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

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==Background==
 
==Background==
*Normal menstruation
+
*Normal menstruation:
**28 + 7 day cycles; 4+ 3 days of bleeding
+
**28 +/- 7d cycles; 4d of bleeding  
*Menorrhagia
+
*Definitions
**prolonged (>7 days) or excessive (>80mL daily) of uterine bleeding occurring at regular intervals  
+
**Menorrhagia
*Metrorrhagia
+
***Prolonged (>7d) or excessive (>60mL daily) vaginal bleeding at regular intervals  
**uterine bleeding occurring at irregular and more frequent than normal intervals
+
**Metrorrhagia
 +
***Irregular vaginal bleeding outside the normal cycle
 
*Menometrorrhagia
 
*Menometrorrhagia
**prolonged/excessive bleeding occurring at irregular and ore frequent intervals than normal
+
**Excessive irregular vaginal bleeding
*Postmenopausal bleeding  
+
*Postcoital bleeding
**recurrence of bleeding in a menopausal woman 1 year after cessation of cycles
+
**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==
 +
*Must rule-out:
 +
**Pregnancy
 +
**Trauma
 +
**Bleeding dyscrasia
 +
**Infection
 +
**Retained foreign body
  
 
==DDX==
 
==DDX==
Line 15: Line 28:
 
#Secondary anovulation
 
#Secondary anovulation
 
#Coagulopathy
 
#Coagulopathy
#Endocrinopathies (Cushings, PCOS, DM, thyroid abnl)
+
##Von Willebrand, ITP
 +
#Hypothyroidism
 +
#Hormone replacement therapy
 
#Cirrhosis
 
#Cirrhosis
#Stress/weight gain/excessive diet or exercise
 
  
 
===Reproductive Tract Causes===
 
===Reproductive Tract Causes===
#Dysfunctional uterine bleeding
+
#Fibroids
#Ruptured ovarian cyst
+
#Adenomyosis
#Vaginal lac/trauma
+
#Endometriosis
 +
#Neoplasia
 +
#Infection (vaginitis, PID)
 +
#Vaginal trauma
 
#Foreign Body
 
#Foreign Body
 
#IUD
 
#IUD
#Uterine fibroids
 
 
#Atrophic endometrium
 
#Atrophic endometrium
#AVM
+
#Dysfunctional uterine bleeding
#Cancer (Endometrial, cervical, vaginal, genital)
+
##Diagnosis of exclusion
#Polyps
+
##Ovulatory: Excessive wt change, stress, exercise
#Endometrial hyperplasia
+
##Anovulatory: postmenopause, premenopause, PCOS
#Infection
 
#Lichen sclerosis
 
#Urethral prolapse
 
#Inflammation (vulvitis, vaginitis, endometritis)
 
#Iatrogenic (OCPs, Hormone replacement, psychotropic drugs)
 
  
 
==Work-Up==
 
==Work-Up==
# Icon
+
#Urine pregnancy
# Hb
+
#Hb
# ?Orthostatics
+
#Coags (only if h/o or suspect coaulopathy)
# ?IVF/blood
+
#?TSH
# ?CBC
+
#?Pelvic u/s
# ?Coags only if h/o or suspect coaulopathy  
 
# ?TSH
 
# ?pelvic u/s
 
# 2 large bore IV's if unstable
 
  
 
==Treatment==
 
==Treatment==
# gyn consult (emergently if unstable)
+
#Gyn consult
# IV estrogen can stop bleeding quickly, consider starting patient on OCPs (speak to GYN first before! may affect EMB results)
+
#Estrogen IV/PO (similar efficacy)
# temporizing bleeding with foley balloon or kerlix soaked in saline and thrombin
+
#Temporize bleeding w/ foley balloon or kerlix soaked in saline and thrombin
# if local bleeding from trauma - suture or silver nitrate
+
#Suture or silver nitrate if bleeding from trauma
 +
 
 +
==Disposition==
 +
*D/c home w/ OB/GYN f/u
 +
 
 +
==Source==
 +
Tintinalli
  
 
[[Category:OB/GYN]]
 
[[Category:OB/GYN]]

Revision as of 01:28, 20 August 2011

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
  • 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

  • Must rule-out:
    • Pregnancy
    • Trauma
    • Bleeding dyscrasia
    • Infection
    • Retained foreign body

DDX

Systemic Causes

  1. Secondary anovulation
  2. Coagulopathy
    1. Von Willebrand, ITP
  3. Hypothyroidism
  4. Hormone replacement therapy
  5. Cirrhosis

Reproductive Tract Causes

  1. Fibroids
  2. Adenomyosis
  3. Endometriosis
  4. Neoplasia
  5. Infection (vaginitis, PID)
  6. Vaginal trauma
  7. Foreign Body
  8. IUD
  9. Atrophic endometrium
  10. Dysfunctional uterine bleeding
    1. Diagnosis of exclusion
    2. Ovulatory: Excessive wt change, stress, exercise
    3. Anovulatory: postmenopause, premenopause, PCOS

Work-Up

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

Treatment

  1. Gyn consult
  2. Estrogen IV/PO (similar efficacy)
  3. Temporize bleeding w/ foley balloon or kerlix soaked in saline and thrombin
  4. Suture or silver nitrate if bleeding from trauma

Disposition

  • D/c home w/ OB/GYN f/u

Source

Tintinalli