Vaginal Bleeding

1. 1. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology: Practice Bulletin No. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 (reaffirmed 2024);120(1):197-206. doi:10.1097/AOG.0b013e318262e320

2. 2. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology: Practice Bulletin No. 136: Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol2013 (reaffirmed 2022); 122 (1):176-185. doi: 10.1097/01.AOG.0000431815.52679.bb

History of present illness should begin with asking the patient about the onset of the bleeding, including the timing and relationship to any causative factors. How the patient noticed the bleeding and how certain she is that the source is the vagina should be discussed. Bleeding on toilet tissue or in the toilet, and sometimes blood on underwear or a pad, may be from the genital, urinary, or gastrointestinal tract.

Questions should be asked to elicit the characteristics of the bleeding:

• Onset: Start of the bleeding and whether there were any possible causative factors

• Pattern: Intermittent or constant; relationship to menstrual cycle or sexual activity

• Duration

• Volume: Spotting, light bleeding, normal menstrual flow, or heavier; soaking a pad or tampon every 1 to 2 hours, passing blood clots, and/or feeling faint suggest heavy bleeding

• Relationship to other symptoms: Presence of pelvic or abdominal pain or pressure, fever, or urinary or bowel symptoms

Clinicians should also ask about the following:

• Menstrual history, including date of last normal menstrual period, age at menopause (when appropriate), cycle length and regularity, quantity and duration of typical menstrual bleeding

• Previous episodes of abnormal bleeding and whether the cause was identified

• Sexual history, including possible history of sexual assault

Ranges for normal menses are as follows: frequency (every 24 to 38 days), regularity (length of the longest and shortest cycles vary by < 7 to 9 days), duration (4.5 to 8 days), and volume of blood loss (5 to 80 mL) (see table Normal Menstrual Parameters).

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

• Missed menses, breast swelling, and nausea: Pregnancy-related bleeding

• Vaginal dryness and pain with vaginal intercourse: Genitourinary syndrome of menopause

• Post-coital bleeding: Cervical cancer

• Fever, pelvic pain, vaginal discharge: Pelvic inflammatory disease

• Irregular periods with very heavy bleeding after several months of no period: Ovulatory dysfunction

• Heavy, regular periods and pelvic pressure: Uterine fibroids

• Sudden onset of unilateral pelvic pain, particularly in the middle of the menstrual cycle and/or during sexual intercourse: Ruptured ovarian cyst

• Chronic pelvic or abdominal pain, bloating, change in bowel habits, or weight loss: Gynecologic cancer

• Easy bruising and excessive bleeding during toothbrushing, minor lacerations, or venipuncture: A bleeding disorder

Past medical history should identify disorders known to cause vaginal bleeding, including a recent pregnancy, chronic irregular menses, or known structural disorders (eg, uterine fibroids, adenomyosis). Clinicians should identify risk factors for gynecologic cancers, including endometrial cancer (obesity, diabetes, unopposed estrogen [either endogenous, due to chronic ovulatory dysfunction, or exogenous, due to prolonged estrogen use without a progestin]), or family history of colorectal cancer or endometrial cancer before age 50 (suggesting Lynch syndrome), and cervical cancer (abnormal or inadequate cervical cancer screening, immunosuppression).

Medications should include specific questions about use of hormonal contraceptives, menopausal hormone therapy, other hormones, and other medications that can cause AUB (eg, anticoagulants, progestin-only contraceptives).

Family history of bleeding disorders or gynecologic cancers should be discussed.

Social history should include questions about domestic violence or recent history of sexual assault.

Vital signs are reviewed for fever and signs of hypovolemia (eg, tachycardia, hypotension). During the general examination, clinicians should look for signs of anemia (eg, conjunctival pallor).

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

A pelvic examination is done. External inspection and speculum examination help identify lesions of the vulva, vagina, cervix, and urethra or evidence of physical trauma. Bimanual examination is done to evaluate uterine size, mobility, consistency, tenderness, and contour (eg, fibroids cause an uneven shape) and ovarian size, mobility, and tenderness. If gastrointestinal bleeding is suspected, rectal examination is done.

Patterns of physical examination findings that suggest a systemic or gynecologic disorder that can cause abnormal uterine bleeding include:

• Hirsutism, acne, obesity, and enlarged ovaries: Polycystic ovary syndrome

• Warm and moist or dry skin, eye abnormalities, tremor, abnormal reflexes, or goiter: A thyroid disorder

• Nipple discharge: Hyperprolactinemia

• Hepatomegaly, jaundice, asterixis (flapping tremor of the wrist), or splenomegaly: A liver disorder

• Abdominal mass or ascites: Cancer, including gynecologic cancers (abdominal mass alone may be uterine fibroids)

• Multiple bruises, petechiae, purpura, or mucosal (eg, gingival) bleeding: A bleeding disorder

The following findings are of particular concern:

• History of irregular menses, unprotected sex, nausea, or breast tenderness: Bleeding may be pregnancy-related

• Heavy, persistent bleeding: May result in anemia, hemodynamic instability, or shock

• Post-coital bleeding: Possible cervical cancer

• Postmenopausal vaginal bleeding: Possible uterine cancer

Significant hypovolemia or hemorrhagic shock is unlikely except for heavy bleeding after a prolonged duration of amenorrhea or due to uterine fibroids, or, rarely, due to a ruptured ovarian cyst.

In reproductive-aged women, examination may detect a genital tract lesion or pelvic mass or other findings (eg, pelvic tenderness, cervical friability) that identifies the source of bleeding and suggests a cause. Vulvar, vaginal, or cervical lesions or vaginal or cervical discharge may be from an infection or a benign or malignant neoplasm. Cervical bleeding without a grossly visible lesion may be cervical intraepithelial neoplasia or cancer. A firm, nodular, enlarged, mobile uterus is likely to be uterine fibroids. A globular, soft, enlarged uterus is likely to be adenomyosis. However, a fixed pelvic mass suggests cancer or an inflammatory disorder (eg, pelvic inflammatory disease).

For patients with a normal pelvic examination and irregular menses consistent with ovulatory dysfunction, further evaluation should be done to identify an endocrine disorder. In patients with irregular vaginal bleeding who started progestin-only contraceptives within the past 6 months or who have been taking estrogen-progestin contraceptives for ≥ 2 years, the cause may be due to iatrogenic ovulatory dysfunction or endometrial atrophy.

In postmenopausal women with vaginal bleeding, further evaluation should be done for gynecologic cancer.

All patients of reproductive age with vaginal bleeding require a urine or blood pregnancy testVaginal Bleeding During Early Pregnancy and Vaginal Bleeding During Late Pregnancy).

Blood tests are done to evaluate suspected complications or etiologies, which may include (1)

• Anemia: For heavy, prolonged, persistent, or recurring bleeding, a complete blood count (CBC); if anemia is identified and is not obviously due to iron deficiency (eg, based on microcytic, hypochromic red blood cell [RBC] indices), iron studies (serum iron, total iron binding capacity [TIBC], and ferritin); for acute, heavy bleeding, a blood type and cross-match in case blood transfusion is needed

• Endocrine disorders: Depending on history and symptoms, tests for thyroid disease (thyroid-stimulating hormone), polycystic ovary syndrome (total testosterone

• Hepatic disease: Liver tests

A positive screen of a medical history for risk factors for a bleeding disorder includes any of the following (2):

• Heavy menses since menarche

• One of the following: Postpartum hemorrhage, surgery-related bleeding, or bleeding with dental work

• Two or more of the following: bruises > 5 cm in diameter at least 1 to 2 times a month, epistaxis 1 to 2 times a month, frequent gum bleeding, or family history of bleeding symptoms

Imaging includes transvaginal ultrasound if women have any of the following:

• A suspected structural lesion (based on history or examination)

• Risk factors for endometrial cancer

Endometrial sampling is indicated for patients with abnormal uterine bleeding combined with

• Age > 45 years

• Age < 45 with unopposed estrogen exposure (as occurs in women with a high body mass index, polycystic ovary syndrome) or failed medical management

• In postmenopausal bleeding, endometrial thickening > 4 mm on ultrasound or any bleeding in patients at high risk of endometrial cancer

• Risk factors for uterine cancer

Sampling can be done by endometrial biopsy or dilation and curettage (D & C).

Secondary evaluation with saline-infusion sonohysterography helps to characterize small intrauterine lesions (eg, endometrial polyps, submucous myomas). Hysteroscopy is the gold standard for diagnosis of intrauterine structural causes of abnormal uterine bleeding.

Vulvar or vaginal biopsy is done if a lesion found on examination is potentially malignant or the diagnosis is uncertain.

Cervical biopsy is done if the cervix is the source of the bleeding, and there is a cervical lesion or abnormal Papanicolaou (Pap) test result that indicates biopsy. A Pap test is done for cervical bleeding if there are no abnormal findings on examination, and the patient has not had a recent Pap test.

1. 1. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology: Practice Bulletin No. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 (reaffirmed 2024);120(1):197-206. doi:10.1097/AOG.0b013e318262e320

2. 2. Kouides PA, Conard J, Peyvandi F, Lukes A, Kadir R: Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding. Fertil Steril. 2005;84(5):1345-1351. doi:10.1016/j.fertnstert.2005.05.035