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.
Vaginal bleeding in infants and children is discussed here. (See Vaginal Bleeding for a discussion of vaginal bleeding in adult women.)
External Female Reproductive Anatomy
Internal Female Reproductive Anatomy
Causes of Vaginal Bleeding in Children
The causes of vaginal bleeding depend on age (see table Some Causes of Vaginal Bleeding in Infants and Children).
Newborn girls may have a small amount of vaginal bleeding. Before birth, estrogen may pass through the placenta from the mother. After birth, these high levels of estrogen decrease rapidly, sometimes causing a small amount of vaginal bleeding during the first 1 to 2 weeks of life.
During childhood, any vaginal bleeding is abnormal. When it occurs, it is most often caused by
A foreign object (such as toilet paper or a toy) in the vagina
Injury or possible sexual abuse
Dermatologic conditions of vulva (such as dermatitis, lichen sclerosus)
Prolapse (protrusion) of the urethra is an uncommon cause of vaginal bleeding in children. The urethra is the tube through which urine exits the body, and in females the opening of the urethra is just above the vaginal opening. Before puberty, there is less support of the female urethra, so its inside lining may protrude through the opening. This protrusion can cause irritation of the tissue and bleeding, sometimes accompanied by pain with urination.
Bleeding may occur due to skin conditions of the vulva. Such bleeding may be due to severe inflammation, chafing of inflamed skin, or as a result of scratching (if itchy). Dermatitis may result if an allergic reaction or skin inflammation is caused by chemicals that come into contact with the vagina or genital area, which can result in discharge, irritation, or itching. Such chemicals may be present in laundry detergents, bleach, fabric softeners, bubble bath, soaps, feminine hygiene sprays, douches, vaginal creams, menstrual pads, synthetic fabric underwear, fabric dyes, toilet tissue, condoms, diaphragms, and spermicides. Also, children may develop lichen sclerosus, an uncommon skin condition that can cause itchy white patches on the vulva.
Children may also have hormonal abnormalities that cause puberty to begin too early—a disorder called precocious puberty. In these children, menstrual periods start, breasts develop, and pubic and underarm hair appears earlier than normal.
Rarely, children develop cancer of the reproductive tract, which may result in vaginal bleeding.
Evaluation of Vaginal Bleeding in Children
Doctors first focus on determining whether the cause of vaginal bleeding is a serious or life-threatening disorder requiring emergency care.
Warning signs
In girls, any vaginal bleeding is a cause for concern. Reasons for increased concern are
Loss of consciousness, weakness, light-headedness, cold and sweaty skin, difficulty breathing, and a weak and rapid pulse (which indicate shock)
Difficulty walking or sitting, bruises or tears around the genitals or anus or mouth, and/or vaginal discharge or redness (which may be signs of sexual abuse)
When to see a doctor
Infants and children with vaginal bleeding should be seen by a doctor immediately.
What the doctor does
The doctor asks about a child's symptoms and medical history. The medical history is obtained from the parent (or caregiver) and the child, if age appropriate. For infants, the doctor asks about whether there were any complications during pregnancy or birth. Family history of cancer is important.
Doctors do a general physical examination.
If a pelvic examination is necessary, the doctor talks to the parent and child about the examination so they know what to expect and to build trust between the child and doctor. The goal of the examination should be to obtain necessary information without causing fear or unnecessary discomfort to the child. An external pelvic examination (of the vulva [labia]) and opening of the vagina may be performed, If an internal pelvic examination is needed, the child is usually given anesthesia so that the examination can be done without causing discomfort.
Testing
The information from the history and physical examination often suggests a cause of the vaginal bleeding and additional tests that may be needed.
A complete blood count is done if bleeding is severe or persistent or if the doctor suspects a pelvic infection.
If there is a vaginal discharge, the doctor collects a sample using methods appropriate for children. The sample is tested for common vaginal infections. If sexual abuse is suspected, testing for sexually transmitted infections is done with blood tests and urine or vaginal samples.
If there are signs of precocious puberty, hormonal tests are done.
If the doctors suspect a pelvic mass or the cause of bleeding has not been identified with physical examination, ultrasound is done. If ultrasound is inconclusive, another imaging test, such as magnetic resonance imaging (MRI), may be needed.
Treatment of Vaginal Bleeding in Children
The main objectives of managing vaginal bleeding are
Control active bleeding
Treat or manage the underlying cause to prevent future episodes
Rule out sexual abuse
Treat iron deficiency (anemia)
Vaginal bleeding in children is treated based on the cause.
Infections are treated with medications.
Removal of a foreign object from the vagina usually requires a procedure with the child sedated or under anesthesia.
Surgery is required for either noncancerous or cancerous tumors.
If sexual abuse is suspected, documentation is done based on the physical examination and local medical and legal requirements for sexual assault victims. Children should be examined and receive support during and after the evaluation by trained health care professionals.
If bleeding has caused iron deficiency anemia, iron supplements are required.
Key Points
Bleeding may appear to be from the vagina, but bleeding can originate elsewhere in the female genital tract or from the urinary or digestive tract.
Vaginal bleeding is abnormal and uncommon in children.
When vaginal bleeding occurs, likely causes are an infection in the vagina, foreign object in the vagina (such as toilet paper), and injury (including from sexual abuse).
Infants and children with vaginal bleeding should be seen by a doctor immediately.
