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Vaginal bleeding
ICD-10 N92-N93, N93.8
MedlinePlus 007496

Vaginal bleeding is any bleeding through the vagina, including bleeding from the vaginal wall itself, as well as (and more commonly) bleeding from another location of the female reproductive system. Generally, it is either a physiologic response during the non-conceptional menstrual cycle or caused by hormonal or organic problems of the reproductive system. Vaginal bleeding may occur at any age, but always needs investigation when encountered in female children or postmenopausal women. Vaginal bleeding during pregnancy may indicate a possible pregnancy complication that needs to be medically addressed.

Blood loss per vaginam (Latin: through the vagina) (PV) typically arises from the lining of the uterus (endometrium), but may arise from uterine or cervical lesions, the vagina, and rarely from the Fallopian tube. During pregnancy it is usually but not always related to the pregnancy itself. Rarely, the blood may actually arise from the urinary tract (hematuria), although the vast majority of females can identify the difference. It can also be a sign of vaginal cancer.

Differential diagnosis[edit]

There are many potential causes for abnormal vaginal bleeding.

Bleeding in children[edit]

Bleeding before the expected time of menarche could be a sign of precocious puberty. Other possible causes include the presence of a foreign body in the vagina, molestation, vaginal infection (vaginitis), and rarely, a tumor.

Premenopausal women[edit]

Most unusual bleeding or irregular bleeding (metrorrhagia) in premenopausal women is caused by changes in the hormonal balance of the body. These changes are not pathological. Exceptionally heavy bleeding during menstruation is termed menorrhagia or hypermenorrhea, while light bleeding is called hypomenorrhea. Women on hormonal contraceptives can experience breakthrough bleeding and/or withdrawal bleeding. Withdrawal bleeding occurs when a hormonal contraceptive or other hormonal intake is discontinued.[1]

There are pathological causes of unusual vaginal bleeding as well. Dysfunctional uterine bleeding is a common cause of menorrhagia and irregular bleeding. It is due to a hormonal imbalance, and symptoms can be managed by use of hormonal contraception (although hormonal contraception does not treat the underlying cause of the imbalance). If it is due to polycystic ovary syndrome, weight loss may help, and infertility may respond to clomifene citrate.[citation needed] Uterine fibroids (leiomyoma) are benign tumors of the uterus that cause bleeding and pelvic pain in approximately 30% of affected women. Adenomyosis, a condition in which the endometrial glands grow into the uterine muscle, can cause dysmenorrhea and menorrhagia.[2] Cervical cancer may occur at premenopausal age, and often presents with "contact bleeding" (e.g. after sexual intercourse). Uterine cancer leads to irregular and often prolonged bleeding. In recently pregnant women who have delivered or who have had a miscarriage, vaginal bleeding may be a sign of endometritis or retained products of conception.

Pregnant women[edit]

Vaginal bleeding occurs during 15-25% of first trimester pregnancies. Of these, half go on to miscarry and half bring the fetus to term.[3] There are a number of causes including rupture of a small vein on the outer rim of the placenta. It can also herald a miscarriage or ectopic pregnancy, which is why urgent ultrasound is required to separate the two causes. Bleeding in early pregnancy may be a sign of a threatened or incomplete miscarriage.

In the second or third trimester a placenta previa (a placenta partially or completely overlying the cervix) may bleed quite severely. Placental abruption is often associated with uterine bleeding as well as uterine pain.

Postmenopausal women[edit]

Endometrial atrophy, uterine fibroids, and endometrial cancer are common causes of postmenopausal vaginal bleeding.

Clinical evaluation[edit]

Sonohysterography performed because of postmenopausal bleeding. In serial images, polyps would be more immobile than freely moving debris within the uterine cavity which are seen in the image.

The cause of the bleeding can often be discerned on the basis of the bleeding history, physical examination, and other medical tests as appropriate. The physical examination for evaluating vaginal bleeding typically includes visualization of the cervix with a speculum, a bimanual exam, and a rectovaginal exam. These are focused on finding the source of the bleeding and looking for any abnormalities that could cause bleeding. In addition, the abdomen is examined and palpated to ascertain if the bleeding is abdominal in origin. Typically a pregnancy test is performed as well.[2] If bleeding was excessive or prolonged, a CBC may be useful to check for anemia. Abnormal endometrium may have to be investigated by a hysteroscopy with a biopsy or a dilation and curettage.

In an emergency or acute setting, vaginal bleeding can lead to hypovolemia.[2]

The treatment will be directed at the cause. Hormonal bleeding problems during the reproductive years, if bothersome to the woman, are frequently managed by use of combined oral contraceptive pills.

Postmenopausal bleeding[edit]

In postmenopausal bleeding, guidelines from the United States consider transvaginal ultrasonography to be an appropriate first-line procedure to identify which women are at higher risk of endometrial cancer. A cut-off threshold of 3 mm or less of endometrial thickness should be used for in women with postmenopausal bleeding in the following cases:

A cut-off threshold of 5 mm or less should be used for women on sequential hormone replacement therapy consisting both of an estrogen and a progestagen.[4]

It the endometrial thickness equals the cut-off threshold or is thinner, and the ultrasonography is otherwise reassuring, no further action need be taken. Further investigations should be carried out if symptoms recur.[4]

If the ultrasonography is not reassuring, hysteroscopy and endometrial biopsy should be performed. The biopsy may be obtained either by curettage at the same time as inpatient or outpatient hysteroscopy, or by using an endometrium sampling device such as a pipelle which can practically be done directly after the ultrasonography.[4]

Complications[edit]

Severe acute bleeding, such as caused by ectopic pregnancy and post-partum hemorrhage, leads to hypovolemia (the depletion of blood from the circulation), progressing to shock. This is a medical emergency and requires hospital attendance and intravenous fluids, usually followed by blood transfusion. Once the circulating volume has been restored, investigations are performed to identify the source of bleeding and address it.[2] Uncontrolled life-threatening bleeding may require uterine artery embolization (occlusion of the blood vessels supplying the uterus), laparotomy (surgical opening of the abdomen), occasionally leading to hysterectomy (removal of the uterus) as a last resort.

A possible complication from protracted vaginal blood loss is iron deficiency anemia, which can develop insidiously. Eliminating the cause will resolve the anemia, although some women require iron supplements or blood transfusions to improve the anemia.

References[edit]

  1. ^ Farlex Medical Dictionary > Withdrawal Bleeding, in turn citing Mosby's Medical Dictionary, 8th edition
  2. ^ a b c d Morrison, LJ; Spence, JM (2011). Vaginal Bleeding in the Nonpregnant Patient. Tintinalli's Emergency Medicine: A Comprehensive Study Guide (New York City: McGraw-Hill). 
  3. ^ Snell, BJ (Nov–Dec 2009). "Assessment and management of bleeding in the first trimester of pregnancy.". Journal of midwifery & women's health 54 (6): 483–91. doi:10.1016/j.jmwh.2009.08.007. PMID 19879521. 
  4. ^ a b c Investigation of post-menopausal bleeding. A national clinical guideline.. Updated by ECRI Institute on June 8, 2012.

Original courtesy of Wikipedia: http://en.wikipedia.org/wiki/Vaginal_bleeding — Please support Wikipedia.
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1872 news items

 
New York Times
Fri, 07 Nov 2014 18:33:55 -0800

In Louisiana, a woman who went to the hospital for unexplained vaginal bleeding was locked up for over a year on charges of second-degree murder before medical records revealed she had suffered a miscarriage at 11 to 15 weeks of pregnancy. Florida has ...

Press & Sun-Bulletin

Press & Sun-Bulletin
Thu, 20 Nov 2014 08:30:51 -0800

Symptoms may include a heavy feeling in the pelvis, pain in the lower abdomen, vaginal bleeding, weight gain or loss, abnormal menstrual periods, unexplained back pain that gets worse, and gas, nausea, vomiting or loss of appetite. It can be diagnosed ...

90.3 KAZU

90.3 KAZU
Fri, 21 Nov 2014 09:03:45 -0800

A trans man of color who had persistent and dangerously heavy vaginal bleeding for months had to jump through hoop after hoop to receive appropriate care; medical professionals accused him of exaggerating his condition to get insurance to cover ...

New York Daily News

New York Daily News
Thu, 20 Nov 2014 17:34:24 -0800

She had vaginal bleeding and bruises on her arms when examined at a hospital a couple of days later. Rubenstein, 70, has denied a rape occurred and maintained sex was consensual. The famed civil rights lawyer has not been arrested. But a potentially ...
 
LiveScience.com
Tue, 06 May 2014 07:26:15 -0700

For women with regular periods, abnormally heavy bleeding may be a sign of blood cancer, and although this symptom is rare, it shouldn't be missed, a new study says. Researchers reviewed information from about 2,000 young and middle-age women with ...

New York Post

New York Post
Thu, 20 Nov 2014 01:32:49 -0800

The accuser went to the hospital Oct. 3 because of vaginal bleeding and bruises on her arms. Montgomery and his client last met with investigators about three weeks ago. Since then, the DA's office has stopped responding to his inquiries. “Our client ...
 
dailyRx
Sat, 08 Nov 2014 09:10:12 -0800

Dabigatran was tied to a greater risk of blood in the urine (hematuria), vaginal bleeding, bleeding in joint spaces (hemarthrosis) and coughing up blood (hemoptysis). The risk of stomach and intestinal bleeding was especially high. Dabigatran users ...

Medical Research News and Interviews on MedicalResearch.com (blog)

Drug Discovery & Development
Wed, 05 Nov 2014 11:07:30 -0800

Patients with atrial fibrillation who take the blood thinner dabigatran are at greater risk for major bleeding and gastrointestinal bleeding than those who take warfarin, according to a new study by researchers at the University of Pittsburgh Graduate ...
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