Nonpregnant vaginal bleeding: Difference between revisions
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==Source== | ==Source== | ||
Tintinalli | Tintinalli - Vaginal Bleeding | ||
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==See Also== | ==See Also== |
Revision as of 08:15, 12 January 2014
Background
- Normal menstruation:
- 28 +/- 7d cycles; 4d of bleeding
Definitions
- Menorrhagia
- Prolonged (>7d) or excessive (>60mL daily) vaginal bleeding at regular intervals
- Metrorrhagia
- Irregular vaginal bleeding outside the normal cycle
- Menometrorrhagia
- Excessive irregular vaginal bleeding
- Polymenorrhea
- Frequent and light bleeding
- Postcoital bleeding
- Vaginal bleeding after intercourse, suggesting cervical pathology
- Postmenopausal bleeding
- Any bleeding that occurs >6 mo after cessation of menstruation
- Dysfunctional uterine bleeding
- Bleeding not due to an organic cause
Diagnosis
- 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
DDX
Systemic Causes
- Secondary anovulation
- Coagulopathy
- Von Willebrand, ITP
- Hypothyroidism
- Hormone replacement therapy
- Cirrhosis
Reproductive Tract Causes
- Fibroids
- Adenomyosis
- Endometriosis
- Neoplasia
- Infection (vaginitis, PID)
- Vaginal trauma
- Foreign Body
- IUD
- Atrophic endometrium
- Dysfunctional uterine bleeding
- Diagnosis of exclusion
- Ovulatory: Excessive wt change, stress, exercise
- Anovulatory: postmenopause, premenopause, PCOS
Work-Up
- Urine pregnancy
- Hb
- Coags (only if h/o or suspect coaulopathy)
- ?TSH,prolactin (only if suspect endocrine d/o)
- ?Pelvic u/s
Treatment
- Gyn consult only if uncontrolled
- 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)
- Temporize bleeding w/ foley balloon or kerlix soaked in saline and thrombin
- Suture or silver nitrate if bleeding from trauma
Disposition
- D/c home w/ OB/GYN f/u
Source
Tintinalli - Vaginal Bleeding
- ↑ 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.