Vaginal Bleeding Not Related to Pregnancy: Clinical Evaluation and Management

Introduction

Abnormal vaginal bleeding is a common emergency department complaint and affects approximately 20-30% of women during their reproductive years. The presentation of abnormal vaginal bleeding may be due to abnormal uterine bleeding (AUB), bleeding from the cervix, or bleeding from the infracervical vaginal structures. A normal menstrual cycle lasts 4.5 to 8 days and occurs with an interval of 24 to 38 days.

Abnormal uterine bleeding ( AUB) is defined as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and that occurs in the absence of pregnancy. SUA can be classified as acute or chronic .

• Acute AUB is defined as vaginal bleeding sufficient to require immediate intervention to prevent further blood loss.
   
• SUA is considered chronic if it has been present for most of the previous six months.

initial evaluation

The initial evaluation of a patient with vaginal bleeding should begin with the ABC.

Be sure to promptly evaluate for hypovolemia and hemodynamic instability.

If the patient appears unstable, insert two large-bore intravenous lines and prepare her for blood transfusion and clotting factor replacement as necessary.

All patients of reproductive age (usually between 12 and 52 years) with vaginal bleeding should have a pregnancy test as soon as possible. This result will affect the diagnostic algorithms and treatment pathway. The remainder of this review will focus on the evaluation and treatment of non-pregnancy-related vaginal bleeding .

History and physical examination

Obtain a medical history focused on the patient’s current bleeding episode. The questions should aim to answer the following:

Bleeding pattern

• Bleeding frequency
• Any intermenstrual bleeding
• Regular or irregular over time

Amount of bleeding , which can be estimated by the number of tampons or pads used (a normal tampon or pad can contain 20 to 30 ml of blood and should not be changed more frequently than every 2 hours).

• Presence of large clots.
• Presence of pain.

Recent gynecological interventions or trauma

A gynecologic history should be obtained, including previous menstrual history, sexual activity and contraceptive use, history of abnormal Pap tests, gynecologic interventions or surgeries, and, if applicable, postmenopausal history. An obstetric history is also necessary and should include the number of pregnancies with outcomes, complications, and type of delivery.

Review of the patient’s medical history should include an evaluation of underlying coagulopathy , especially in adolescents and young adults. Ask patients about continued heavy periods since menarche, postpartum hemorrhage, any bleeding unexplained or unexpected with surgery or dental work, excessive bruising, recurrent epistaxis, bleeding gums, and whether there is a family history of bleeding disorders.

Underlying diseases of the thyroid, liver, and endocrine system, including polycystic ovary syndrome, can cause heavy bleeding.

Be sure to review the patient’s medication list. Contraceptives, blood thinners, selective serotonin reuptake inhibitors (SSRIs), tamoxifen, and even herbal supplements such as ginseng, gingko, and soy supplements can cause increased vaginal bleeding.

The physical examination should evaluate for signs of hypovolemia or anemia. Look for any signs of trauma. Examine the skin for ecchymoses or petechiae suggesting an underlying coagulopathy.

An accompanied pelvic examination is an important part of the examination in patients with vaginal bleeding. Start by evaluating the external genital region for non-vaginal causes of bleeding, such as bleeding from the rectum, urethra, or labia.

Perform a speculum examination to identify signs of trauma to the vaginal vault, evaluate for vaginal or cervical injuries, look for retained foreign bodies, and quantify the amount of bleeding. A bimanual examination can clarify enlargement or irregularity of the uterus or ovaries.

Causes

Vaginal bleeding not related to pregnancy can be divided into uterine and extrauterine sources.

Abnormal uterine bleeding can be further classified by structural and nonstructural causes, which is important in determining the most effective long-term treatment.

Common causes of abnormal uterine bleeding may also depend on age :

• Adolescence : anovulatory cycles and bleeding disorders.
   
• Reproductive years : complications related to pregnancy.
   
• 30 years : structural causes such as fibroids and polyps.
   
• Perimenopausal : anovulatory cycles.
   
• Postmenopausal : malignancy, atrophic vaginitis, use of exogenous hormones.

Structural causes:

Polyps:

• Endometrial or endocervical.
• Most of the time benign.
• It often causes intermenstrual bleeding (bleeding between normally scheduled periods).
• Diagnosed by ultrasound (US) or hysteroscopy.

Adenomyosis:

• Endometrial glands and stroma invade the myometrium.
• Patients often have heavy, painful menstrual periods that begin in their 30s and 40s.
• Bimanual examination may reveal a large, doughy uterus .

Leiomyoma (Fibroids):

• Most common benign pelvic tumors.
• Most are asymptomatic, but can cause pelvic pain and abnormal bleeding.
• Large fibroids can be palpated on bimanual examination.

Malignancy:

Consider endometrial hyperplasia in any woman > 45 years or < 45 years with a history of obesity, PCOS, or unopposed estrogen.

All patients with postmenopausal bleeding require referral for ultrasound and biopsy.

Non-structural causes:

Coagulopathy:

• It causes up to 20% of abnormal uterine bleeding in adolescents.
• Von Willebrand disease is the most common cause.
• Also consider myeloproliferative disorders, ITP, anticoagulant use, and liver disease.

Ovulatory dysfunction:

• It is more frequently observed in adolescents, perimenopausal patients.
   
• It can also occur in patients with polycystic ovary syndrome, liver disease, kidney disease, exogenous hormone use, and thyroid disease.
   
• Eating disorders, weight loss, increased stress, and exercise can also suppress the hypothalamic-pituitary-adrenal axis and cause anovulatory cycles.
   
• It typically presents with irregular and heavy bleeding; Patients often have prolonged amenorrhea with periodic heavy bleeding.

Endometrial causes:

• Patients have normal ovulatory cycles and a structurally normal uterine cavity.
• May have associated breast tenderness, abdominal distension, pelvic pain.
   
• The diagnosis is made in patients with heavy menstrual bleeding and no other identified anomalies.

Iatrogenic:

• Oral contraceptive pills (OCPs) are the most common cause of breakthrough bleeding.
   
• 40% of patients taking OCPs will have abnormal bleeding in the first 6 months.
   
• Bleeding after 6 months of OCP treatment or recurrence after amenorrhea is established should prompt further evaluation by the gynecologist.

Extrauterine causes of vaginal bleeding include:

Infectious : PID, endometritis, cervicitis, vaginitis

It can be identified on pelvic examination and treating the infection will treat the bleeding.

Cervical erosions or polyps, vaginal or perineal trauma, retained foreign body.

It can be identified on pelvic examination. Cervical erosions or polyps should be closely followed up with a gynecologist.

Vaginal or perineal trauma may require repair with sutures. Be sure to question patients privately about sexual abuse or assault.

Retained foreign bodies are usually tampons. These can be gently removed with tweezers.

If you are recently pregnant, consider retained products of conception or uterine atony.

Assessment

Obtain a urine pregnancy test early in all patients presenting with vaginal bleeding. If a urine sample is not readily available, obtain a qualitative serum pregnancy test.

If the patient appears unstable , type and crossmatch is necessary to prepare for transfusion.

In stable patients , a hemoglobin level may be useful to identify anemia. However, hemoglobin levels take time to fall after blood loss and may be falsely reassuring in a patient with acute, severe bleeding.

Consider a TSH if it was not obtained recently.

Coagulation studies may be useful if the history and physical examination are concerning for coagulopathy.

Transvaginal ultrasound is the imaging modality of choice in vaginal bleeding. This can be performed on an urgent or outpatient basis depending on the patient’s clinical status, pain, examination findings, and gynecological follow-up.

Do not delay resuscitation or treatment of massive uterine bleeding for imaging studies.

Treatments

massive uterine bleeding

If the patient is hemodynamically unstable , begin resuscitation with fluids and blood products to achieve a target mean arterial pressure (MAP) of 60-65 mmHg.

Reverse any drug-induced coagulopathy and immediately consult a gynecologist.

While continuing resuscitation is performed, initial treatment in the ED should focus on medical management. Hormonal agents are the first line treatment:

Conjugated estrogen 25 mg IV q4-6hrs.

Contraindicated in patients with a history of blood clots or cardiovascular disease.

Consider tranexamic acid (TXA) 1300 g PO every 6-8 hours or 10 mg/kg (max 600 mg) IV.

Increased risk of thromboembolic sequelae with IV administration; Discuss with gynecology the risks and benefits if considering IV.

Consider desmopressin acetate in patients with concern for von Willebrand disease.

Be prepared to use intrauterine tamponade if bleeding is not controlled with medical treatment. Definitive treatment will likely be provided by gynecology or interventional radiology.

Timing methods include:

Due to intrauterine causes:

Intrauterine tamponade with a 26F Foley catheter inflated with 30ml of saline solution.

Vaginal packing can plug sources of cervical or infracervical bleeding. In particular, while vaginal tamponade with betadine-soaked gauze can be used as a temporary measure in suspected uterine bleeding, tamponade may mask the true extent of bleeding and does not provide the same level of tamponade as the intrauterine balloon.

Definitive management may require surgical intervention.

It is important to involve the gynecologist early in the case of massive uterine bleeding. If gynecology services are not available, consider transferring the patient to a facility with an on-call gynecologist while you continue to stabilize the patient.

Options include hysteroscopy, endometrial ablation, myomectomy, dilation and curettage, and emergent hysterectomy.

In some cases, interventional radiology can perform uterine artery embolization.

Heavy uterine bleeding (stable)

Oral contraceptive pills (OCPs), NSAIDs, and tranexamic acid are the most common medications used in the treatment of stable vaginal bleeding.

Oral contraceptives (OCP):

Any combination of OCPs (0.25 milligrams of norgestimate and 0.035 milligrams of ethinyl estradiol) may be prescribed three times a day for seven days. On average, bleeding stops in three days. Regular OCP use results in a 50% decrease in future heavy menstrual bleeding. Bleeding may return when the medication is stopped.

NSAIDs: 400 mg ibuprofen every six hours from the first day of the period until bleeding stops. Decreases both pain and blood loss by altering the arachidonic acid cascade to increase vasoconstriction and platelet aggregation

Progestin- only therapy :

Use instead of combined OCPs if there is concern for endometrial pathology or hyperplasia

Medroxyprogesterone acetate 20 mg three times a day for seven days or 10 mg once a day for ten days

Oral tranexamic acid (TXA):

1300 mg PO three times daily for five days

Antifibrinolytic effects decrease the volume of menstrual blood loss by 26-60% 16

Follow-up

If the patient appears unstable, consult the gynecologist immediately while stabilization is being carried out. These patients will likely require admission for transfusions or definitive surgical treatment.

If the patient appears stable , she can be safely discharged home with close gynecological follow-up. All patients with abnormal uterine bleeding > 45 years or < 45 years with obesity or PCOS require gynecologic referral for outpatient endometrial biopsy to evaluate endometrial hyperplasia or malignancy.