Nonpregnant vaginal bleeding
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
- 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
- ?Pelvic u/s
Treatment
- Gyn consult
- 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