Nonpregnant vaginal bleeding

Background

• Normal menstruation:
  • 28 +/- 7d cycles; 4d of bleeding

Definitions

1. Menorrhagia
   1. Prolonged (>7d) or excessive (>60mL daily) vaginal bleeding at regular intervals
2. Metrorrhagia
   1. Irregular vaginal bleeding outside the normal cycle
3. Menometrorrhagia
   1. Excessive irregular vaginal bleeding
4. Polymenorrhea
   1. Frequent and light bleeding
5. Postcoital bleeding
   1. Vaginal bleeding after intercourse, suggesting cervical pathology
6. Postmenopausal bleeding
   1. Any bleeding that occurs >6 mo after cessation of menstruation
7. Dysfunctional uterine bleeding
   1. Bleeding not due to an organic cause

Diagnosis

• Hemodynamically stable pt in ED must rule-out:
  • Pregnancy
  • Trauma
  • Bleeding dyscrasia
  • Infection
  • Retained foreign body
  • If ruled these out the refer for outpt w/u

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,prolactin (only if suspect endocrine d/o)
5. ?Pelvic u/s

Treatment

1. Gyn consult only if uncontrolled
2. Medroxyprogesterone
   1. 150mg IM x 1 then 20mg PO Q8hrs x 3 days
   2. In a trial of 48 patients all had cessation in 5 days.
3. Estrogen IV/PO (similar efficacy)
4. Temporize bleeding w/ foley balloon or kerlix soaked in saline and thrombin
5. Suture or silver nitrate if bleeding from trauma

Disposition

• D/c home w/ OB/GYN f/u

Source

Tintinalli

See Also

Vaginal Bleeding (Main)