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Vaginal bleeding can be thought of as pregnancy related or non-pregnancy related. Causes may be primary or abnormal uterine bleeding, or secondary genital tract bleeding

Introduction

Vaginal bleeding can be thought of as pregnancy related or non-pregnancy related.

The following relates to vaginal bleeding in the non-pregnant patient

Of the causes of non-pregnant related bleeding, the causes be thought of as:

  • Primary or abnormal uterine bleeding.
  • Secondary genital tract bleeding.

Primary or abnormal uterine bleeding is the most common cause.

All women of childbearing age with PV bleeding must be assumed to be pregnant until proven otherwise.

All postmenopausal women with PV bleeding must be assumed to have carcinoma (vaginal, cervical or endometrial) till proven otherwise.

See also:

  • Vaginal Bleeding in Early Pregnancy – Threatened Miscarriage
  • Vaginal Bleeding in Early Pregnancy – Miscarriage
Terminology

Menorrhagia: Menstrual cycles that are either excessive or prolonged. A strict definition of menorrhagia is defined as a loss of more than 80 mL per menstrual cycle (about 6 tampons per day for 4 to 5 days).

Metromenorrhagia:                Excessive or prolonged bleeding that occurs at irregular intervals.

Oligomenorrhoea:                  Interval between uterine bleeding from 35 days to 6 months.

Polymenorrhoea:                    Regular bleeding that occurs at intervals shorter than 21 days.

Amenorrhoea:                        The absence of bleeding for more than 6 months

Intermenstrual bleeding:        Bleeding that occurs between otherwise regular menstrual periods.

Physiology

The Normal menstrual Cycle:

In general terms, a normal menstrual cycle is characterized by: 1

●          An intermenstrual length of 24 to 35 days

●          A luteal phase length of 14 ± 1 days

●          Vaginal mucus which changes at the time of ovulation to become more copious, clear and stretchy

●          Breast and abdominal swelling in the late luteal phase

●          Menstrual bleeding of under 80 mL over 4 to 7 days.

Pathophysiology

Causes of abnormal vaginal bleeding in the non-pregnant patient include:

1.         Primary or abnormal uterine bleeding:                            

            ●          Associated with ovulatory cycles:

                        ♥          Most common cause of abnormal uterine bleeding

♥          It presents as regular and heavy bleeding, which can lead to           anemia.

♥          Menstrual blood has been shown to have increased fibrinolytic      activity and/or increased prostaglandins.   

●          Associated with non-ovulatory cycles (also known as Dysfunction             Uterine Bleeding):

                        ♥          Less common cause of abnormal uterine bleeding

                        ♥          It presents as irregular bleeding of variable heavy volume.

♥          In anovulatory cycles, (and other high estrogen states), there is a     relative lack of progesterone to oppose the estrogenic stimulation   of the endometrium.

This results in excessive endometrial proliferation (and occasionally hyperplasia/ metaplasia). The endometrium becomes unstable and prone to irregular shedding. 

Anovulatory cycles are due to immaturity of disturbances of the hypothalamic – pituitary axis, and so tends to be seen at the extremes of reproductive ages:

♥♥       In the first decade after menarche

♥♥       In premenopausal women.

Also in:

♥♥       PCOS

♥♥       Physical / emotional stress

2.         Secondary genital tract bleeding:

●          Anatomical causes:

            Examples include:

            ♥          Malignant disease (uterine, cervical, vaginal).

            ♥          Fibroids

            ♥          Endometriosis/ adenomyosis.

            ♥          Polyps

            ♥          Varices

            ♥          AVMs

●          Infection

●          Trauma

●          Systemic disease:

            Endocrine disease:

            ♥          Thyroid disorders

            ♥          Hyperprolactinemia

            ♥          Polycystic Ovarian Syndrome (PCOS).

            Hematological disease:

            ♥          Coagulopathies

●          Iatrogenic causes:

                        ♥          IUDs

                        ♥          Drugs:

                                    ♥♥       Anticoagulants/

Clinical Assessment

Important Points of history

1.         The differentiation of anovulatory bleeding from ovulatory bleeding may be made on history.

●          Ovulatory bleeding follows the usual cyclic periodicity, but is heavy in nature.

●          Anovulatory bleeding is irregular in timing and amount.

2.         Bleeding suggestive of a secondary cause:

●          Here bleeding may occur with either regular cycles or, more frequently, with inter-menstrual or post-coital bleeding.

3.         The presence of clots is abnormal and usually suggests heavy bleeding.

4.         Check for any significant symptoms of anemia.

5.         Take a general history for possible secondary causes.

Important Points of Examination:

  1. Assess for any hemodynamic compromise.

2.         Look for signs of anaemia

3.         Look for evidence of an endocrinopathy:

4.         PV examination to look for any local pathology/ trauma.

 
Investigations

These will be guided by the clinical situation and the degree of suspicion for any given pathology

The following may need to be considered:

Blood tests:

1.         FBE:

●          Anaemia

●          Infection

●          Haematological disorders

2.         CRP if infection is suspected.

3          Beta HCG:

            ●          This is essential in all women of child bearing age and should be done in all cases to rule out pregnancy related PV bleeding.

4.         Iron studies, if a hypochromic, microcytic blood film is seen

5.         Coagulation profile if there is a clinical suspicion for a coagulopathy or the patient is on warfarin.

6.         Group and save or cross match blood as clinically indicted.

7.         Tests for endocrinopathy

These are not routinely indicated, but rather should be done where there is reasonable clinical suspicion.

            ●          TFTs

            ●          Pituitary hormones.

            ●          Oestrogen/ progesterone levels

8.         Vagina/ cervical swabs for M&C, if infection is suspected.

Ultrasound:

Especially for fibroids/ adenomyosis/ polyps.

A limited assessment of the endometrium.

EUA and D&C:

This may ultimately be needed, especially to rule out malignancy and especially in cases of post menopausal bleeding.

Management

Attend to any immediate resuscitation issues:

●          Transfusion may be required in cases of severe/symptomatic anemia.

Primary or abnormal uterine bleeding:

There are 4 principle pharmacological treatments for abnormal uterine bleeding:

1.         The progestins

2.         Anti-fibrinolytic agents

3.         Anti-prostaglandin agents

4.         Combined oral contraceptive pill (COCP)

Considerations for these options include:

●          All these agents may be used for ovulatory or non-ovulatory abnormal uterine       bleeding.

●          Ovulatory bleeding will benefit relatively more than non-ovulatory bleeding by   treatment with:

            ♥          An antifibrinolytic agent – Tranexamic acid.

            ♥          An antiprostaglandin agent –  Ibuprofen/ naproxen/ mefenamic acid

●          Non-ovulatory bleeding will benefit relatively more than ovulatory bleeding        by treatment with:

            ♥          Progestins

Options for mild to moderate bleeding:

The progestins: 1

●          Norethisterone:

            ♥          5 mg b.d or tds; on days 1- 21 of a 28 day cycle for up to 6 months (for                         ovulatory cycles)

5 mg orally, once daily for the same 12 days of each calendar month (for anovulatory cycles)

Or

●          Medroxyprogesterone acetate. 1

♥          10 mg 1-3 times a day (depending on degree of bleeding) on days 1- 21             of a 28 day cycle for up to 6 months (for ovulatory cycles)

10 mg orally, once daily for the same 12 days of each calendar month (for anovulatory cycles).

Anti-fibrinolytic agents: 1

●          Tranexamic acid:

                      1 – 1.5 gram 6-8 hourly for the first 3 to 5 days of menstruation.

Anti-prostaglandin agents: 1

●          Mefenamic acid:

            ♥          500 mg orally, 3 times daily.

●          Ibuprofen:

            ♥          200 to 400 mg orally, 3 to 4 times daily. Maximum daily dose 1600 mg.

●          Naproxen:

♥          500 mg orally initially, then 250 mg every 6 to 8 hours. Maximum        daily dose 1250 mg.

LNG-IUS Device:

If long term treatment is required then a Levonorgestrel-releasing intrauterine system (LNG-IUS) device may be used, which is placed into the uterus.

The levonorgestrel-releasing intrauterine system (LNG-IUS) releases levonorgestrel at an initial rate of 20 micrograms daily, and provides effective contraception for 5 years.

An LNG-IUS should only be inserted by a trained practitioner.

Combined oral contraceptive pill (COCP): 1

●          The COCP produces a thinner endometrium, and has a high degree of patient         acceptability and convenience.

It is the most widely used first-line drug in primary care for controlling heavy menstrual bleeding, whether cycles are ovulatory or anovulatory.

There are many preparations available – but one with at least30 micrograms of ethinyloestradiol should be used.

Options for acute emergency heavy menstrual bleeding: 1

High dose regimens may be necessary for the short term control of heavy bleeding.

Tranexamic acid:

In the acute setting, tranexamic acid is considered first-line treatment.

It can be given orally or IV in more serious situations:

●          Tranexamic acid 1 to 1.5 g orally, 6 to 8 hourly until bleeding stops.

Or

●          Tranexamic acid, 10 mg/kg IV, every 8 hours until bleeding stops.

Hormonal treatment:

If tranexamic acid is unavailable or not tolerated, hormonal treatments may be used:

●          Norethisterone 5 to 10 mg orally, every 4 hours until bleeding stops.

Or

●          Medroxyprogesterone 10 mg orally, every 4 hours until bleeding stops.            Maximum daily dose 80 mg

Or

          An ethinyloestradiol 30 to 35 micrograms combined oral contraceptive pill     orally, every 6 hours until bleeding stops. Re-evaluate after 48 hours

Occasionally if the bleeding still doesn’t stop, a high dose oestrogen may be required, (though this nausea can become a significant problem)

Use an ethinyloestradiol 50 micrograms combined oral contraceptive pill orally, every 6 hours until bleeding stops. Re-evaluate after 48 hours.

Surgical options

The ultimate treatment option will be surgical.

Endometrial ablation or hysterectomy may be preferred to drug therapy in women who:

●          No longer wish to be able to conceive

●          Are perimenopausal

●          Have poorly controlled symptoms

●          Have adverse effects from the drugs

●          Have significant uterine pathology.

Hysterectomy is preferred to drug therapy for women with endometrial hyperplasia with atypia where endometrial ablation is not appropriate.

Secondary genital tract bleeding:

Treatment in these situations is, of course, primarily directed to the underlying cause.

Preventive Measures

It is important to emphasize to women that preventive measures that are available that reduce the risk of one of the most important causes of non-pregnancy related PV bleeding, cervical carcinoma.

These measures include:

●          Papanicolaou (PAP) smear screening.

●          Gardasil vaccination:

            ♥          For the Human Papilloma Virus, a major cause of cervical carcinoma. 

Disposition:

Admission to hospital will be necessary for those with:

  • Hemodynamic compromise.
  • Clinically significant or severe anaemia
  • Significant systemic illness requiring investigation and/ or stabilization.

If the patient is not unwell then referral to Gynaecology outpatients should be made. This is urgent for women with postmenopausal bleeding.


References

FOAMed

Publications

Fellowship Notes

Dr Jessica Hiller LITFL Author

Doctor at Sir Charles Gairdner Hospital in Western Australia. Graduated from Curtin University in 2023 with a Bachelor of Medicine, Bachelor of Surgery. I am passionate about Obstetrics and Gynaecology, with a special interest in rural health care.

Dr Lucy J Yarwood LITFL author

MSc, MBChB University of Manchester. Currently doctoring in sunny Western Australia, aspiring obstetrician and gynaecologist

Physician in training. German translator and lover of medical history.

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