Nonpregnant vaginal bleeding

Background

• This page is for the generalized approach to undifferentiated vaginal bleeding in non-pregnant women
• Normal menstruation:
  • 28 +/- 7 day cycles
  • 3-7 days of bleeding
  • Usual amount bleeding per period 10-35 cc
  • Each normal sized tampon or pad holds 5 cc when soaked through
• Bleeding from the uterine corpus that is irregular in volume, frequency or duration, in absence of pregnancy, is abnormal
• Vaginal bleeding before the age of menarche may be the result of infection, trauma (ex. sexual assault, foreign body) or a structural lesion

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)
• Polymenorrhea: frequent and light bleeding
• Postcoital bleeding: vaginal bleeding after intercourse, suggesting cervical pathology
• Postmenopausal bleeding: recurrence of bleeding >6 mo after menopause
• Amenorrhea: bleeding that is absent for > 6 months

Clinical Features

• Vaginal bleeding in a non-pregnant woman

Differential Diagnosis

Nonpregnant Vaginal Bleeding

Systemic Causes

• Cirrhosis
• Coagulopathy (Von Willebrand disease, ITP)
• Group A strep vaginitis (prepubertal girls)
• Hormone replacement therapy
• Anticoagulants
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Hypothyroidism
• Polycystic Ovary Syndrome
• Secondary anovulation

Reproductive Tract Causes

• Adenomyosis
• Atrophic endometrium
• Dysfunctional uterine bleeding
• Endometriosis
• Fibroids
• Foreign Body
• Infection (vaginitis, PID)
• IUD
• Neoplasia (especially in women >45 years old or in younger women with other risk factors)
• Vaginal Trauma

Evaluation

PALM-COEIN Classification of Vaginal Bleeding

• 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)

• Age 12-18: most commonly immature hypothalamic-pituitary-ovarian axis, also consider bleeding dyscrasia
• Age 19-39: most commonly structural lesion (fibroid, polyp) or PCOS
• Age 40+: most commonly endometrial atrophy, also consider malignancy especially in post-menopausal

Work-Up

• Urine pregnancy
• Complete blood count
• Coags (if history of or suspect coagulopathy)
• TSH, prolactin (if suspect endocrine disorder)
• C. trachomatis and N. gonorrhoeae testing if risk of infection (consider with post-coital bleeding)
• Consider follow up for non-emergent pelvic ultrasound
  • No indication for emergent ultrasound in ED

Evaluation

• Hemodynamically stable patient in ED must rule-out:
  • Pregnancy
  • Trauma
  • Bleeding dyscrasia
  • Infection
  • Retained vaginal foreign body
  • If work up negative, can refer for further outpatient work up

Management

Mild Bleeding

• Iron supplementation
  • 324mg ferrous sulfate tablet PO TID (each tab contains 65mg of elemental iron)
• Ibuprofen
  • For cramps and can theoretically decreases intra-uterine bleeding
  • Reduces endometrial prostaglandin levels and promotes vasoconstriction in the uterus

Moderate continued bleeding

Patients can benefit from initiation of birth control or for acute cessation consider medroxyprogesterone therapy in the ED

• Medroxyprogesterone
  • Give only if endocervical curettage/endometrial biopsy does not need to be performed (young patient) or has already been performed, since the hormone may alter the results
  • High Dose regimen: 150mg IM x 1 then 20mg PO Q8hrs x 3 days
  • In a trial of 48 patients all had cessation in 5 days.
  • Alternative regimen: 10mg PO q8 x 7 days then 10mg daily x 3 weeks

Life Threatening

• Establish large bore IV access
• Prepare for emergent blood transfusion uncrossmatched O-negative blood if typed blood is not available.
• It is possible to temporize bleeding w/ intravaginal packing with kerlix soaked in with thrombin
• If bleeding is due to a traumatic cause emergent surgical repair is necessary
• Tranexamic acid
  • Coordinate with OBGYN prior to administration due to the increased thrombotic risk
  • Acutely 1.0-1.3 grams IV
  • Then 1-1.3 g TID PO for 5 days

Pharmacologic Treatment Regimens For Acute Abnormal Uterine Bleeding

Drug	Suggested Dose	Contraindications
Conjugated equine estrogen	25 mg IV every 4-6 h until bleeding stops, up to 24 h	Active or past thromboembolic disease, breast cancer, or liver disease
Combination oral contraceptive pills	1 pill tid PO for 7 days or 1 pill bid PO for 5 days, then 1 pill qd until pack is finished	> 35 y who smoke, hx of DVT or PE, breast cancer, liver disease, known thromboembolic disorders, pregnancy, ischemic heart disease, cerebrovascular disease, or uncontrolled hypertension
Progestin-only oral contraceptive pills (medroxyprogesterone acetate)	20 mg tid PO for 7 days or 10 mg qd PO for 10 days	Active or past DVT or PE, liver disease, or breast cancer
NSAIDs: Ibuprofen	200-400 mg 3-4 times/day PO for 5 days	Advanced renal disease
Antifibrinolytic agents (tranexamic acid)	1.3 g tid PO for up to 5 days	Active intravascular clotting or subarachnoid hemorrhage

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
• Surgical options, when medical management fails, include hysterectomy, endometrial baloon tamponade, dilatation and curettage, uterine artery embolization

See Also

Vaginal bleeding (main)

• Non-pregnant vaginal bleeding
  • Prepubertal vaginal bleeding
• Pregnant
  • Vaginal bleeding in pregnancy (less than 20wks)
  • Vaginal bleeding in pregnancy (greater than 20wks)
  • Postpartum hemorrhage

See Also

• Vaginal Bleeding (Main)