Vaginal bleeding occurs normally during menstrual periods (menses). Bleeding during menses is actually from the uterus (when the lining of the uterus is shed, if no fertilized egg becomes implanted).
Abnormal vaginal bleeding may be blood from the vagina itself, or the blood may be coming from other parts of the female reproductive tract (vulva, cervix, uterus, fallopian tubes, or ovaries). Sometimes bleeding appears to be coming from the vagina (blood appears on underwear, toilet paper, or in the toilet water), but the bleeding is from other nearby organ systems, such as the urinary or digestive tract. Abnormal vaginal bleeding during the reproductive years (between the first menstrual period and menopause) in women who are not pregnant and in postmenopausal women is discussed here. (Also see vaginal bleeding in early pregnancy or late pregnancy and in children.)
Abnormal vaginal bleeding includes any vaginal bleeding that occurs
Before puberty
Between menstrual periods (intermenstrual bleeding)
During pregnancy
After menopause (12 months or more after the last menstrual period)
Menstrual periods are considered abnormal if they
Occur too frequently (fewer than 24 days apart) or too infrequently (longer than 34 days apart)
Last longer than 8 days
Involve excessive blood loss (loss of more than about 3 ounces of blood)
Do not occur regularly
Prolonged or excessive vaginal bleeding, regardless of cause, can result in iron deficiency anemia and sometimes dangerously low blood pressure (shock).
Internal Female Reproductive Anatomy
External Female Reproductive Anatomy
Causes of Vaginal Bleeding
Vaginal bleeding can result from
Imbalance of the complex hormonal system that regulates the menstrual cycle
An infection, growth, or other disorder of the reproductive tract, such as polyps, uterine fibroids, infection of the cervix, pelvic inflammatory disease, or cancer of the cervix, uterus, or ovaries
Blood disorders or use of blood thinning medications that cause excessive bleeding (uncommon)
In addition, bleeding that appears to be vaginal may originate from the urinary or gastrointestinal tract.
Common causes
During the childbearing years, the most common cause of vaginal bleeding is
Ovulatory dysfunction (ovulation is delayed or does not happen), which can cause abnormal uterine bleeding (menstrual periods that are irregular or too heavy or bleeding in between periods)
Uterine bleeding due to ovulatory dysfunction occurs when the hormonal control of menstruation changes and the lining of the uterus sheds irregularly. It is more likely to occur in adolescents (when menstrual periods are just starting) or in women in their late 40s (when periods are nearing an end), but it can occur at any age before menopause. A common cause of a hormonal imbalance is polycystic ovary syndrome.
Other common causes of vaginal bleeding during the childbearing years include
Complications of pregnancy
Fibroids (masses of the muscle layer of the uterus
Polyps of the cervix or uterus
Bleeding when the egg is released (at ovulation) during the menstrual cycle
Use of birth control pills (oral contraceptives), if there is spotting or bleeding between periods (called breakthrough bleeding)
After menopause, the most common cause is
Thinning of the lining of the vagina or uterus due to menopause
Less common causes
Cancers or precancers of the reproductive tract can cause vaginal bleeding. Bleeding may be a sign of cervical cancer, which typically causes bleeding after vaginal intercourse and is more likely than other gynecologic cancers to occur before age 50. Bleeding may also be a sign of a precancerous condition such as the thickening of the uterine lining (endometrial hyperplasia) or cancer of the lining of the uterus (endometrial cancer), which often affects more women after menopause. Cancers of other reproductive organs, including vulvar cancer, vaginal cancer, or ovarian cancer, may also cause bleeding.
Certain hormonal disorders (such as hypothyroidism) may cause menstrual cycle abnormalities.
Excessively heavy menstrual periods may be the first sign of a bleeding disorder.
Less commonly, physical trauma (for example, sexual assault or insertion of objects into the vagina for sexual or other reasons) can cause vaginal bleeding.
Evaluation of Vaginal Bleeding
Doctors first focus on determining whether the cause of vaginal bleeding is a serious or life-threatening disorder (such as a ruptured ectopic pregnancy) and whether the bleeding is excessive, possibly resulting in shock.
Doctors check for pregnancy in all women of childbearing age.
Warning signs
In women with vaginal bleeding, certain characteristics are cause for concern:
Excessive bleeding
Loss of consciousness, weakness, light-headedness, cold and sweaty skin, difficulty breathing, and/or a weak and rapid pulse (which could be signs of shock)
Bleeding that occurs after menstrual periods stop (after menopause)
Vaginal bleeding is considered excessive if women experience any of the following:
Soaking more than 1 pad or tampon per hour for > 2 hours
Passing large blood clots or what appears to be tissue
When to see a doctor
Women with most warning signs should see a doctor immediately, as should those with large clots or clumps of tissue in the blood or with symptoms suggesting a bleeding disorder. Symptoms of a bleeding disorder include easy bruising, excessive bleeding during toothbrushing or after minor cuts, and rashes of tiny reddish purple dots or larger splotches (indicating bleeding in the skin). However, if the only warning sign is vaginal bleeding after menopause, a delay of a week or so is not harmful.
Women without warning signs should schedule a visit when practical, but a delay of several days is not likely to be harmful.
What the doctor does
Doctors first ask the woman questions about her symptoms and medical history. Doctors then do a physical examination. The information from the history and physical examination often suggests a cause and additional tests that may be needed (see table Some Causes of Vaginal Bleeding in Nonpregnant Women).
Doctors ask about the bleeding:
Onset: Start of the bleeding and any possible known cause for the bleeding
Pattern: Intermittent or constant; when it occurs in relation to menstrual periods and sexual activity
Duration: How long bleeding lasts
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
They also ask about the woman's menstrual history:
How old she was when menstrual periods started
How long they last
How heavy they are
How long the interval between periods is
Whether they are regular
The doctor asks about any previous episodes of abnormal bleeding, disorders that can cause bleeding (such as a recent miscarriage), and medication use, including birth control pills, other hormones, or other medications that can cause excessive bleeding, such as anticoagulants and nonsteroidal anti-inflammatory drugs (NSAIDs). The doctor also asks about sexual history, including possible history of sexual assault or domestic violence, and any other symptoms, such as light-headedness, abdominal pain, and excessive bleeding after toothbrushing or a minor cut.
The physical examination includes a pelvic examination. During the examination, doctors can identify disorders of the cervix, uterus, vagina, vulva, or urethra in women of all ages.
If no blood is present in the vagina, a rectal examination may be done to determine whether bleeding is coming from the digestive tract.
Testing
If women are of childbearing age, doctors always do
A urine or blood test for pregnancy
If the urine pregnancy test is negative but doctors still suspect pregnancy, a blood test for pregnancy is done. It involves measuring a hormone produced by the placenta called human chorionic gonadotropin (hCG). The blood test is more accurate than the urine test when a pregnancy is very early (less than 5 weeks).
Tests commonly done include
Blood tests to measure thyroid hormone levels
If bleeding has been heavy or lasted a long time, a complete blood cell count to check for iron deficiency (anemia).
Other blood tests are done depending on the disorder doctors suspect. For example, if a bleeding disorder is suspected, the blood's ability to clot is assessed. If polycystic ovary syndrome is suspected, blood tests to measure androgen hormone levels are done.
Ultrasound is often used to look for abnormalities in the reproductive organs if women have risk factors for endometrial cancer or if doctors suspect problems such as fibroids, polyps, or a tumor. For ultrasound, a handheld ultrasound device is usually inserted into the vagina, but it may be placed on the abdomen.
If ultrasound detects thickening of the uterine lining (endometrial hyperplasia), hysteroscopy or sonohysterography may be done to look for small growths in the uterus. For hysteroscopy, a viewing tube is inserted into the uterus through the vagina. For sonohysterography, fluid is injected into the uterus during ultrasound to make abnormalities easier to identity.
If results of these tests are abnormal or if they are inconclusive, doctors may take a sample of tissue from the lining of the uterus for analysis in the following circumstances:
Women are over age 45.
Women have risk factors for cancer of the reproductive tract, including cancers of the lining of the uterus (endometrial cancer) and ovaries.
Women are under age 45 with too much estrogen being produced, as occurs in women with polycystic ovary syndrome or a high body mass index.
In postmenopausal women, the lining of the uterus (endometrium) is thickened (seen on an ultrasound) or there is a high risk of uterine cancer.
The sample may be obtained by suction (through a tube) or by scraping—a procedure called dilation and curettage (D and C). In postmenopausal women, the sample is usually obtained by hysteroscopy, which enables doctors to see inside the uterus and locate the abnormality.
Other tests may be done, depending on which disorders seem possible. For example, a biopsy of the cervix may be done to check for cervical cancer.
If abnormal bleeding does not result from any of the usual causes, it may be related to changes in the hormonal control of the menstrual cycle.
Treatment of Vaginal Bleeding
The main objectives of managing vaginal bleeding are
Control active bleeding
Treat or manage the underlying cause to prevent future episodes
Treat iron deficiency (anemia)
If women have extremely heavy bleeding and very low blood pressure, they are immediately given fluids intravenously and blood transfusions as needed to restore blood pressure. Laparoscopy or laparotomy is often required if there is an emergency. For laparoscopy, doctors make a small incision just below the navel and insert a viewing tube (laparoscope). Laparotomy requires a large incision into the abdomen. Both procedures enable doctors to directly view organs and look for abnormalities.
When vaginal bleeding results from another disorder, that disorder is treated if possible. If bleeding has caused iron deficiency anemia, women are given iron supplements.
Birth control pills or other hormones may be used to treat abnormal uterine bleeding related to changes in the hormonal control of the menstrual cycle.
Polyps, fibroids, cancers, and some benign tumors may be surgically removed from the uterus.
Essentials for Older Women: Vaginal Bleeding
Postmenopausal vaginal bleeding (occurring more than 12 months after the last menstrual period) is relatively common but is always considered abnormal. Such bleeding can indicate a precancerous disorder (such as thickening of the lining of the uterus) or cancer. Thus, if such bleeding occurs, older women should see a doctor promptly so that cancer can be ruled out or be treated immediately.
Older women should see a doctor promptly if they have
Any vaginal bleeding
A vaginal discharge that is pink or brown, possibly containing small amounts of blood
However, postmenopausal bleeding has many other causes.
The most common cause is
Thinning of the lining of the uterus or vagina (genitourinary syndrome of menopause)
Other causes include
Use of estrogen or other hormone therapy, particularly when use is stopped
Polyps in the cervix or uterus
Precancerous or cancerous lesions of lining of the uterus
Cancer of the vulva, vagina, cervix, uterus, or ovary
Infections of the vulva or vagina
Accidental injury or chafing from foreign objects in the vagina (eg, pessary)
Urethral caruncle
Skin disorders of the vulva (for example, lichen planus, lichen sclerosus, dermatitis)
Because the tissues of the vagina may be thin and dry, examination of the vagina may be uncomfortable. Doctors may try using a smaller instrument (speculum) to make the examination less uncomfortable. If postmenopausal women have vaginal bleeding, doctors take a sample of the lining of the uterus for microscopic examination (biopsy) to look for cancer cells.
Key Points
In women who are not pregnant, the most common cause of vaginal bleeding is hormonal imbalance (ovulatory dysfunction).
Abnormal uterine bleeding is related to changes in the hormonal control of the menstrual cycle that prevent the ovaries from releasing an egg.
In women of childbearing age, a pregnancy test is done even when women do not think they could be pregnant.
If any vaginal bleeding occurs after menopause, an evaluation to rule out cancer is necessary.
