Abnormal vaginal bleeding is a common complaint in females presenting to the ED. Determination of pregnancy status in patients of reproductive age is critical to formulate the appropriate differential diagnosis and to guide subsequent testing and decision making.
All patients should be asked about the amount and duration of bleeding. Reproductive and sexual history, history of sexually transmitted infections, trauma, medications, and the possibility of foreign bodies should be elicited. Symptoms of a possible bleeding disorder (history of bruising, epistaxis, other abnormal bleeding), endocrine disorder, or liver disease should be noted. A complete abdominal and pelvic examination, including speculum and bimanual exam, should be performed on nonvirginal patients to look for structural or traumatic causes of bleeding. Skin or conjunctiva pallor, abnormal vital signs, or a report of dizziness, syncope, or weakness can indicate significant blood loss.
Diagnosis and Differential
In prepubertal girls, causes of vaginal bleeding include genital trauma and/or sexual abuse, vaginitis, tumors, and foreign bodies. Bleeding coupled with vaginal discharge raises concerns for retained foreign bodies. Up to 20% of adolescents with abnormal uterine bleeding may have a primary coagulation disorder such as von Willebrand disease. Anovulatory cycles are also common during the teenage years. In women of reproductive age and 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.
The new term abnormal uterine bleeding (AUB) encompasses all causes of abnormal bleeding in nonpregnant women and divides etiologies of AUB into structural and nonstructural causes. The use of the term dysfunctional uterine bleeding is no longer recommended. AUB may be ovulatory or anovulatory. Anovulatory cycles are common at the extremes of reproductive age. Patients with anovulatory cycles may 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.
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 prolonged PT or elevated 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 stable, nonpregnant patients as the results will rarely change ED management.
Emergency Department Care and Disposition