Vaginal Bleeding (Non-Pregnant)

Background

• This page is for the generalized approach to undifferentiated vaginal bleeding in non-pregnant women
• Normal menstruation:
  • 28 +/- 7 day cycles
  • 4 days of bleeding
  • Usual amount bleeding per period 10-35 cc
  • Each normal sized tampon or pad holds 5 cc when soaked through

Vaginal Bleeding Definitions

• Menorrhagia: >7 day (prolonged) or >80 mL/day (excessive) uterine bleeding at regular intervals
• Metrorrhagia: irregular vaginal bleeding outside the normal cycle
• Menometrorrhagia - Excessive irregular vaginal bleeding
• Intermenstrual bleeding - variable amounts between regular menstrual periods
• Midcycle spotting - spotting just before ovulation (due to decline in estrogen)
• Postmenopausal bleeding - recurrence of bleeding after menopause
• Polymenorrhea: Frequent and light bleeding
• Postcoital bleeding: vaginal bleeding after intercourse, suggesting cervical pathology
• Postmenopausal bleeding: Any bleeding that occurs >6 mo after cessation of menstruation

Clinical Features

• Vaginal bleeding in a non-pregnant woman

Differential Diagnosis

Nonpregnant Vaginal Bleeding

Systemic Causes

• Cirrhosis
• Coagulopathy (Von Willebrand, ITP)
• Group A strep vaginitis (prepubertal girls)
• Hormone replacement therapy
• Hypothyroidism
• Secondary anovulation

Reproductive Tract Causes

• Adenomyosis
• Atrophic endometrium
• Dysfunctional uterine bleeding
• Endometriosis
• Fibroids
• Foreign Body
• Infection (vaginitis, PID)
• IUD
• Neoplasia
• Vaginal Trauma

Evaluation

Work-Up

• Urine pregnancy
• hemoglobin
• Coags (only if history of or suspect coaulopathy)
• ?TSH, prolactin (only if suspect endocrine disorder)
• Consider follow up for non-emergent pelvic ultrasound
  • No indication for emergent ultrasound in ED

Evaluation

• Hemodynamically stable patient in ED must rule-out:
  • Pregnancy
  • Trauma
  • Bleeding dyscrasia
  • Infection
  • Retained foreign body
  • If work up negative, can refer for further outpatient work up

Management

Mild Bleeding

• Iron supplementation
• Ibuprofen
  • For cramps and can theoretically decreases intra-uterine bleeding

Moderate continued bleeding

Patients can benefit from initiation of birth control or for acute cessation consider medroxyprogesterone therapy in the ED

• Medroxyprogesterone
  • Give only if endocervical curettage/endometrial biopsy does not need to be performed (young patient) or has already been performed, since the hormone may alter the results
  • High Dose regimen: 150mg IM x 1 then 20mg PO Q8hrs x 3 days
  • In a trial of 48 patients all had cessation in 5 days.
  • Alternative regimen: 10mg PO q8 x 7 days then 10mg daily x 3 weeks

Life Threatening

• Establish large bore IV access
• Prepare for emergent blood transfusion uncrossmatched O-negative blood if typed blood is not available.
• It is possible to temporize bleeding w/ intravaginal packing with kerlix soaked in with thrombin
• If bleeding is due to a traumatic cause emergent surgical repair is necessary
• Tranexamic acid
  • Coordinate with OBGYN prior to administration due to the increased thrombotic risk
  • Acutely 10 mg/kg IV, max dose of 600 mg
  • Then 1-1.5 g TID PO for 5 days

Disposition

• Most can be discharged home with OB/GYN follow-up
• For severe anemia or persistent exceedingly heavy flow, consider admission and/or discussion with OB/GYN

See Also

• Vaginal Bleeding (Main)

Authors

Daniel Ostermayer, Ross Donaldson, Kevin Lu, Manuel Celedon, Jordan Swartz, Allen Bookatz, Claire, Neil Young