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Vaginal bleeding is a common complaint in females presenting to the ED. Determination of pregnancy status in each patient is important in order to formulate the appropriate differential diagnosis and to guide subsequent testing and decision making.

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Clinical Features

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Adolescents and adults should be asked about amount and duration of bleeding, reproductive history, sexual history, history of sexually transmitted infections, history of trauma, medication, possibility of foreign bodies; bleeding disorders (history of bruising, epistaxis, other abnormal bleeding), endocrine disorder, liver disease and associated GU or systemic symptoms. An abdominal and gynecologic examination, including speculum examination as well as a vaginoabdominal examination (bimanual) should be performed on nonvirginal adults and adolescents to look for structural or traumatic causes of bleeding. Skin or conjunctiva pallor or abnormal vital signs can indicate significant anemia.

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Diagnosis and Differential

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In prepubertal children, bleeding from genital trauma and/or sexual assault needs to be considered and excluded. Vulvovaginitis is unusual but is the most common cause of vaginal bleeding in the prepubertal female and can be associated with pain. Although nonspecific vulvovaginosis is most commonly diagnosed, specific infections with candidiasis, streptococcal infections, Escherichia coli and Shigella, viruses and pinworms also occur. Bleeding coupled with vaginal discharge raises concerns for retained foreign bodies. Less common etiologies include precocious puberty and menarche, congenital abnormalities, urethral prolapse, and tissue sensitivity to chemicals in soaps and creams.

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In women of reproductive age or perimenopausal women, bleeding can arise from the uterus or cervix and is most commonly due to anovulation, pregnancy, exogenous hormone use, coagulopathy, uterine leiomyomas, cervical and endometrial polyps, pelvic infections, and thyroid dysfunction. In postmenopausal women, the most common causes of vaginal bleeding are exogenous estrogens, atrophic vaginitis, endometrial lesions including cancer, and other tumors. Primary coagulation disorders account for up to 20% of menorrhagia in teenagers, and include von Willebrand disease, myeloproliferative disorders, and immune thrombocytopenia. Skin signs such as petechiae may be absent.

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Dysfunctional uterine bleeding (DUB) may only be diagnosed after organic and systemic causes of bleeding have been excluded. DUB may be ovulatory or anovulatory. Typically, perimenarcheal and perimenopausal DUB is anovulatory. Patients with anovulatory cycles present with prolonged menses, irregular cycles, or intermenstrual bleeding. Usually the bleeding is painless and minimal, but severe bleeding can occur, resulting in anemia and iron depletion.

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A pregnancy test must be obtained on all women of reproductive age to rule out pregnancy as a cause of bleeding. Other laboratory evaluation is guided by the history and physical examination. A CBC should be checked if signs of excessive bleeding or anemia are present. A PT or INR may identify a coagulopathy. Obtain thyroid function tests in patients with symptoms and signs of thyroid dysfunction. Ultrasonography is an important imaging modality to determine uterine size, characteristics of the endometrium and to detect structural abnormalities. Ultrasound may be deferred for outpatient evaluation in ...

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