Nonpregnant vaginal bleeding

Background

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

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

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

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 - Vaginal Bleeding

See Also

Vaginal Bleeding (Main)