Vaginal Bleeding
Vaginal Bleeding: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics
Vaginalbleeding is physiologic in the neonatal period and during the normalmenstrual cycle. Maternal estrogen stimulates endometrial growthin the fetus, but after delivery, the decrease in serum estrogenleads to endometrial sloughing and mild vaginal bleeding, whichmay last for a few weeks.A normal menstrual cycle generallylasts 21–35 days, with flow lasting 3–7 days.Normal blood loss during cycle is usually 30–40 mL butcan be up to 80 mL, which usually translates into 10–15 soakedtampons or pads during each cycle.In any other circumstances, vaginalbleeding is abnormal. Principal Causes of Vaginal Bleeding
- Beforenormal menarche
- Trauma
- Vulvovaginitis
- Foreign body
- Urethral prolapse
- Condyloma acuminata
- Exogenous hormone preparations
- Precocious puberty
- Premature menarche
- Hypothyroidism
- Genital tract tumors
- After menarche
- Trauma
- Vulvovaginitis
- Foreign body
- Pelvic inflammatory disease
- Cervicitis
- Cervical polyps
- Anovulatory cycles
- Ovulation
- Endometriosis
- Genital tract tumors
- Bleeding disorders
- Endocrine disorders
- Systemic diseases
- Drugs
- Complications of pregnancy
Clinical Features and Diagnosis
Before Normal Menarche
In addition to conditions discussed in thissection, genital tract tumors can cause vaginal bleeding (see section Genital Tract Tumors below).
Trauma
Blunt traumafrom a fall or bicycle injury is common cause of vaginal bleedingduring childhood. Abrasions and lacerations of vulva, vagina, and,less commonly, cervix may occur.Sexual abuse or rape is another commoncause of genital tract injury and bleeding.Trauma also may injure urethra, bladder,rectum, and abdominal viscera. Exam of these areas should be performedin anyone with significant vaginal or vulvoperineal injury. Dependingon circumstances and age of child, vaginal exam under general anesthesiamay be necessary. Vulvovaginitis
Nonspecificvulvovaginitis usually presents with nonbloody discharge. Pathogens thatmay be associated with blood-tinged discharge are Shigella speciesand group A Streptococcus. Vaginal culture is diagnostic.Some children with pinworm infestationmay scratch so much that excoriation and bleeding occur. Seeingthreadlike white pinworms or viewing pinworm eggs under microscopeis diagnostic. Foreign Body
Highestincidence of vaginal foreign body is at 2–4 yrs of age.Some common items are pins, paper clips,beads, crayons, and toilet paper.Vaginal bleeding may occur with orwithout discharge, which is usually foul smelling.Sometimes foreign body can be palpableon rectal exam. Pelvic radiography may be diagnostic if foreignbody is radiopaque.Vaginoscopy is usually necessary fordiagnosis and removal, and sometimes it is necessary to performthis exam under anesthesia. Urethral Prolapse
Is the protrusion of mucosa through the urethralmeatus. Small urethral opening is seen in middle of inflamed, edematous,purplish tissue that is above and separate from vaginal introitus.Mild bleeding appears to come from the vagina, but its origin isthe prolapse.
Condyloma Acuminata
Human papillomavirus (HPV) is the cause of condyloma acuminata, which are skin-coloredwarts with cauliflower-like appearance that can involve labia, perinealarea, and vagina.Because incubation period may be manymonths, child with warts before age 2 yrs may have been infectedas infant. Whether longer intervals result in this infection isunknown.Nonsexual contact also may be possibleexplanation in infants and children. However, possibility of sexualabuse should be considered regardless of age, because this is asexually transmitted infection.Diagnosis of condyloma acuminata isusually clinical. Biopsy is definitive, and specific HPV type canbe established by molecular techniques. Exogenous Hormone Preparations
Exogenous hormone preparations that containestrogens may induce breast development and uterine bleeding. Historyand physical exam are usually diagnostic.
Precocious Puberty
Precocious puberty with premature onset ofmenses can produce vaginal bleeding (see Chap. 48, Precocious Puberty).
Premature Menarche
Isolatedmenses that occur earlier than normal menstruation and without otherevidence of sexual development characterize the rare condition ofpremature menarche.Intermittent spotting or bleeding maycontinue for several days at a time. These episodes may occur onceor in cycles for several months. Puberty occurs at normal time,and menstrual cycles are normal.This disorder is most likely due totransient production of estrogen by ovary.In some girls, abdominal U/Sreveals ovarian follicular cysts. Hypothyroidism
With primary severe hypothyroidism, cross-reactivityof high levels of TSH with ovarian follicle-stimulating hormonereceptors can cause increase in estrogen secretion and subsequentbreast development and vaginal bleeding. Regression occurs followingtreatment with thyroid hormone.
After Menarche
Trauma
Injuriesto vulva and vagina from falls or straddle injuries may cause vaginalbleeding. Sexual assault is another cause of vaginal trauma andbleeding.Erosions of cervix may occur in girlswho have had sexual intercourse or who have borne a child. Intermittentvaginal spotting is frequent occurrence.Diagnosis is confirmed by exam of thecervix. Vulvovaginitis, Foreign Body, and Pelvic Inflammatory Disease
See previous section. In adolescent girls,most common foreign body is retained tampon. Pelvic inflammatorydisease is discussed in Chap.71, Vaginal Discharge.
Cervicitis
Infection with C. trachomatis, N. gonorrhoeae,herpes simplex virus, or T. vaginalis may cause cervicitis. Cervixis inflamed and mucopurulent discharge may be visible. Diagnosisof these infections is discussed in Chap.71, Vaginal Discharge.
Cervical Polyps
May cause intermenstrual spotting in adolescentgirls, especially in those who have borne children or who have hadgonorrhea. Exam of cervix is diagnostic.
Anovulatory Cycles
In adolescence,uterus is most often source of abnormal vaginal bleeding. Most commoncause is anovulatory cycles, which lead to dysfunctional uterinebleeding.During first years after menarche,bleeding may be frequent, prolonged, irregular, and excessive.Prolonged anovulation increases riskfor dysfunctional uterine bleeding. Reason seems to be an impairednegative feedback system. Unopposed estrogen produces thickenedendometrium, and without adequate progesterone, sloughing occurswith potential for heavy bleeding.This is diagnosis of exclusion. Ovulation
Mild, self-limited, midcycle bleeding for1–2 days may be associated with transient decrease in serumestrogen that occurs at time of ovulation. Bleeding also may beaccompanied by mild pain (mittelschmerz).
Endometriosis
Irregular menses with anovulation has beenassociated with endometriosis, which is discussed in Chap. 2, Abdominal Pain.
Genital Tract Tumors
Benign andmalignant tumors of female genital tract are rare in pediatric population butcan present with abnormal vaginal bleeding.Cervical papilloma may present withvaginal bleeding, and soft, friable polypoid mass may be seen arisingfrom cervix.Adenocarcinoma of vagina or cervixand rhabdomyosarcoma (sarcoma botryoides) may present with vaginalbleeding or blood-tinged vaginal discharge. History of maternalingestion of diethylstilbestrol or other synthetic estrogen duringpregnancy may exist with adenocarcinoma. Mass may be seen on pelvicexam with vaginal or cervical tumor.Uterine tumors may present with vaginalbleeding, mass protruding from os, enlarged uterus, or pelvic mass. Although genital tract tumors are rare,they should be considered in any child or adolescent who has abnormalgenital tract bleeding, vaginal discharge, tissue protruding fromvagina, abdominal enlargement, or pelvic mass.Vaginoscopy, pelvic U/S, andlaparoscopy are useful in diagnosis. Histologic diagnosis is definitive. Bleeding Disorders
Presenceof excessive or gushing bleeding with cyclic menses from time ofmenarche should suggest coagulation disorder [e.g., thrombocytopenia(idiopathic thrombocytopenic purpura, leukemia, aplastic anemia),von Willebrand disease, or, rarely, a factor deficiency].CBC, blood smear, platelet count, prothrombintime, activated partial thromboplastin time, and bleeding time effectivelyscreen for most bleeding disorders. See Chap. 52, Purpura and Bleeding,for discussion of these disorders. Endocrine Disorders
Irregularmenses may be associated with hypothyroidism, hyperthyroidism, hyperprolactinemia,and adrenal disorders (Addison disease, Cushing syndrome, late-onsetcongenital adrenal hyperplasia).Ovarian disease (e.g., steroid-secretingovarian tumors, polycystic ovary syndrome, and premature ovarianfailure) also may cause abnormal bleeding. Polycystic ovary syndromeshould be considered in adolescent with hirsutism, acanthosis nigricans,acne, and obesity. Systemic Diseases
Menstrualfunction is usually normal with diabetes mellitus, but irregularcycles can occur, especially with poorly controlled disease.Females with chronic renal diseaseon dialysis have irregular menses that vary from occasional spottingto dysfunctional uterine bleeding. Drugs
Use of oralcontraceptives may produce intermittent vaginal spotting or bleeding,especially during initial 3 mos of use. Intermittent spotting orbreakthrough bleeding also may occur with injectable medroxyprogesteroneand long-acting progesterone implants.Medications (e.g., anticoagulants andplatelet inhibitors) may be associated with excessive bleeding.Irregular menses may be caused by tricyclicantidepressants and valproic acid. Anabolic steroids also may produceanovulatory cycles with irregular bleeding. Complications of Pregnancy
Before 20 Wks' Gestation
Pregnant female with uterine bleeding before20 wks' gestation has complicated intrauterine pregnancy,ectopic pregnancy, or molar pregnancy.
Intrauterine Pregnancy
Threatenedabortion is diagnosed if U/S shows intrauterine pregnancywith viable fetus.Spontaneous abortion is consideredinevitable when there is gross rupture of membranes in presenceof cervical dilatation.In incomplete abortion, tissue fragmentshave already been expelled from uterus. Bleeding is usually heavy,and painful uterine contractions may occur.Missed abortion is retention of deadproducts of conception in utero for several weeks. After fetal death,vaginal bleeding may or may not occur. Occasionally, serious coagulationdefects may occur with prolonged retention of dead fetus. Ectopic Pregnancy
Classically,ectopic pregnancy presents with pelvic pain, vaginal bleeding, andamenorrhea.Although most females have pelvic pain,the other 2 symptoms are less consistent.Results of urine or serum pregnancytest are positive. If question exists about possibility of ectopicpregnancy in nonemergent situation, serial quantitative serum humanchorionic gonadotropin pregnancy tests are useful.Pelvic U/S can help in demonstratingpresence of normal intrauterine pregnancy or mass.Laparoscopy should be considered ifdiagnosis remains uncertain.If vaginal bleeding occurs during firstor second trimester with signs of cardiovascular compromise, rupturedectopic pregnancy is possible. Immediate fluid resuscitation ismandatory, and emergency laparoscopy or laparotomy may be necessary.If patient is stable, pelvic U/S may help clarify diagnosis. Molar Pregnancy
Hydatidiform mole presents with uterine bleedingusually during first trimester. Bleeding may be intermittent orcontinuous. Uterus is often larger than expected for duration ofgestation. Pelvic U/S is diagnostic.
After 20 Wks' Gestation
Third-trimester bleeding may indicate anemergency due to placenta previa or abruptio placenta, and obstetricevaluation should be undertaken without delay.
Diagnostic Approach
Before Menarche
Trauma,vulvovaginitis, and foreign body are most common causes of abnormalvaginal bleeding before menarche.Complete history and physical examshould be performed, including exam of external genitalia and vaginalintroitus. Exam under anesthesia is necessary with significant trauma,foreign body that cannot be removed, or suspected genital tumor.Approach to precocious puberty andvulvovaginitis is described in Chap.48, Precocious Puberty, and Chap. 71,Vaginal Discharge,respectively. After Menarche
Girls withabnormal vaginal bleeding should have complete history and physicalexam, which includes speculum exam of vagina and cervix and bimanualvaginal exam. Source of bleeding must be determined, whether vulvar,vaginal, cervical, or uterine. If significant vaginal trauma hasoccurred from injury, exam of vagina and cervix may have to be performedunder anesthesia.Diagnostic approach to vulvovaginitisin this age group is discussed in Chap.71, Vaginal Discharge. If uncertainty about pregnancyexists, urine pregnancy test should be performed.If bleeding is from normal-sized uterus,most common cause is from anovulatory cycle, but this is diagnosisof exclusion. Other common causes include ovulation and oral contraceptiveuse. Abnormal vaginal discharge and abdominal pain suggest pelvicinflammatory disease. Heavy cyclic bleeding suggests coagulationdisorder, and certain tests should be performed: CBC with differential,analysis of blood smear, platelet count, prothrombin time, activatedpartial thromboplastin time, and bleeding time. Uterine tumors arerare in adolescent age group.If bleeding is from enlarged uterus,it is likely that there is complication of pregnancy (e.g., spontaneousabortion, ectopic pregnancy, placenta previa, or abruptio placenta).If individual is <20 wks pregnant and has normal BP, eitherectopic pregnancy or spontaneous abortion is likely. In either case, pregnancytest should be performed unless it is a known pregnancy, and obstetricconsultation should be obtained.In girl who is <20 wks pregnantand hypotensive with severe bleeding, ectopic pregnancy is mostlikely cause. If uterine bleeding occurs during third trimesterof pregnancy, placenta previa or abruptio placenta is likely. Externalgenitalia should be inspected and obstetric consultation shouldbe requested. An intravenous line should be placed, CBC drawn, andblood sent for type and cross-match. If patient is hypotensive,fluid resuscitation should be started immediately. References
- Bravender T, Emans SJ. Menstrual disorders:dysfunctional uterine bleeding. Pediatr Clin North Am 1999;46:545–553.
- Claessens EA, Cowell CA. Acute adolescent menorrhagia.Am J Obstet Gynecol 1981;139:277–280.
- Cunningham FG, et al. Williams obstetrics, 20th ed.Stamford: Appleton & Lange, 1997.
- Emans SJH, et al. Pediatric and adolescent gynecology,4th ed. Philadelphia: Lippincott-Raven, 1998.
- Hill NCW, et al. The aetiology of vaginal bleedingin children: a 20-year review. Br J Obstet Gynecol 1989;96:467–470.
- Muram D. Vaginal bleeding in childhood and adolescence.Obstet Gynecol Clin North Am 1990;17:389–407.
- Muram D, et al. Vaginal bleeding and menstrual disordersin adolescence. In: Sanfilippo JS, ed. Pediatric and adolescentgynecology. Philadelphia: WB Saunders, 1994:222–232.
- Paradise JE. Vaginal bleeding. In: Fleischer GR, LudwigS, eds. Textbook of pediatric emergency medicine, 4th ed. Philadelphia:Lippincott Williams & Wilkins, 2000:613–620.
- Pickering LK, ed. 2000 Red book: report of the Committeeon Infectious Diseases, 25th ed. Elk Grove Village, IL: AmericanAcademy of Pediatrics, 2000.
>>
Book Source Details
- Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
- Author(s): Paul S. Bellet
- Year of Publication: 2006
- Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.
More About Vagina conditions
More Medical Textbooks Online about Vagina conditions
Review other book chapters online related to Vagina conditions:
Medical Books Excerpts
- Dysmenorrhea
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Menorrhagia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Metrorrhagia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Dysmenorrhea
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Menorrhagia
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Urethral Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Vaginal Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Dysmenorrhea (Nursing: Interpreting Signs and Symptoms)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
