Difference between revisions of "Vaginal Bleeding (Non-Pregnant)"

(Reproductive Tract Causes)
(DDX)
Line 27: Line 27:
 
**If ruled these out the refer for outpt w/u
 
**If ruled these out the refer for outpt w/u
  
==DDX==
+
==Differential Diagnosis==
===Systemic Causes===
+
{{VB DDX nonpregnant}}
#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==
 
==Work-Up==

Revision as of 18:39, 12 September 2014

Background

  • Normal menstruation:
    • 28 +/- 7d cycles; 4d of bleeding

Definitions

  1. Menorrhagia
    1. Prolonged (>7d) or excessive (>60mL daily) vaginal bleeding at regular intervals
  2. Metrorrhagia
    1. Irregular vaginal bleeding outside the normal cycle
  3. Menometrorrhagia
    1. Excessive irregular vaginal bleeding
  4. Polymenorrhea
    1. Frequent and light bleeding
  5. Postcoital bleeding
    1. Vaginal bleeding after intercourse, suggesting cervical pathology
  6. Postmenopausal bleeding
    1. Any bleeding that occurs >6 mo after cessation of menstruation
  7. Dysfunctional uterine bleeding
    1. 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

Differential Diagnosis

Nonpregnant Vaginal Bleeding

Systemic Causes

  • Cirrhosis
  • Coagulopathy (Von Willebrand, ITP)
  • Group A strep vaginitis (prepubertal girls)
  • Hormone replacement therapy
  • Hypothyroidism
  • Secondary anovulation

Reproductive Tract Causes

Work-Up

  1. Urine pregnancy
  2. Hb
  3. Coags (only if h/o or suspect coaulopathy)
  4. ?TSH,prolactin (only if suspect endocrine d/o)
  5. ?Pelvic u/s

Treatment

  1. Gyn consult only if uncontrolled
  2. Medroxyprogesterone
    1. 150mg IM x 1 then 20mg PO Q8hrs x 3 days
    2. In a trial of 48 patients all had cessation in 5 days.[1]
  3. Estrogen IV/PO (similar efficacy)
  4. Temporize bleeding w/ foley balloon or kerlix soaked in saline and thrombin
  5. Suture or silver nitrate if bleeding from trauma

Disposition

  • D/c home w/ OB/GYN f/u

Source

Tintinalli - Vaginal Bleeding

  1. 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.

See Also

Vaginal Bleeding (Main)