Author: Susan Uí Bhroin / Editor: Lauren Fraser / Codes: CAP34, ObC7, ObP2, ObP4, SLO1, SLO2, SLO3 / Published: 09/12/2021
Vaginal bleeding, either normal menstruation or abnormal bleeding, affects almost all females at some point in their lives and many of these patients are sufficiently concerned to attend the ED.1–4
Here are some statistics to highlight the scale of the issue:
- Approximately 25% of the UK population are females of reproductive age;5
- 14% of women of reproductive age experience abnormal uterine bleeding (AUB):6
- Around 5% of GP consultations for women aged 30-49 years relate to heavy menstrual bleeding (HMB).7 This does not include the many other causes of vaginal bleeding.
HMB is one of the most common causes of abnormal bleeding. It is defined by the patient’s perception of heavy or excessive bleeding and the affect it has on her life, as opposed to the actual volume of blood lost.8,9 HMB has a number of consequences for women, leading to the following:
- Iron deficiency anaemia – HMB is one of the leading causes of iron deficiency anaemia in females worldwide:10
- Blood transfusions and inpatient stays in hospital ;
- Missed days at school or work;
- Psychosocial and sexual difficulties.9,10
Vaginal bleeding can also be a symptom of cancer, particularly gynaecological malignancy, but also haematological cancers. Cancer Research UK report that uterine cancer is the fourth most common cancer in women in the UK, with approximately 9,400 new diagnoses and 2,400 deaths each year.11 Many of these patients present with AUB. Postmenopausal bleeding (PMB) is of particular concern and in one study, 5-10% of women with PMB were found to have endometrial cancer.12
Vaginal bleeding can be a huge problem for women and can be a symptom of serious underlying pathology.
|Normal menstrual bleeding||Occurs every 24-38 days with cycle-to-cycle variation of 2-20 days and lasts 4-8 days. Blood loss of 5-80ml which is roughly equivalent to no more than one pad/tampon every 3 hours.13|
|Abnormal uterine bleeding (AUB)||Uterine bleeding that is abnormal in regularity, frequency, volume or duration in a non-pregnant woman.14 The term dysfunctional uterine bleeding is no longer recommended.4|
|Chronic AUB||AUB present for the majority of the last 6 months.15|
|Acute AUB||An episode of heavy bleeding that requires immediate action to prevent further blood loss.15|
|Heavy menstrual bleeding (HMB)||Excessive volume of menstrual bleeding affecting the patient’s quality of life.8-10|
|Intermenstrual bleeding (IMB)||Any bleeding, other than post-coital bleeding, that occurs outside of menstruation.|
|Postmenopausal bleeding (PMB)||Any bleeding that occurs over one year after the last menstrual period.|
|Post-coital bleeding (PCB)||Non-menstrual bleeding that occurs immediately after sexual intercourse.|
Normal menstruation occurs roughly every 4 weeks and less than one pad or tampon is needed every 3 hours.
The definition of heavy menstrual bleeding is based less on actual volume, which is difficult to quantify, and more on the affect it has on the woman’s life.
- This is the first half of the cycle and begins with menstruation16
- The hypothalamus stimulates the pituitary gland to release follicle stimulating hormone (FSH) and leutinizing hormone (LH) which act on the ovary causing maturation of a follicle.17
- Oestrogen levels rise stimulating the endometrium to proliferate and thicken and also causing an LH surge which triggers ovulation.16,17
- This is the second half of the cycle and begins with ovulation.
- The ruptured follicle evolves into the corpus luteum and secretes progesterone.16,17
- If the egg is not fertilised, the corpus luteum involutes after 14 days causing a drop in progesterone which triggers sloughing of the endometrium. This is evident as menstrual bleeding.17
- The first day of the menstrual period marks day one of the next menstrual cycle.16
Abnormal Vaginal Bleeding
The International Federation of Gynaecology and Obstetrics (FIGO) divides AUB in women of reproductive age into structural and non-structural causes using the PALM-COEIN classification system.15 Structural causes (PALM) include polyps, adenomyosis, leiomyomas (fibroids), and malignancy whereas non-structural causes (COEIN) include coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not otherwise classified.15 It is important to note that the cause of the bleeding may be multi factorial and several causes may coexist.14
- Structural causes for AUB
- Localized tumours of the endocervix or endometrium4
- Usually benign but some have atypical or malignant features15
- Often asymptomatic can contribute to AUB15
- Invasion of the myometrium by endometrial tissue4
- Leiomyoma (fibroid)
- Benign fibromuscular tumours of the uterus
- Oten asymptomatic but can contribute to AUB4,15
- Malignancy and hyperplasia
- Serious but relatively uncommon cause of AUB15
- Non-structural causes for AUB
- 13% of those with HMB may have von Willebrand’s Disease18
- Other patients may have single factor deficiencies or platelet disorders17
- Ovarian dysfunction
- Often no known cause but polycystic ovarian syndrome, hypothyroidism, hyperprolactinaemia, stress, obesity, weight loss, anorexia or extreme exercise can all affect ovarian function15
- Primary disorder of local endometrial haemostasis15
- A number of drugs and devices can cause or alter uterine bleeding, including:
- Intrauterine devices – particularly in the first 6 months15
- Breakthrough bleeding on oral contraceptives15
- Tricyclic antidepressants15
- A number of drugs and devices can cause or alter uterine bleeding, including:
- Not yet classified
While the PALM-COEIN system sets out the causes for AUB in women of reproductive age, remember that not all vaginal bleeding is uterine in origin and not all patients are in this age cohort.
Non-uterine causes of vaginal bleeding include:
- Ovarian bleeding
- More commonly presents with intraperitoneal bleeding but may occasionally present with vaginal bleeding. Causes include cancer, torsion, ruptured cyst.19
- Foreign body6,13,17,20
- E.g. retained tampon, condom
- Trauma of the lower genital tract21,22
- Vulva, vagina or cervix
- Blunt or penetrating trauma
- May relate to a sexual assault or rape but may have another explanation such as an accidental injury
- Gynaecological infections
- Pelvic inflammatory disease (PID) is an ascending pelvic infection. It may cause tubo-ovarian abscess, salpingitis or endometritis22 and can present with bleeding.
- Bleeding that is mistakenly reported to be vaginal bleeding e.g. rectal bleeding or haematuria23
SPECIFIC CAUSES OF VAGINAL BLEEDING IN DIFFERENT AGE COHORTS (1,6,13,22,24)
|Neonates||Withdrawal from maternal oestrogen after delivery|
|Perimenopausal women||HMB caused by anovulatory cycles which become more common in this cohort|
- Vaginal bleeding can be uterine, or from elsewhere in the genital tract
- Uterine bleeding has structural and non-structural causes
- Differential diagnosis changes depending on the age cohort
When assessing a patient with vaginal bleeding, there are 2 essential questions to be asked immediately which will drastically alter your assessment and management:4
- Is she haemodynamically stable?
- Is she pregnant?
If she is stable and non-pregnant proceed with routine history and examination. Vaginal bleeding in non-pregnant women is rarely life-threatening,13 but if the patient is unstable, proceed with resuscitation in parallel to assessment. If she is pregnant, your assessment and management change depending on gestation and presentation but this is beyond the scope of this session.
|History of the Vaginal Bleeding||
|Gynaecological and Obstetric History||
|Other Key Points||
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
BRING A CHAPERONE AND MAINTAIN PATIENT DIGNITY EVERY TIME
- 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
|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.|
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.
Pregnancy status is one of the most important details to clarify when dealing with a patient presenting with vaginal bleeding and must be done as a matter of urgency.13,17 Point of care qualitative urine beta hCG tests are quick and easy to use. Occasionally, however, there may be a delay in obtaining a urine sample. For example, a woman who is hypotensive and shocked may be making little urine, or she may have just emptied her bladder prior to your assessment. Although most point of care tests are licensed for use with urine and/or serum only, these tests have been shown to be just as sensitive when used with whole blood.25–27 The result should be confirmed with a urine qualitative test +/- a serum quantitative test, but positives should be taken seriously.
Other Laboratory Investigations
Initial laboratory investigations for haemodynamically unstable patients are as follows:13,17
- Venous blood gas
- Full blood count
- Group and crossmatch
- Coagulation profile
- Renal profile
ED investigations for stable patients include:4,8,17,21
- Full blood count is indicated for patients with HMB or other significant bleeding.
- Coagulation profile should be sent if the patient is on anticoagulant or there is concern she may have a bleeding disorder.
- STI screen may be indicated if suspicion of infection.
- Testing for systemic causes of bleeding such as renal, liver or thyroid disease should only be undertaken in ED if there are symptoms to suggest an underlying disorder.
It should be noted that in most cases laboratory test results are non-specific and do not contribute to the ED management.21
Pelvic ultrasound should be considered in cases of severe pain and bleeding to out rule serious structural causes such as haemorrhagic cysts, ovarian torsion, or a degenerating fibroid.21 In most cases, however, pelvic ultrasound can be arranged as an outpatient for stable patients as the results rarely change ED management.4,13,17,21
Beta hCG is the single most important investigation in patients presenting with vaginal bleeding. Most stable patients should have a full blood count checked but do not require further investigation in ED.
Life threatening acute vaginal bleeding is rare in non-pregnant patients2,13,21 but can occur, particularly in the context of trauma or a uterine arteriovenous malformation.17 Patients should have initial resuscitation as per any other unstable bleeding patient:
- ABCDE assessment and interventions including activation of major transfusion protocol if indicated17
- Urgent ED gynaecology referral4,17,21
- First line treatment for vaginal bleeding in unstable, non-pregnant patients is with high dose IV oestrogen to promote rapid endometrial regrowth.17,21
- Although first line treatment, this may not be immediately available in ED. In addition, ED practitioners are unlikely to be familiar with IV oestrogen and so this treatment should be led by the gynaecology team.
- Rarely, uterine tamponade may be required for uncontrolled uterine bleeding.
- Specific devices are available for controlling uterine haemorrhage, e.g. Bakri Balloon, but they may not be available in the ED.
- If these are not available, pass a foley catheter through the cervix and inflate the balloon4,13,17 or alternatively pack the uterus with long continuous gauze.13 This must be done with a speculum, under sterile conditions4 and with sufficient analgesia.
- If it is not possible to visualise the cervix due to ongoing bleeding, or the bleeding is from the vagina itself, the vaginal vault can be packed with either commercially available vaginal packing or lubricated continuous gauze.4 The gauze may be soaked in tranexamic acid as an adjunct.4
- If other interventions are unsuccessful, there may be a role for IV tranexamic acid.17
If the patient is stable and not significantly anaemic, she may be treated as an outpatient with one or more of the medical treatments described below.4 The aim of treatment is to reduce both the duration and volume of blood loss, to treat anaemia if present, and to restore quality of life.4,23 Medical treatment of stable, non-pregnant patients with vaginal bleeding can be divided into non-hormonal and hormonal treatments.13 When discussing and agreeing a treatment option with the patient, take into account her preferences, comorbidities, cause for the bleeding and other symptoms she is experiencing e.g. pain/pressure.8
NICE guidelines permit the initiation of pharmacological treatment for HMB without investigating the cause if the history and/or examination suggests a low risk for structural or histological abnormality e.g. persistent IMB, PCB, pressure symptoms, pain, uterus size or pelvic mass.8,28
Pharmacological treatment options are as follows:
- Non-Hormonal Treatments
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) e.g. ibuprofen, mefenamic acid, naproxen
- Promote uterine vasoconstriction, thus reducing HMB.13,21
- Different NSAIDs appear to be equally effective at reducing HMB.13,29
- Contraindications include hypersensitivity to aspirin or an NSAID, peptic ulcer disease, use of anticoagulants, renal and cardiac impairment etc.
- Also have analgesic properties which can be useful for dysmenorrhoea.
- They are as effective as oral contraceptives at reducing HMB but less effective than tranexamic acid and the levonorgestrel-releasing intrauterine system (LIUS) e.g. Mirena coil.29
- Tranexamic acid
- Antifibrinolytic which is more effective for the treatment of HMB than NSAIDs and oral contraceptives but less so than the LIUS21,30
- Does not appear to be associated with an increase in major adverse events but there is insufficient evidence to assess thromboembolism risk30
- May be given in conjunction with NSAIDs9
- Iron supplementation
- Should be started in patients with microcytic anaemia.4
- Vitamin C given in conjunction with iron may improve absorption.4
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) e.g. ibuprofen, mefenamic acid, naproxen
- Hormonal Treatments
- Combined Oral Contraceptive Pill (COCP)
- Can be prescribed as a taper to temporize an episode of heavy bleeding.4,13
- Most effective for patients with bleeding secondary to anovulation.13
- Contraindications to the COCP include:4,13
- Liver disease
- Severe uncontrolled hypertension
- History of stroke or thromboembolic event
- Age>35 in those who smoke
- History of breast/liver cancer (particularly oestrogen dependent tumours)
- Cerebrovascular or ischaemic heart disease
- Progesterone Only Pill (POP)
- May be a safe alternative if the COCP is contraindicated.4,13
- Levonorgestrel-releasing intrauterine system (LIUS) e.g. Mirena coil
- Very effective at reducing HMB21 but not typically an option in ED.
- Can cause an initial change in bleeding pattern, often causing erratic bleeding, particularly in the first few cycles.8,9
- Combined Oral Contraceptive Pill (COCP)
Most stable patients can be discharged home with timely gynaecology outpatient follow up.13,22 Unstable patients and those with significant anaemia may require admission for transfusion and urgent gynaecological inpatient assessment.4
|Diagnosis||Management and Disposition|
|Adenomyosis||First line treatment is with LIUS.6 Second line is with any of TXA, NSAIDs, oral contraceptives.8Definitive treatment is with hysterectomy.|
|Leiomyoma||<3cm – First line treatment is with LIUS.8 Second line is with any of TXA, NSAIDs, oral contraceptives.8 >3cm – Requires referral to gynaecology OPD. TXA/NSAIDs can be used while awaiting investigations and definitive treatment.|
|Malignancy||All suspected malignancy should be referred urgently to gynaecology outpatients on a 2 week wait pathway where available.|
|Coagulopathy||May require both gynaecology and haematology input for specific treatment. Options include hormonal treatments as above, desmopressin and TXA.6|
|Ovarian dysfunction||Medical treatment may be effective but may need referral to gynaecology/endocrinology.4|
|Iatrogenic||It may not be appropriate to stop the offending drug, particularly in ED. Bleeding may be managed medically depending on the cause.|
|Ovarian torsion||Urgent gynaecological referral with a view to emergency surgery.|
|Foreign body||Remove FB if possible, otherwise referral to gynaecology. Antibiotics may be required if signs of infection present.|
|Trauma||Referral to gynaecology for significant trauma. Involve the appropriate authorities if suspected rape, sexual assault, domestic violence.|
|PID||BASHH antibiotic regime: IM Ceftriaxone 1000mg stat, PO doxycycline 100mg BD for 14 days, PO metronidazole 400mg BD for 14 days.If unwell admission is advised for IV antibiotics e.g. fever, tubo-ovarian abscess, pelvic peritonism, etc.|
|Source of bleeding other than genital tract||Treat the underlying cause e.g. UTI/haemorrhoids/rectal tumour.|
- Not believing the patient – if she says the bleeding is heavy and it is impacting her life then she meets criteria for HMB.
- Failing to recognise red flag symptoms of malignancy such as postmenopausal bleeding.
- Failing to recognise that the bleeding is from another source e.g. rectum.
- Not examining the patient fully and missing obvious clinical diagnoses e.g., PID, foreign body.
- Not checking a hCG because the patient says there is no way she could be pregnant! Check a hCG… EVERY TIME!
- Waiting for a urine sample to test for hCG in an unstable patient. Use whole blood on the point of care pregnancy test while awaiting a formal serum hCG.
- Requesting a pelvic ultrasound on all patients. In most cases this will not change your ED management and is not necessary.
- Not being familiar enough with the various treatments to discuss them with the patient.
- Failing to recognise signs of trauma and therefore missing an opportunity to intervene for a vulnerable patient.
- Failing to treat anaemia caused by the heavy menstrual bleeding.
- Buckingham K, Fawdry A, Fothergill D. Management of vaginal bleeding presenting to the accident and emergency department. J Accid Emerg Med. 1999;16:130–5.
- Jennings L, Presley B, Krywko D. Uterine Artery Pseudoaneurysm: A Life-Threatening Cause of Vaginal Bleeding in the Emergency Department. J Emerg Med [Internet]. 2019;56(3):327–31.
- Boone S, Peacock WF, Ordonez E, Powers JM. Management of Nonpregnant Women Presenting to the Emergency Department With Iron Deficiency Anemia Caused by Uterine Blood Loss: A Retrospective Cohort Study. J Emerg Med [Internet]. 2020;59(3):348–56.
- Dyne PL, Miller TA. The Patient with Non–Pregnancy-Associated Vaginal Bleeding. Emerg Med Clin North Am [Internet]. 2019;37:153–64.
- Royal College of General Practitioners. Menstrual Wellbeing Toolkit [Internet]. 2021.
- Deligeoroglou E, Karountzos V. Abnormal Uterine Bleeding including coagulopathies and other menstrual disorders. Best Pract Res Clin Obstet Gynaecol [Internet]. 2018;48:51–61.
- Turner E, Bowie P, Kellock C. First-line management of menorrhagia: Findings from a survey of general practitioners in Forth Valley. Br J Fam Plann. 2000;26(4):227–8.
- National Institute for Health and Care Excellence. Heavy menstrual bleeding: assessment and management; NICE [guideline NG88]. 2018.
- Health Service Executive, Institute of Obstetricians & Gynaecologists Royal College of Physicians of Ireland. The Investigation and Management of Menorrhagia. Clinical Practice Guideline. 2018.
- Rosen MW, Weyand AC, Pennesi CM, Stoffers VL, et al. Adolescents Presenting to the Emergency Department with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol [Internet]. 2020;33:139–43.
- Cancer Research UK. Uterine Cancer Statistics [Internet]. [cited 2020 May 1].
- Gredmark T, Kvint S, Havel G, Mattsson LA. Histopathological findings in women with postmenopausal bleeding. Br J Obstet Gynaecol. 1995 Feb;102(2):133-6.
- Borhart J. Vaginal Bleeding. In: Rosen’s Emergency Medicine:Concepts and Clinical Practice, Ninth Edition. Elsevier; 2018. p. 270–4.
- ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol. 2013 Apr;121(4):891-896.
- Munro MG, Critchley HOD, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet. 2011;113:3–13.
- Hampson E. A brief guide to the menstrual cycle and oral contraceptive use for researchers in behavioral endocrinology. Horm Behav [Internet]. 2020;119.
- Borhart J. Approach to the adult with vaginal bleeding in the emergency department. In: Hockberger R, Grayzel J, editors. UpToDate [Internet]. 2018.
- Shankar M, Lee C, Sabin C, Economides D, Kadir R. von Willebrand disease in women with menorrhagia: A systematic review. BJOG an Int J Obstet Gynecol. 2004;111:734–40.
- Kaunitz A. Differential diagnosis of genital tract bleeding in women [Internet]. UoToDate. 2021 [cited 2021 May 8].
- McLean ME, Santiago-Rosado L. Plight of the pelvic exam. Emerg Med J. 2019;36:383–4.
- Cirilli AR, Cipot SJ. Emergency Evaluation and Management of Vaginal Bleeding in the Nonpregnant Patient. Emerg Med Clin North Am [Internet]. 2012;30:991–1006.
- Schmitz G, Tibbles C. Genitourinary Emergencies in the Nonpregnant Woman. Emerg Med Clin North Am. 2011;29:621–35.
- Kaunitz A. Abnormal uterine bleeding in nonpregnant reproductive-age patients: Evaluation and approach to diagnosis. UpToDateToDate. 2021.
- Teach S. Evaluation of vulvovaginal bleeding in children and adolescents [Internet]. UpToDate. 2020.
- Gottlieb M, Wnek K, Moskoff J, Christian E, Bailitz J. Comparison of result times between urine and whole blood point-of-care pregnancy testing. West J Emerg Med. 2016;17(4):449–53.
- Habboushe JP, Walker G. Novel use of a urine pregnancy test using whole blood. Am J Emerg Med [Internet]. 2011;29(7):840.e3-840.e4.
- Fromm C, Likourezos A, Haines L, Khan ANGA, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med [Internet]. 2012;43(3):478–82.
- Royal College of Obstetricians & Gynaecologists. Advice for heavy menstrual bleeding (HMB) services and commissioners. 2014.
- Rodriguez MB, Lethaby A, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding (Review). Cochrane Database Syst Rev. 2019;2019(9).
- Bryant-Smith AC, Lethaby A, Farquhar C, Hickey M. Antifibrinolytics for heavy menstrual bleeding (Review). Cochrane Database of Systematic Reviews. 2018.