Vaginal bleeding

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Vaginal bleeding that cannot be attributed to expected menstrual bleeding is a common clinical presentation. The most likely underlying cause depends on the patient’s pregnancy status, reproductive stage, and other factors (e.g., use of hormone replacement therapy, risk factors for gynecologic malignancies). Vaginal bleeding in nonpregnant adults encompasses abnormal uterine bleeding (AUB) in premenopausal individuals, postmenopausal bleeding, and postcoital bleeding. Common etiologies in these individuals include causes of AUB (i.e., PALM-COEIN), cervicitis, and vulvovaginal atrophy. Vaginal bleeding in pregnant individuals has different causes at < 20 weeks' gestation (e.g., ectopic pregnancy, spontaneous abortion) and > 20 weeks' gestation (e.g., placenta previa, placental abruption); the latter are detailed in “Antepartum hemorrhage.” Premenarchal vaginal bleeding can be caused by precocious puberty, retained vaginal foreign bodies, trauma, and rarely, tumors. Vaginal bleeding in adolescents is usually due to causes of AUB. In all patients, diagnosis involves a focused history and examination and targeted testing based on clinical suspicion. A urine pregnancy test should be obtained in patients who can become pregnant. When imaging is required, transvaginal ultrasound (TVUS) is the preferred modality in premenopausal individuals and early pregnancy; transabdominal ultrasound is an option in later pregnancy and in children and adolescents. Malignancy (e.g., endometrial cancer) must be ruled out in all postmenopausal individuals; endometrial sampling must be performed if indications for endometrial sampling exist. Trauma (including sexual trauma), coagulopathy, and endocrine disorders are common nonobstetric, nongynecologic causes of bleeding that should be evaluated if clinically suspected. Treatment is based on the underlying cause.

Definitions

• Abnormal uterine bleeding (AUB): any of the following (see “FIGO-AUB classification system 1” for details) ^[2]
  • Abnormal bleeding (classified according to frequency, duration, regularity, and volume)
  • Intermenstrual bleeding
  • Unscheduled bleeding
• Postmenopausal bleeding: bleeding that occurs ≥ 12 months after the onset of permanent amenorrhea due to age-related loss of ovarian follicular function ^[3][4]
• Postcoital bleeding: spotting or bleeding that occurs during or after intercourse and is unrelated to menstruation ^[5]

Etiology ^[6][7][8][9]

Many of these conditions manifest with either painful or painless bleeding depending on several factors (e.g., severity, stage, location). See also “Causes of abnormal uterine bleeding.”

Painless bleeding

• Endometrial causes
  • Endometrial polyps
  • Endometrial hyperplasia
  • Endometrial cancer (early stages)
  • Endometrial atrophy ^[9]
• Cervical causes
  • Cervical ectropion
  • Cervical polyps
  • Cervical intraepithelial neoplasia (CIN) or cervical cancer (early stages)
• Other causes
  • Ovulatory dysfunction (e.g., due to endocrine disorders such as hypothyroidism, hyperprolactinemia, or polycystic ovary syndrome)
  • Coagulopathies (e.g., von Willebrand disease)
  • Iatrogenic, e.g.,
    • IUD displacement
    • Adverse effects of medications such as hormone replacement therapy, oral contraceptives, or tamoxifen ^[3]

Painful bleeding

• Endometrial causes
  • Adenomyosis
  • Uterine leiomyoma
  • Endometrial dysfunction (e.g., pelvic inflammatory disease, chronic endometritis)
  • Endometriosis
  • Endometrial cancer (advanced stages)
• Cervical causes
  • Cervicitis
  • Cervical cancer (advanced stages) ^[3]
• Vulvovaginal causes
  • Vaginal injuries, including sexual abuse
  • Vaginal intraepithelial neoplasia (VaIN) or vaginal cancer
  • Vulvovaginal atrophy, e.g., due to genitourinary syndrome of menopause (GSM) ^[10]
  • Vulvovaginitis
  • Retained foreign body
• Other causes
  • Ruptured ovarian cyst
  • Postoperative complications

Clinical evaluation

Focused history ^[6][11]

• Onset, duration, frequency, and amount of bleeding
• Associated symptoms, e.g.:
  • Pelvic pain
  • Vaginal discharge
  • Dyspareunia in women
  • Symptoms of bleeding disorders
  • Symptoms of hypothyroidism
• Sexual history
• Gynecologic and obstetric history
• Current and past medication review
• Relevant risk factors, e.g.:
  • Risk factors for ectopic pregnancy
  • Risk factors for cervical cancer
  • Risk factors for endometrial cancer
  • Risk factors for STIs
• Family history (e.g., of gynecological malignancies, bleeding disorders)

Focused examination ^[6][11]

• Vital signs: for features of hemodynamic instability
• Abdominal examination
• Pelvic examination
  • External genital examination: Inspect the external anogenital region and urethral orifice for any sources of bleeding.
  • Bimanual examination: Assess for uterine enlargement, adnexal masses, and cervical motion tenderness.
  • Speculum examination: Assess for vaginal and cervical sources of bleeding.
• Evaluation for nonobstetric and nongynecologic causes of bleeding as indicated, e.g.:
  • Clinical features of bleeding disorders
  • Examination of the thyroid gland
  • Clinical features of hyperandrogenism

Use a trauma-informed approach during the clinical evaluation, especially if sexual assault is suspected.

Diagnosis

• Obtain a urine pregnancy test in all individuals who can become pregnant if pregnancy status is unknown. ^[6]
• Perform diagnostics for menopause if the patient's menopausal status is unclear.
• Tailor diagnostic approach and management based on menopausal status and nature of bleeding; see the respective sections.

Approach ^[6]

• Hemodynamically unstable patients
  • Start immediate hemodynamic support and management of hemorrhagic shock.
  • Consult OB/GYN to evaluate the need for urgent intervention.
• Hemodynamically stable patients
  • Identify and treat the underlying cause.
  • See also “Diagnosis of AUB” and “Treatment of AUB.”

Common causes

See also “PALM-COEIN system.”

Approach ^[3][8][22]

Individuals not on HRT

• Assess for risk factors for endometrial cancer.
  • No risk factors and first episode of bleeding: Perform TVUS or endometrial sampling.
  • Risk factors or other indications for endometrial sampling present: Perform endometrial sampling.
• Determine need for further testing.
  • Abnormal endometrial sampling: Refer to a specialist for additional evaluation.
  • Endometrial thickness ≤ 4mm on TVUS and/or normal endometrial sampling: No further testing.
  • Endometrial thickness > 4 mm or inadequate visualization on TVUS: Perform endometrial sampling if not already performed.
  • Endometrial sampling insufficient for diagnosis: Consider TVUS if not already performed. ^[8]
  • Persistent or recurrent symptoms:
    • Obtain hysteroscopy-guided endometrial sampling if not already performed.
    • Otherwise, refer to specialist for additional evaluation.
• Evaluate for other common causes of PMB as indicated.
• Treat underlying cause.

Individuals on HRT ^[4]

• Refer to a specialist.
• Diagnostic studies (e.g., TVUS, endometrial sampling) may be indicated depending on:
  • Presence of risk factors for endometrial cancer
  • Extent of bleeding
  • Time since HRT initiation or dosage change ^[3][4]
• Adjust HRT regimen if indicated.

A comprehensive evaluation of all individuals with PMB is essential to rule out endometrial cancer and endometrial intraepithelial neoplasia. ^[8]

Common causes

Approach ^[5][31]

There is currently no standard diagnostic algorithm for postcoital bleeding. Depending on extent and nature of bleeding, perform diagnostics for AUB and evaluation of PMB as indicated.

• Obtain a pregnancy test in all individuals who can become pregnant.
• Evaluate for cervical pathology, including:
  • Diagnostics for cervicitis
  • Cervical cancer screening (if not up-to-date)
  • Colposcopy in selected patients, e.g.:
    • As part of risk-based management for abnormal cervical cancer screening results
    • With features suggestive of cervical cancer on pelvic examination
• For persistent bleeding, refer to gynecology for consideration of additional workup.

Rule out endometrial cancer in postmenopausal patients with postcoital bleeding. ^[5]

Common causes

The underlying cause of postcoital bleeding remains unclear in the majority of patients, but bleeding often resolves spontaneously. ^[5]

The following applies to antepartum patients. Postpartum hemorrhage is detailed separately.

Etiology ^{[37][38][39][40]}

Painless bleeding

• < 20 weeks' gestation
  • Implantation bleeding
  • Threatened abortion
• > 20 weeks' gestation (antepartum hemorrhage)
  • Placenta previa
  • Vasa previa

Painful bleeding

• < 20 weeks' gestation
  • Ectopic pregnancy or heterotopic pregnancy
  • Spontaneous abortion
  • Subchorionic hematoma
  • Gestational trophoblastic disease
• > 20 weeks' gestation (antepartum hemorrhage)
  • Placental abruption (e.g., due to trauma in pregnancy)
  • Uterine rupture

Initial management

• Assess hemodynamic status.
• Hemodynamically unstable patients
  • Initiate immediate hemodynamic support and management of hemorrhagic shock.
  • Urgently consult OB/GYN to evaluate the need for emergency surgery.
• See also “Management of ruptured ectopic pregnancy” and if > 20 weeks' gestation, “Initial management of antepartum hemorrhage.”

Clinical evaluation ^[38][39]

Focused history

• Onset, duration, frequency, and amount of bleeding
• Prior bleeding episodes during pregnancy
• Associated symptoms (e.g., pain)
• Obstetric and gynecologic history
• Relevant risk factors, e.g.:
  • Risk factors for ectopic pregnancy
  • Risk factors for spontaneous abortion

Focused examination

• Vital signs: for features of hemodynamic instability
• Clinical assessment of volume status
• Abdominal examination, including assessment for peritoneal signs
• Pelvic examination
  • All patients: external genital examination
  • In patients < 20 weeks' gestation, perform a bimanual and speculum examination to assess for:
    • Nonobstetric causes of bleeding (e.g., infection, cervical polyps)
    • Adnexal masses or tenderness
    • Products of conception
    • Open or closed cervical os
  • In patients > 20 weeks' gestation, do not perform a pelvic examination until after placenta previa and vasa previa have been excluded on TVUS.

In pregnant patients > 20 weeks' gestation with vaginal bleeding, evaluate the placenta with TVUS before performing a pelvic examination. ^[7]

Diagnostics ^[39][41]

• All patients
  • Obtain CBC and type and screen.
  • Consider additional laboratory studies based on clinical suspicion (e.g., coagulation studies in patients with suspected bleeding disorders). ^[38]
• Patients < 20 weeks' gestation: Obtain β-hCG and TVUS. ^[40][42][43]
  • Sonographic signs of intrauterine pregnancy (IUP): Manage as threatened abortion; see “Spontaneous abortion” for details. ^[44]
  • TVUS findings of pregnancy failure: See “Spontaneous abortion.” ^[44]
  • TVUS findings suggestive of ectopic pregnancy: Perform diagnostics for ectopic pregnancy. ^[45]
  • Pregnancy of unknown location: Arrange close follow-up (e.g., within 48 hours) for re-evaluation. ^[7][46]
• Patients > 20 weeks' gestation ^[40]
  • Obtain TVUS and/or transabdominal ultrasound to assess for placenta previa and vasa previa.
  • Perform electronic fetal heart rate monitoring.
  • See “Antepartum hemorrhage” for additional details.

Suspect ectopic pregnancy in all patients with vaginal bleeding unless IUP is confirmed on ultrasound. Consider heterotopic pregnancy in patients receiving infertility treatment. ^[42][43]

TVUS is the preferred imaging modality to evaluate bleeding in the first trimester of pregnancy. ^[42]

Management ^[39]

• Identify and treat the underlying cause.
• RhD-negative individuals: Provide management of RhD-negative individuals during pregnancy.

Administer anti-D immunoglobulin to all nonsensitized Rh-negative patients with vaginal bleeding, ideally within 72 hours of symptom onset. ^[47]

Common causes

For patients > 20 weeks' gestation, see “Causes of antepartum hemorrhage.”

Always consider ectopic pregnancy in individuals with a pregnancy < 20 weeks' gestation who present with vaginal bleeding. ^[7]

Implantation bleeding, which occurs around the time of expected menses, should also be considered as a benign cause of vaginal spotting or bloody discharge. ^[37]

Etiology

Premenarchal children ^[55]

• Neonatal uterine bleeding
• Precocious puberty
• Coagulopathy
• Retained foreign body (e.g., toilet paper)
• Vulvovaginitis in children
• Vaginal injuries or trauma, including child sexual abuse
• Tumors (e.g., juvenile granulosa cell tumor, rhabdomyosarcoma)

Adolescents ^[11]

Vaginal bleeding in nonpregnant adolescents is usually due to causes of AUB. The most common causes include:

• Physiological
• Medications (e.g., hormonal contraceptives)
• Infection (e.g., PID, cervicitis)
• Coagulopathy
• Tumors

Management

Premenarchal children ^[55][56]

• Perform a history and external genital examination to assess for:
  • Vulvovaginitis
  • Vaginal injuries
  • Retained foreign bodies
  • Child sexual abuse
• Determine Tanner stage.
• If no cause evident on clinical evaluation, refer to a specialist (e.g., gynecology, endocrinology) for further management.

Adolescents ^[11]

• Perform diagnostics for AUB with the following considerations:
  • A speculum examination is not necessary.
  • Obtain coagulation factors in all patients with heavy bleeding.
  • Cervical cancer screening is not indicated.
  • Consider transabdominal ultrasound as the initial modality when imaging is indicated.
• Treatment depends on the underlying cause (see also “Treatment of AUB”).

Exclude pregnancy as a cause of vaginal bleeding in all sexually active adolescents. ^[11]

• Bleeding from the vulva, e.g., due to:
  • Genital herpes
  • Genital warts
  • Vulvar dermatoses (e.g., lichen planus, lichen sclerosus)
  • Vulvar injuries
  • Vulvar cancer
• Bleeding from the urinary tract, e.g., due to: ^[55]
  • Urethral prolapse
  • Urethral diverticulum
  • Urethritis
  • Urethral cancer
• Bleeding from the anal canal, e.g., due to:
  • Hemorrhoids
  • Anal fissures
  • Anorectal tumors