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Vaginal bleeding

Last updated: May 13, 2025

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Summarytoggle arrow icon

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.

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Vaginal bleeding in nonpregnant adultstoggle arrow icon

Definitions

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

Painful bleeding

Clinical evaluation

Focused history [6][11]

Focused examination [6][11]

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

Diagnosis

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Premenopausal bleedingtoggle arrow icon

Approach [6]

Common causes

See also “PALM-COEIN system.”

Common causes of AUB [6][11]
Characteristic clinical features Diagnostic findings Management
Polycystic ovary syndrome
Uterine leiomyoma [11][12]
Adenomyosis [15][16]
  • Imaging (TVUS, MRI): asymmetric myometrial thickening
  • Biopsy (selected patients): histopathological confirmation [17]

Endometrial polyps [18][19][20]

Endometrial hyperplasia or cancer
Bleeding disorders
Medications
  • Discontinuation of contributing medications, if possible

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Postmenopausal bleedingtoggle arrow icon

Approach [3][8][22]

Individuals not on HRT

Individuals on HRT [4]

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

Common causes

Common causes of postmenopausal bleeding [22]
Characteristic clinical features Diagnostic findings Management
Genitourinary syndrome of menopause [10][23][24]
Endometrial polyps [18][19]
Endometrial hyperplasia [25][26]
Endometrial cancer [27]
Cervical cancer [28][29]
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Postcoital bleedingtoggle arrow icon

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.

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

Common causes

Common causes of postcoital bleeding [5][31]

Characteristic clinical features

Diagnostic findings Management
Cervical ectropion [5][32]
Cervicitis [33]
PID [33]
Cervical polyps [32][34]
  • Small and asymptomatic: monitoring
  • Symptomatic: polypectomy
Cervical cancer [28][29]
Endometrial polyps [18][36]
Vulvovaginal atrophy [23]
Vaginal injuries

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

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Vaginal bleeding in pregnancytoggle arrow icon

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

Etiology [37][38][39][40]

Painless bleeding

Painful bleeding

Initial management

Clinical evaluation [38][39]

Focused history

Focused examination

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

Diagnostics [39][41]

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]

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.”

Common causes of vaginal bleeding in early pregnancy (< 20 weeks' gestation) [7][39][41][44]
Characteristic clinical features Diagnostic findings Management
Subchorionic hematoma [37][48]
Ectopic pregnancy [45][50]
Threatened abortion [44]
Spontaneous abortion [39][44]
Molar pregnancy [52][53]

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]

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Vaginal bleeding in children and adolescentstoggle arrow icon

Etiology

Premenarchal children [55]

Adolescents [11]

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

Management

Premenarchal children [55][56]

Adolescents [11]

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

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