Vaginal Bleeding
Differential Overview
❑ Ovulatory bleeding
❑ Anovulatory bleeding
❑ Uterine leiomyoma
❑ Dysfunctional bleeding
❑ Threatened abortion
❑ Cervical erosion or polyp
❑ Perimenopause
❑ Retained products of gestation
❑ Ectopic pregnancy
❑ Oral contraceptives
❑ Hyperandrogenism
❑ Cervical cancer
❑ Endometrial cancer
❑ Anticoagulation therapy
❑ Thrombocytopenia
❑ Hypothalamic-pituitary-gonadal immaturity
Diagnostic Approach
Passage of clots or inability to control bleeding with tampons is consistent with heavy flow (menorrhagia). Bleeding between normal cyclic menses is metrorrhagia. Remember to establish that bleeding is uterine and not from the rectum or urethra.
In adolescents, anovulation is the cause in 90% of cases of metrorrhagia, although pregnancy should be considered. An underlying bleeding diathesis is found in about 20% of adolescents with menorrhagia. In adult premenopausal women, pregnancy and malignancy are the most important considerations, although leiomyomas (fibroids) are the most common. In perimenopausal women, anovulatory cycles and progesterone deficiency with long periods of unopposed estrogen lead to endometrial hyperplasia and polyps. Bleeding in postmenopausal women should be thoroughly evaluated for endometrial cancer, which will be found in 10% of cases.
Clinical Findings
Ovulatory bleeding Minor bleeding may occur near the midpoint between cycles (metrorrhagia), and is associated with weight gain, breast tenderness, bloating, or dysmenorrhea.
Anovulatory bleeding Bleeding has an unpredictable pattern and variable flow.
Uterine leiomyoma Fibroids occur in 30% of women older than age 35; thus, they may fortuitously coexist with another source of bleeding. They commonly cause heavy cyclical menses. Fibroids are palpable as an asymmetric, rubbery, lumpy uterus.
Dysfunctional bleeding It occurs with stress or exercise. Prolonged bleeding occurs after amenorrhea. Bleeding may be stopped with ethinyl estradiol and induced with medroxyprogesterone, and is diagnostic if the cycle normalizes after bleeding is stopped.
Threatened abortion Bleeding occurs when signs of pregnancy are present: morning nausea, breast swelling, darkening of the nipple and areola, bluish cervix, and an enlarged uterus.
Cervical erosion or polyp They cause intermenstrual and postcoital spotting, and are visible on pelvic exam.
Perimenopause Anovulatory bleeding results in irregular intermenstrual intervals, periods of amenorrhea, and heavy, prolonged bleeding.
Retained products of gestation This is a main cause of bleeding occurring post-abortion (spontaneous or induced).
Ectopic pregnancy A delayed period is followed by spotting to continuous bleeding and unilateral pelvic pain with an adnexal mass. Rupture is signaled by hypotension, marked tenderness, and severe pain radiating to the shoulder.
Oral contraceptives Breakthrough bleeding may occur with a dosage change, missed doses, or psychologic stress.
Hyperandrogenism Polycystic ovary syndrome (PCOS) should be suspected in patients with chronic irregular cycles, hirsuitism, obesity and acanthosis nigricans.
Cervical cancer Bleeding is post-coital, intermenstrual, and spotting occurs.
Endometrial cancer Intermenstrual or postmenopausal bleeding is usually manifest as heavy periods and a watery discharge containing some blood.
Anticoagulation therapy This is easily recognized as heavy periods occurring in a patient on anticoagulants.
Thrombocytopenia A low platelet count may present with heavier-than-normal menstrual flow and petechiae observed on the distal legs.
Hypothalamic-pituitary-gonadal immaturity This is a common cause of irregular bleeding in adolescents.
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
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