Nonpregnant vaginal bleeding: Difference between revisions
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{{Vaginal bleeding definitions}} | {{Vaginal bleeding definitions}} | ||
== | ==Clinical Features== | ||
* | *Vaginal bleeding in a non-pregnant woman | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{VB DDX nonpregnant}} | {{VB DDX nonpregnant}} | ||
==Work-Up== | ==Diagnosis== | ||
===Work-Up=== | |||
*Urine pregnancy | *Urine pregnancy | ||
*Hb | *Hb | ||
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*Consider follow up for non-emergent [[pelvic ultrasound]] | *Consider follow up for non-emergent [[pelvic ultrasound]] | ||
**No indication for emergent ultrasound in ED | **No indication for emergent ultrasound in ED | ||
===Evaluation=== | |||
*Hemodynamically stable pt in ED must rule-out: | |||
**Pregnancy | |||
**Trauma | |||
**Bleeding dyscrasia | |||
**Infection | |||
**Retained foreign body | |||
**If ruled these out the refer for outpt w/u | |||
==Treatment== | ==Treatment== | ||
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*For severe anemia or persistent exceedingly heavy flow, consider admission and/or discussion with OB/GYN | *For severe anemia or persistent exceedingly heavy flow, consider admission and/or discussion with OB/GYN | ||
== | ==References== | ||
<references/> | <references/> | ||
==See Also== | ==See Also== | ||
[[Vaginal Bleeding (Main)]] | *[[Vaginal Bleeding (Main)]] | ||
[[Category:OB/GYN]] | [[Category:OB/GYN]] | ||
Revision as of 06:12, 30 July 2015
Background
- This page is for the generalized approach to undifferentiated vaginal bleeding in non-pregnant women
- Normal menstruation:
- 28 +/- 7 day cycles
- 4 days of bleeding
Vaginal bleeding definitions
- Menorrhagia: >7 day (prolonged) or >80 mL/day (excessive) uterine bleeding at regular intervals
- Metrorrhagia: irregular vaginal bleeding outside the normal cycle
- Menometrorrhagia: excessive irregular vaginal bleeding
- Intermenstrual bleeding: variable amounts between regular menstrual periods
- Midcycle spotting: spotting just before ovulation (due to decline in estrogen)
- Polymenorrhea: frequent and light bleeding
- Postcoital bleeding: vaginal bleeding after intercourse, suggesting cervical pathology
- Postmenopausal bleeding: recurrence of bleeding >6 mo after menopause
- Amenorrhea: bleeding that is absent for > 6 months
Clinical Features
- Vaginal bleeding in a non-pregnant woman
Differential Diagnosis
Nonpregnant Vaginal Bleeding
Systemic Causes
- Cirrhosis
- Coagulopathy (Von Willebrand disease, ITP)
- Group A strep vaginitis (prepubertal girls)
- Hormone replacement therapy
- Anticoagulants
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Hypothyroidism
- Polycystic Ovary Syndrome
- Secondary anovulation
Reproductive Tract Causes
- Adenomyosis
- Atrophic endometrium
- Dysfunctional uterine bleeding
- Endometriosis
- Fibroids
- Foreign Body
- Infection (vaginitis, PID)
- IUD
- Neoplasia (especially in women >45 years old or in younger women with other risk factors)
- Vaginal Trauma
Diagnosis
Work-Up
- Urine pregnancy
- Hb
- Coags (only if h/o or suspect coaulopathy)
- ?TSH,prolactin (only if suspect endocrine d/o)
- Consider follow up for non-emergent pelvic ultrasound
- No indication for emergent ultrasound in ED
Evaluation
- Hemodynamically stable pt in ED must rule-out:
- Pregnancy
- Trauma
- Bleeding dyscrasia
- Infection
- Retained foreign body
- If ruled these out the refer for outpt w/u
Treatment
- Iron supplements
- Ibuprofen
- For cramps and theoretically decreases intra-uterine bleeding
- Hormones
- Give only if endocervical curettage/endometrial biopsy does not need to be performed (young patient) or has already been performed, as they may alter test results
- Medroxyprogesterone
- 150mg IM x 1 then 20mg PO Q8hrs x 3 days
- In a trial of 48 patients all had cessation in 5 days.[1]
- Estrogen IV/PO (similar efficacy)
Life Threatening
- Give blood transfusion
- O-negative blood if emergent
- Establish good access
- Temporize bleeding w/ foley balloon or kerlix soaked in saline and thrombin
- Suture or silver nitrate if bleeding from trauma
Disposition
- Most can be discharged home with OB/GYN follow-up
- For severe anemia or persistent exceedingly heavy flow, consider admission and/or discussion with OB/GYN
References
- ↑ Ammerman SR, Nelson AL. A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study. Am J Obstet Gynecol. 2013. 208(6):499.e1-e5.