Abnormal vaginal bleeding

Abnormal vaginal bleeding in the non-pregnant patient

Classification terms

• Ovulatory abnormal bleeding AKA menorrhagia AKA heavy menstrual bleeding = Heavy or prolonged periods, generally >80mL. Occurs in a cyclic pattern.
• Anovulatory abnormal bleeding AKA dysfunctional uterine bleeding = Bleeding that is irregular and of variable volume. Occurs in a noncyclic pattern.
  • Related to insufficient progesterone in the absence of a corpus luteum. Common at extremes of reproductive age and in PCOS.
• Metrorrhagia AKA intermenstrual bleeding = Bleeding between periods.
• Oligomenorrhoea = Infrequent periods.
• Amenorrhoea = Absent periods for >6 months.

Normal menstruation

• Interval 21-35 days
• Duration 3-7 days
• Average volume 30-40mL

Anatomical sites of abnormal bleeding

• Uterus
• Cervix
• Vagina
• Vulva
• *Systemic e.g. coagulopathy

Diagnostic considerations

• Shock and severe anaemia are the primary emergency concerns.
• Coagulopathy occurs in 20% of younger patients. Testing is required if there are any other clinical features suggesting bleeding diathesis.
• Malignancy must be assumed until proven otherwise in older patients. Ensure gynaecology follow up for endometrial biopsy.
• Other diagnoses not to miss: PID, abuse, endocrinopathy.
• Clearly delineate PV bleeding from urethral or rectal bleeding, which elderly patients in particular may not be able to discern.
• Gynaecologists use the PALM-COEIN classification to separate causes into structural and non-structural, though precise cause will seldom be determined in the ED.

FIGO classification system [PALM-COEIN] classification of causes

• STRUCTURAL
  • Polyps (endometrial and cervical)
    • Age >35. Intermenstrual bleeding. USS or hysteroscopy.
  • Adenomyosis
    • Painful heavy periods. Age >30. USS or MRI.
  • Leiomyomata (fibroids)
    • Palpable if large. Usually asymptomatic. Age >30. USS.
  • Malignancy and hyperplasia (vaginal, cervical incl ectropion, endometrial)
    • Age >45 or risk factors. USS, endometrial Bx.
• NON-STRUCTURAL
  • Coagulopathy e.g. vWD, drugs, cirrhosis.
  • Ovulatory dysfunction, DUB. Responds well to hormone Rx.
    • Extremes of reproductive age. Usually minor in adolescents.
    • Endocrinopathy
      • Thyroid disease
      • Pituitary disease incl hyperprolactinaemia, gonadotropin excess.
    • PCOS
  • Endometrial. Cyclical menorrhagia without clear cause.
  • Iatrogenic
    • Devices: IUD, retained tampon.
    • Drugs: anticoagulants, chemotherapeutics, corticosteroids, OCP and HRT, tamoxifen.
  • Not YET classified
    • Trauma
    • AVM
    • PID, especially endometritis
    • Vaginal atrophy
    • Liver disease
    • Renal disease
    • Stress
    • Illness
    • Rapid weight change

Common causes by age

• Fertile
  • Anovulation due to immaturity or PCOS
  • OCP
  • Pregnancy
  • PID
  • Fibroids, polyps (age>30)
  • Coagulopathy (up to 20%)
• Perimenopausal
  • Anovulation due to age
  • Fibroids, polyps
  • Hypothyroidism
• Postmenopausal
  • Atrophy
  • HRT
  • Neoplasms: malignant and benign

History

• Age. Note malignancy.
• HPC
  • Bleeding: quantity, pads/tampons, clots (suggests large volume if present), timing, products, colour, frequency
  • Pain, dyspareunia, dysmenorrhoea
  • PV DC
  • Fever
  • Trauma e.g. postcoital
• PMHx
  • Period: menarche, LMP, cycle length and pattern
  • Pap smears
  • Pregnancy: GxPxMxTx, fertility Rx
  • Prior gynaecologic issues incl surgeries, cancers, STIs
  • Coagulopathy
  • VTE risk factors (to check if hormone Rx can be used)
• Medications
• SHx
  • Assault
  • Sex: partners and gender, types, condoms, contraception
• FHx
  • Heavy PVB
  • Coagulopathy

Examination

• Shock: tachycardia, hypotension, massive visible blood loss
• Anaemia: pallor, weakness
• Coagulopathy: petechiae, gingival bleeding
• Hypothyroidism: thin hair, overweight
• PCOS: hirsutism, obesity
• Uterine masses: palpate abdomen, bimanual
• PID: bimanual for cervical motion tenderness, adnexal tenderness, foul discharge
• Source of bleeding: vulva, vaginal speculum

Investigations

• Bedside:
  • HCG urine or serum
• Laboratory:
  • FBC for anaemia
  • TFT if suspect thyroid disease
  • Coagulation profile if other features of coagulopathy such as chronic menorrhagia, easy bruising, excessive procedural bleeding, epistaxis
• Radiology:
  • TV USS for structural cause including masses, assessment of uterine size, endometrial characteristics, cysts, fluid

Management

• Unstable patient with unclear cause:
  • Transfuse, apply principles of haemostatic resuscitation
  • Conjugated equine estrogens e.g. Premarin 25mg IV
  • TXA 1g IV
  • Consider uterine tamponade with 26Fr Foley or Bakri balloon. Vaginal packing may hide ongoing losses and should be monitored closely if attempted.
  • Prepare for theatre by calling gynaecologist and anaesthetist.
• Admission if severe anaemia or shock
• Supportive cares
  • Analgesia
  • Iron infusion for chronic anaemia
• Address specific causes
  • Reverse coagulopathy
  • Vaginal wall trauma
    • Generally settles spontaneously, but may require surgical management if beyond mucosa
  • Cervical malignancy
    • AgNO3 cautery if required, consider vaginal packing, gynaecology admission
  • Pelvic Inflammatory Disease (PID)
    • Doxycycline + metronidazole + ceftriaxone
    • Partner tracing and treatment
  • Polyps, fibroids
    • Surgical resection
  • AVM
    • IR embolization
  • Endocrinopathy
    • e.g. hypothyroidism treated with thyroxine
  • PCOS
    • Weight loss, etc.
• Medical therapies
  • 3 broad arms: TXA, NSAIDs, and hormones.
  • Should account for acuity, aetiology, severity, comorbidities, fertility
  • 90% of stable cases will respond well to medical therapy
  • Irregular heavy bleeding is likely anovulatory and responds especially well to hormone treatments. This includes PCOS and those at extremes of reproductive age. Therapies are otherwise quite similar for menorrhagia and anovulatory DUB.
  • Hormones. Note thrombosis risk. Take average of 3 days for bleeding to stop.
    • Oral
      • COCP. Also provides contraception. <35 µg ethinyl oestradiol. Often need antiemetics co-prescribed.
      • Progestogen alone. Avoids ADRs of oestrogen, including VTE and unwanted endometrial proliferation.
        • Norethisterone 5mg TDS
        • Medroxyprogesterone acetate 10mg BD
        • ADR: hypooestrogenism w long use, NV, HA, acne, fluid retention,
    • IUS
      • Levonorgestrel e.g. Mirena. Avoids systemic ADRs. Not an ED option.
    • IM injection
      • Progestogen with long action e.g. Depo-provera. Not an ED option.
    • IV
      • Conjugated equine estrogens (Premarin) 25mg IV 4-hourly for unstable patients with uncertain cause. Promotes rapid endometrial growth.
  • TXA 1g PO TDS for the first 3-5 days of menstruation. Avoid if active thromboembolic disease.
  • NSAIDs. Reduce PGE2 and have additional analgesic effects. Especially for patients with contraindications to hormones. Take until bleeding resolves.
    • Mefenamic acid 500mg TDS or
    • Ibuprofen 400mg TDS or
    • Naproxen 500mg BD.
• Gynaecology follow up
  • Required for most patients
  • Procedures: hysteroscopy, hysterogram, D&C, endometrial ablation, hysterectomy, polypectomy, myomectomy, embolization
  • Other medical treatments: GnRH analogues, clomiphene
  • Endometrial Bx for older patients

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References

FOAM

• Nickson C. Pelvic Inflammatory Disease (PID). LITFL
• Nickson C. Haemostatic resuscitation. LITFL

Journal

• Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011 Apr;113(1):3-13. 
• Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. ACOG 2013 [updated 2020]

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