With hormonal causes, ovulation does not occur or occurs infrequently; as a result, estrogen, unopposed by progesterone, stimulates endometrial growth. As a result, the endometrium sloughs and bleeds irregularly, incompletely, and sometimes excessively or for a long time.
Common causes of vaginal bleeding vary by age and menstrual status (see Table 2: Approach to the Gynecologic Patient: Common Causes of Abnormal Vaginal Bleeding ). Among children, vaginal bleeding is very uncommon.
|
Table 2
|
| | |
|
Common Causes of Abnormal
Vaginal Bleeding
|
|
Patient Characteristics
|
Common Causes
|
|
Infants
|
In utero endometrial stimulation by placental estrogens (causing minimal bleeding)
|
|
Children
|
Trauma, vaginal foreign body with vaginitis, prolapse of the urethral meatus, precocious puberty with premature menses
|
|
Women of reproductive age with syncope or hemorrhagic shock
|
Ruptured ectopic pregnancy
|
|
Women of reproductive age with positive pregnancy test
|
Spontaneous complete or incomplete abortion, ectopic pregnancy, gestational trophoblastic disease, endometritis secondary to retained products of conception
|
|
Women of reproductive age with negative pregnancy test
|
Hormonally related: Dysfunctional uterine bleeding (most common), brain lesions, drugs (eg, hormonal contraceptives), hypothyroidism, adrenal or ovarian tumors.
Structural: Vaginal disorders (eg, cancers, adenosis, trauma, granulomas secondary to previous surgery). Cervical (eg, cancer, polyps, myomas, condylomata acuminata). Uterine (eg, cancers, adenomyosis such as benign invasion of the myometrium by the endometrium, endometrial polyps, submucous and pedunculated fibroids; occasionally, delayed endometritis secondary to retained products of conception). Ovarian (eg, tumors)
|
|
Postmenopausal women
|
Structural disorders of the vagina (eg, cancer; atrophic vaginitis), cervix (eg, cancer, polyps), uterus (eg, endometrial cancer, atrophy, hyperplasia [endometrium > 5 mm], polyps), or ovaries (eg, tumors)
|
|
In women of reproductive age, bleeding can result from complications of an unsuspected pregnancy. Products of conception retained after spontaneous or therapeutic abortion may cause bleeding within hours or, occasionally, after weeks.
Evaluation
History:
A complete gynecologic history is obtained. For all age groups, history should include quantity and duration of bleeding, relationship of bleeding to menses, and questions about trauma. Symptoms of abnormal bleeding (eg, easy bruising, excessive gingival bleeding with toothbrushing, excessive bleeding from lacerations or venipuncture) suggest a bleeding disorder.
Pregnancy-related bleeding is considered in all women of reproductive age, particularly those with pelvic pain, irregular menses, or symptoms of pregnancy. Light-headedness, syncope, or other symptoms of hemorrhagic shock without excessive vaginal bleeding may indicate profuse internal bleeding due to an ectopic pregnancy or a ruptured ovarian cyst. Bleeding with pelvic pain, fever, and vaginal discharge, particularly in women who have had a recent spontaneous or therapeutic abortion, suggests retained products of conception, endometritis, or both. Hirsutism, particularly with obesity, suggests polycystic ovary syndrome (see Menstrual Abnormalities: Polycystic Ovary Syndrome (PCOS)), a common cause of dysfunctional bleeding. Virilization, symptoms and signs of hypothyroidism, or galactorrhea suggests other hormonal abnormalities. In postmenopausal women, vaginal bleeding suggests a gynecologic cancer.
Examination:
A general examination, including assessment for signs of hemorrhagic shock (eg, tachycardia, tachypnea, poor capillary refill, confusion, hypotension), is done. The skin is examined for signs of bleeding disorders (eg, petechiae, purpura, ecchymoses). A complete gynecologic examination is also done.
If
vaginal bleeding occurs late in pregnancy (eg, during the 3rd trimester),
digital pelvic examination is contraindicated until placental position
is determined. Such bleeding may indicate placenta previa (
see Abnormalities of Pregnancy: Placenta Previa
);
if placenta previa is present, examination can result in sudden,
massive bleeding. In other cases, speculum examination helps determine whether bleeding originates from the vagina, cervix, or uterus. If no blood is seen, rectal examination is done to determine whether bleeding is GI in origin.
In women of reproductive age, hemorrhagic shock suggests copious external bleeding, which is usually clinically obvious, or some concealed bleeding, often due to ruptured ectopic pregnancy. Pelvic examination may reveal masses, lesions, or other signs characteristic of structural gynecologic disorders. A tender pelvic mass with bleeding suggests rupture of an ectopic pregnancy or ovarian cyst.
In children, breast development and pubic or axillary hair suggest precocious puberty and premature menses.
Testing:
All women of reproductive age are tested for pregnancy. Vaginal bleeding during pregnancy involves a specific approach (see Approach to the Pregnant Woman and Prenatal Care: Evaluation; see Approach to the Pregnant Woman and Prenatal Care: Evaluation). Suspected ectopic
pregnancy requires immediate pelvic ultrasonography and measurement
of Hb or Hct and serum levels of the β subunit
of human chorionic gonadotropin plus, if hemorrhagic shock
is suspected, blood typing and cross-matching. In women who are not pregnant, Hb or Hct is measured if bleeding is unusually heavy (eg, > 1 pad or tampon/h) or has lasted at least several days or if there are symptoms of anemia or hypovolemia. If anemia is identified and is not obviously due to iron deficiency, iron studies are done. Pelvic ultrasonography, particularly using intrauterine saline, which contrasts with uterine tissue, can help identify submucous or pedunculated fibroids, endometrial polyps, and endometrial hyperplasia.
If examination and ultrasonography do not detect any abnormalities in women > 35, endometrial sampling by aspiration or, if the cervical canal requires dilation, D & C is done. If cancer is suspected, specific tests are done. If a bleeding disorder is suspected, von Willebrand's factor, platelet count, PT, and PTT are measured.
Treatment
Hemorrhagic shock is treated (see Shock and Fluid Resuscitation: Prognosis and Treatment). Iron deficiency anemia may require supplemental iron. Definitive treatment of vaginal bleeding is directed at the cause. Hormones, usually oral contraceptives, are used to treat dysfunctional uterine bleeding (see Menstrual Abnormalities: Dysfunctional Uterine Bleeding (DUB)).
Last full review/revision November 2005
Content last modified January 2007
| |
