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
  • 4 days of bleeding

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
• Leiomyoma (Fibroid)
• Foreign Body
• Infection (vaginitis, PID)
• IUD
• Neoplasia (especially in women >45 years old or in younger women with other risk factors)
• Vaginal Trauma

Diagnosis

Work-Up

• Urine pregnancy
• Hb
• Coags (only if h/o or suspect coaulopathy)
• ?TSH, prolactin (only if suspect endocrine d/o)
• Consider follow up for non-emergent pelvic ultrasound
  • No indication for emergent ultrasound in ED

Evaluation

• 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

Treatment

1. Iron supplements
2. Ibuprofen
   • For cramps and theoretically decreases intra-uterine bleeding
3. Hormones
   • Give only if endocervical curettage/endometrial biopsy does not need to be performed (young patient) or has already been performed, as they may alter test results
   • Medroxyprogesterone
     • 150mg IM x 1 then 20mg PO Q8hrs x 3 days
     • In a trial of 48 patients all had cessation in 5 days.
   • Estrogen IV/PO (similar efficacy)
4. Tranexamic acid
   • Acutely 10 mg/kg IV, max dose of 600 mg
   • Then 1-1.5 g TID PO for 5 days
   • Use only in women not at high risk for thrombosis

Life Threatening

1. Give blood transfusion
   • O-negative blood if emergent
   • Establish good access
2. Temporize bleeding w/ foley balloon or kerlix soaked in saline and thrombin
3. Suture or silver nitrate if bleeding from trauma

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

See Also

• Vaginal Bleeding (Main)