NICE states that pharmacological treatment for HMB can be considered without physical examination if the patient has no associated symptoms such as pain, pressure or persistent intermenstrual bleeding,8 but many patients attending ED will require examination.

  • Vital signs
    • Blood pressure may initially be normal despite large volume blood loss in the young, healthy population17
    • It is likely that the patient will be tachycardic before their blood pressure drops1
  • Abdominal examination
    • Look for a mass, localised tenderness or signs of peritonism17
    • Normal uterus and ovaries should not be palpable on abdominal exam9
  • Pelvic examination


    • Role in the ED is controversial but it may yield valuable information13,14,17,20,22
    • Assess for ongoing bleeding, foreign bodies, signs of trauma and vaginal or cervical discharge on inspection before examining uterine size and contour, adnexal masses or tenderness and cervical motion tenderness17
    • Avoid pelvic examination in the initial assessment of premenarchal patients17
  • If the source of bleeding is not clearly identified, examination should seek other sources including rectal bleeding17

Key Features on Assessment for each of the Differential Diagnoses

  History Examination
Polyps Often asymptomatic. When bleeding is present, it is often IMB. Often normal unless it is a prolapsed uterine polyp or cervical polyp.
Adenomyosis Often asymptomatic. Can cause HMB and dysmenorrhoea. Uterus typically feels soft and diffusely enlarged on bimanual palpation.
Leiomyoma Often asymptomatic. Can cause HMB, pelvic pain/pressure and reproductive dysfunction. May be palpated as suprapubic mass.
Malignancy PMB should always raise suspicions but any AUB carries the possibility. Ask about weight loss and other systemic symptoms. Masses may be felt, cervical lesions may be seen on speculum examination.
Coagulopathy History of mucosal bleeding, unexplained bruising, bleeding problems after surgery, delivery or tooth extraction. Family history. Bruising may be noted.
Ovarian dysfunction Irregular menstrual periods varying in frequency, duration and volume. History of endocrine dysfunction e.g. hypothyroidism, PCOS etc. Features of underlying disorder e.g. Hirsutism in PCOS.
Endometrial HMB in context of regular, predictable menstrual cycles with no other cause found. No specific findings.
Iatrogenic Current and recent medications. No specific findings.
Ruptured ovarian cyst Sudden onset, unilateral, lower abdominal pain which may occur during exercise or sexual intercourse. Sometimes associated with light PV bleeding but usually not. Localised tenderness +/- signs of peritonism.
Ovarian torsion Sudden onset lower abdominal pain often with nausea and vomiting. May also occur during vigorous activity. Adnexal mass. Localised tenderness +/- signs of peritonism.
Foreign body History may or may not be offered. Foreign body visible, malodourous discharge, signs of infection.
Trauma History of recent sexual assault, rape, accidental injury. Wound may be visible on vulva or vagina.
Infection/PID History of STI or unprotected sex. Abnormal discharge. fever, post-coital bleeding. Tenderness with signs of peritonism and cervical motion tenderness in PID.
Source of bleeding other than genital tract Blood only seen after passing urine or faeces or on toilet paper when wiping. Blood on rectal examination, haematuria evident.

Learning bite

The 2 key questions at the start of the assessment are: Is the patient haemodynamically stable? Is she pregnant?

Targeted history should focus on the history of the bleeding; gynaecological and obstetric history; bleeding history; medical history and associated symptoms.