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

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**28 +/- 7 day cycles
 
**28 +/- 7 day cycles
 
**4 days of bleeding  
 
**4 days of bleeding  
 +
**Usual amount bleeding per period 10-35 cc
 +
**Each normal sized tampon or pad holds 5 cc when soaked through
  
 
{{Vaginal bleeding definitions}}
 
{{Vaginal bleeding definitions}}

Revision as of 20:32, 4 November 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
    • Usual amount bleeding per period 10-35 cc
    • Each normal sized tampon or pad holds 5 cc when soaked through

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)
  • Postmenopausal bleeding - recurrence of bleeding after menopause
  • 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
  • The International Federation of Gynecology and Obstetrics (FIGO) introduced a new classification system known by the acronym PALM-COEIN
  • PALM: structural causes
    • Polyp (AUB-P)
    • Adenomyosis (AUB-A)
    • Leiomyoma (AUB-L)
    • Malignancy and hyperplasia (AUB-M)
  • COEIN: nonstructural causes
    • Coagulopathy (AUB-C)
    • Ovulatory dysfunction (AUB-O)
    • Endometrial (AUB-E)
    • Iatrogenic (AUB-I)
    • Not yet classified (AUB-N)

Clinical Features

  • Vaginal bleeding in a non-pregnant woman

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

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

  1. Iron supplements
  2. Ibuprofen
    • For cramps and theoretically decreases intra-uterine bleeding
  3. 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)
  4. Tranexamic acid [2]
    • Acutely 10 mg/kg IV, max dose of 600 mg[3]
    • Then 1-1.5 g TID PO for 5 days
    • Use only in women not at high risk for thrombosis

Life Threatening

  1. Give blood transfusion
    • O-negative blood if emergent
    • Establish good access
  2. Temporize bleeding w/ foley balloon or kerlix soaked in saline and thrombin
  3. 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

  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.
  2. Leminen and Hurskainen. Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety. Int J Womens Health. 2012; 4: 413–421.
  3. Committee on Gynecological Practice. Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. April 2013. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Management-of-Acute-Abnormal-Uterine-Bleeding-in-Nonpregnant-Reproductive-Aged-Women

See Also