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
  • Usual amount bleeding per period 10-35 cc
  • Each normal sized tampon or pad holds 5 cc when soaked through

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

If you are concerned for malignancy, hormonal therapy should be avoided unless discussed with OBGYN, as these medications may interfere with possible biopsy results.

Mild Bleeding

• Iron supplementation
  • 324mg ferrous sulfate tablet PO TID (each tab contains 65mg of elemental iron)
• NSAIDs
  • e.g. ibuprofen 400 mg PO q6h, or naproxen 500 mg PO BID
  • For cramping pain and can decreases intra-uterine bleeding. Reduces endometrial prostaglandin levels and promotes vasoconstriction in the uterus

Moderate continued bleeding

Patients may benefit from initiation of short or long-term birth control for acute cessation.

Combined OCPs

• Any combined OCP that contains 35 ug of ethinyl estradiol TID for 7 days. (e.g., Ortho-Novum 1/35®)
  • 88% success, median time 3 days
• Contraindications
  • Cigarette smoking if older than 34 years
  • Hypertension
  • History of VTE
  • Cerebrovascular disease
  • CAD or valvular disease
  • History of breast cancer
  • Diabetes with vascular involvement
  • Surgery with immobilization
  • Liver cirrhosis
  • Other pro-coagulative conditions (e.g. Lupus, Factor V Leiden)

Medroxyprogesterone

• 20 mg PO TID for 7 days
  • 76% success, median time 3 days
• Alternative, not officially endorsed by ACOG: 150mg IM x 1 then 20 mg PO TID x 3 days
  • In a trial of 48 patients all had cessation in 5 days.
• Contraindications
  • History of VTE
  • History of arterial thromboembolic events
  • History of breast cancer
  • Liver disease

Life Threatening

• Establish large bore IV access
• Prepare for emergent blood transfusion uncrossmatched O-negative blood if typed blood is not available.
• It is possible to temporize bleeding w/ intravaginal packing with kerlix soaked in with thrombin
• If bleeding is due to a traumatic cause emergent surgical repair is necessary
• Tranexamic acid
  • Coordinate with OBGYN prior to administration due to the increased thrombotic risk
  • Acutely 1.0-1.3 grams IV
  • Then 1-1.3 g TID PO for 5 days

Pharmacologic Treatment Regimens For Acute Abnormal Uterine Bleeding

Drug	Suggested Dose	Contraindications
Conjugated equine estrogen	25 mg IV every 4-6 h until bleeding stops, up to 24 h	Active or past thromboembolic disease, breast cancer, or liver disease
Combination oral contraceptive pills	1 pill TID PO for 7 days or 1 pill bid PO for 5 days, then 1 pill daily until pack is finished	> 35 y who smoke, history of DVT or PE, breast cancer, liver disease, known thromboembolic disorders, pregnancy, ischemic heart disease, cerebrovascular disease, or uncontrolled hypertension
Progestin-only oral contraceptive pills (medroxyprogesterone acetate)	20 mg TID PO for 7 days or 10 mg daily PO for 10 days	Active or past DVT or PE, liver disease, or breast cancer
NSAIDs: Ibuprofen	200-400 mg 3-4 times/day PO for 5 days	Advanced renal disease
Antifibrinolytic agents (tranexamic acid)	1.3 g TID PO for up to 5 days	Active intravascular clotting or subarachnoid hemorrhage

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)