Abnormal Vaginal Bleeding
Objectives
Describe normal menses
Describe various causes of vaginal bleeding
Educate patients about abnormal vaginal bleeding
Triage and perform assessment of patients presenting
with vaginal bleeding
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Question…
What is the average blood loss during
a typical menstrual cycle?
A.
B.
C.
D.
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20 cc
40 cc
60 cc
80 cc
Case Study 1
42-year-old Veteran
“Heavy” vaginal bleeding
for 3 days
Some cramping
Married, 2 children
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What
should
be
Case Study
the first
#1
question(s)
on your mind?
Initial Assessment
Hemodynamic
stability
Pregnancy
Abdominal/pelvic
pain
Menstruation
patterns
Other symptoms
Blood loss
Check for hypotension, tachycardia,
orthostasis, fever, ill appearance.
LMP, contraception, menopause,
hysterectomy
• Early pregnancy bleeding may be lifethreatening
• Many women unaware of pregnancy
• Always consider her to be pregnant
and rule that out first
─ Urine test detects pregnancy 2 wks
after conception
─ Serum test detects about 1 wk
after conception
─ All clinics caring for women should
have point-of-care (on-site) urine
pregnancy tests; urine results
faster, newer tests highly accurate
Remaining assessment points discussed later.
Hemodynamically Unstable?
YES  urgent evaluation
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Pregnant?
POSITIVE
PREGNANCY TEST  Urgent evaluation
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Answer
What is the average blood loss during
a typical menstrual cycle?
A. 20 cc
B. 40 cc
C. 60 cc
D. 80 cc
Now we’ll explore normal menses,
including average blood loss.
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Cycle every
24 - 35
days
Symptoms
associated
with
menstrual
cycle
Normal
Menses
Duration
2 - 7 days
Average
blood loss
40 ml (2
tbs) per
cycle
Pad count
not reliable
to quantify
blood loss
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Menstrual Cycle
First part of cycle:
• Estrogen dominant 
endometrium builds
Ovulation occurs 14
days before onset of
the next period
After ovulation,
corpus luteum is
formed and creates
progesterone.
Second part of cycle:
• Progesterone
dominant 
endometrium is
stabilized
Correlation Between Cycle Duration
and Bleeding
Intervals
between
cycles
Endometrial
proliferation
Duration of
bleeding
• Shorter intervals between cycles  endometrium has less time
to proliferate  shorter duration of bleeding
• Longer intervals between cycles  endometrium proliferates 
longer periods of bleeding
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Back to the case of our 42 yo veteran with onset
“heavy” vaginal bleeding and cramping. Why does
heavy bleeding occur?
NON-PREGNANT CAUSES: present as…
• Regular, cyclic (ovulatory bleeding)
• Irregular, not cyclic (anovulatory bleeding)
PREGNANCY COMPLICATIONS (discussed later)
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What Causes Ovulatory Bleeding?
Can be heavy, prolonged bleeding at regular intervals
or intermenstrual bleeding
Possible causes:
• Coagulopathy
• Neoplasm/malignancy
• Structural lesions (fibroids, polyps)
• Other (inflammation, infection like STI or endometritis)
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• Structural lesions can cause
regular, heavy bleeding
Uterine Lesions
• Fibroids or other lesions that
are in or near the lining, in
particular, can cause heavy
bleeding
• Fibroids usually cause regular,
heavy bleeding but can also
cause intermenstrual bleeding
• Other lesions, such as polyps,
or even inflammation and
infection can also cause heavy
bleeding
• Endometritis (infection in the
uterine lining, is particularly
prevalent during post-partum
or post-procedure periods
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What Causes Anovulation and
Anovulatory Bleeding?
Primary hypothalamic-pituitary dysfunction
• Pituitary tumors and pituitary syndromes
• Stress, eating disorders, intense exercise
Other endocrine problems
• Polycystic ovary syndrome
• Hyper- or hypothyroidism
Medications
• Hormonal contraceptives
Many other causes
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• In normal menstrual
cycle, endometrial
lining builds up with
estrogen and
stabilizes with
progesterone
Anovulation
• If ovulation doesn’t
occur, progesterone
isn’t produced
• Thus, endometrium
continues to build,
isn’t stabilized, and
begins to slough off
• A woman might
experience irregular
bleeding which can
be heavy or light
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Back to the case…
42-year-old veteran
Hemodynamic
Stability
Pregnancy
What more should you ask?
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Ask about abdominal or pelvic pain:
• Related to worsening menstrual
cramps with increased flow?
• Something serious like an ectopic
pregnancy (with positive
pregnancy test)?
• Query pain duration, constant or
cyclical, location (midline or
lateral), sudden onset or gradual
Initial Assessment
Hemodynamic
stability
Pregnancy
Abdominal/pelvic
pain
Menstruation
patterns
Ask about menstruation patterns
• What is normal for her?
• History of irregular/heavy menses?
Other symptoms
Ask about other symptoms:
• Related to anemia: SOB, lightheadedness, syncope, fatigue
• Related to infection: fever, chills
Blood loss
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Estimating Blood Loss
Try to obtain objective evidence
• For triage, try to quantify bleeding by number of pads the woman
is using, or ask her to compare it with her normal menses.
− Typical definition of profuse bleeding: soaks large sanitary pad or
tampon every hour or two, for two or more hours
− Prolonged uterine bleeding = bleeding for >7 days
• For diagnosis, pad/tampon counts are unreliable. Studies show
50% of women complaining of heavy bleeding have normal blood
loss.
Estimates of blood loss taken by history are not reliable, though you
may get a sense of changes in pattern. CBC and ferritin can help figure
out if she has ongoing, significant blood loss, but these may be normal
in a patient with acute blood loss only.
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Our 42 yo veteran with onset “heavy”
vaginal bleeding…
Sexually active with husband
No contraception
Regular periods, 3 months of heavy bleeding
Normal vital signs, appears well but worried
Negative pregnancy test; CBC, ferritin, TSH ordered
It was decided that she should be seen by the provider
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Exam Room Set-Up
Specifics about room set-up and assisting during the exam is covered
in another session, but in general, necessary equipment includes:
•
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•
•
•
•
•
•
•
•
•
Table with foot rests, privacy curtain, lockable door
Gown and cover sheet
Gloves for provider and assistant
Surgical lubricant
Speculum appropriate for patient: Graves (small, med, large) or Pederson
Light source
Supplies for Pap and GC/chlamydia tests
Procto swabs (also known as fox swabs)
Monsels /silver nitrate sticks if recent gynecological procedure
Pad / panty liner / tissues for post-procedure
Female chaperone is required; assistant may be used in this role
Privacy
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Further Evaluation
Specific Treatment – Medications
NSAIDs (e.g., ibuprofen, naproxen)
Hormonal contraceptives (e.g., OCPs, Depo)
Pelvic Ultrasound
Endometrial Biopsy
Nurses are often asked to explain at least the basics of pelvic
US and endometrial biopsy procedures…
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What is it?
Test to look at organs and
structures in the pelvis.
Pelvic Ultrasound
Transabdominal
How is it done?
A “transducer” sends out sound
waves that bounce off body
structures like an echo to create
a picture. A gel, spread on the
pelvis, allows smooth movement
of the transducer over skin and
eliminates air between the skin
and transducer to improve
sound conduction. A typical
exam takes 30-60 minutes.
Are there risks?
No radiation exposure. Usually
painless. May have some mild
discomfort as the transducer is
guided over a full bladder.
Image used with permission from Krames StayWell
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What is it?
Test to look at reproductive
organs.
Pelvic Ultrasound
Transvaginal
How is it done?
A probe, covered with a condom
and surgical lubricant, is inserted
in the vagina. It sends out sound
waves that bounce off body
structures to create a picture.
What are you looking for?
Abnormal findings, such as
fibroids. Thickness of the
endometrial stripe.
Risks?
No radiation exposure. Generally
painless, but pressure from the
probe could be uncomfortable.
Patients with vaginal atrophy/
dryness might be uncomfortable.
Image used with permission from Krames StayWell
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Endometrial Biopsy
What is an endometrial biopsy?
Tissue is taken from uterine lining (endometrium)
and checked for abnormal or malignant cells.
When is it recommended?
For abnormal bleeding…heavy or
prolonged. Generally women >40.
How is it done?
Office-based, no sedation, typically pre-medicate
with an NSAID.
What are you looking for?
• Cause of abnormal bleeding
• Checking for endometrial cancer
(very accurate for diagnosing
endometrial cancer)
Patient will lie down with feet in foot rests. Provider
will insert speculum to visualize the cervix. Cervix is
cleaned with antiseptic and then grasped with a
tenaculum to stabilize the uterus. Cervical dilator
may be used to open cervical canal if there is
stenosis. Small, hollow, plastic tube is gently passed
into uterine cavity. Gentle suction removes sampling
of the lining.
Patient might be taken to OR for HSC, D&C with
anesthesia. However, office procedures are safe – we
have seen decreases in morbidity and mortality since
office-based endometrial biopsies were introduced.
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What are potential complications?
• Are rare; generally a very safe
procedure
• Infection, bleeding, cramping
• Perforation of the uterus
Endometrial Biopsy
Image used with permission from Krames StayWell
Back to our 42 yo veteran with
“heavy” vaginal bleeding……
Normal endometrial biopsy
Ultrasound showed 2 small fibroids
Bleeding was controlled by low-dose oral contraceptive
Whether or not fibroids are causing the heavy bleeding is not
certain – it could be just changes in her cycle as she
approaches the perimenopausal years.
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Question…
Vaginal bleeding in a woman with a new positive
pregnancy test may be due to:
A.
B.
C.
D.
E.
Threatened abortion
Incomplete spontaneous abortion
Ectopic pregnancy
Vaginal laceration/abrasion
All of the above
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Case Study 2
33-year-old Veteran
Normal cycles, but over past 4-6 weeks
has had spotting on most days and
some heavier bleeding for a few days
Sexually active with a single male
partner
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What are
ALWAYS your
two primary
triage
concerns?
1) Is she hemodynamically
stable?
2) Is she pregnant?
Initial Assessment
Hemodynamic
stability
Pregnancy
After establishing status of
her hemodynamic stability
and pregnancy, you can
move on to a more detailed
pain assessment, assessment
of her menstrual patterns,
other symptoms, and
estimated blood loss.
Abdominal/pelvic
pain
Menstruation
patterns
Other symptoms
Note that this evaluation
follows the same steps as the
evaluation for the previous
patient.
Blood loss
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Case Study 2 Continued….
No acute distress
Normal vital signs
No pain
Positive urine pregnancy test
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What Diagnoses Do You Need to Have
in Mind?
1st trimester
2nd & 3rd trimester
(Spotting may be
normal, but some
abnormalities
need to be kept in
mind)
(Bleeding is NEVER
normal; causes might
include abruptio
placenta or placenta
previa)
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Unrelated to
pregnancy
(Vaginal lesions or
lacerations,
cervical polyps, or
ectropion may
still occur –why
the exam is
important)
Causes of First Trimester Bleeding
Ectopic pregnancy outside of uterus (97% of time in
fallopian tube)
Miscarriage (impending, inevitable, incomplete, or
complete AB)
Physiologic or implantation bleeding (small amount
of spotting/bleeding approx 10-14 days after
fertilization; diagnosis of exclusion; no intervention)
Non-pregnancy causes (discussed already)
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Answer
Vaginal bleeding in a woman with a new positive
pregnancy test may be due to:
A.
B.
C.
D.
E.
Threatened abortion
Incomplete spontaneous abortion
Ectopic pregnancy
Vaginal laceration/abrasion
All of the above
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Back to the case of our 33 yo Veteran with
irregular vaginal bleeding… Next steps for
evaluation
Pelvic exam
Serum pregnancy test (levels of HCG will be
checked against weeks of gestation + US)
Ultrasound
Referral for OB care (if woman does not have
an ectopic, chances of adverse outcomes are
low, but still must be followed closely by OB)
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Question…
Does recurrent bleeding or spotting
between periods require further evaluation?
A. Yes
B. No
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Case Study 3
24-year-old Veteran
Spotting between her periods which
come like clockwork every 28 days.
No missed cycles. No pain, cramping,
vaginal discharge.
No sexual activity for over 6 months
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What are
possible
causes?
Causes of Intermenstrual Bleeding
Hormonal
Contraception
IUD
Infection
Endometrial
polyps
Cancer
(most common)
Cervical Polyps or
Ectropion
Postcoital
Bleeding
Physiologic
(spotting at time of
ovulation due to
decline in estrogen)
Many of these may
be evident on exam,
so a complete H&P is
the next step.
Answer
Does recurrent bleeding or spotting
between periods require further evaluation?
A. Yes
B. No
As we have just reviewed, physiologic bleeding is a diagnosis
of exclusion. Therefore, a pelvic exam with cervical cancer
screening is the MINIMUM evaluation this patient will need.
Likely that she will need additional evaluation beyond that.
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Case Study 4
65-year-old Veteran
Light vaginal bleeding, occurring on
two days in past 3 weeks
Menopause 12 years ago
Sexually active with long-term
female partner
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What
questions
should you
ask?
Emphasis is a bit different when
assessing postmenopausal women…
vaginal bleeding
•with
Pregnancy
− Less concern about pregnancy as women get older
− HOWEVER, if a patient is still menstruating, there is a
chance of pregnancy… we have seen pregnancy in women
who are in their early 50’s
• Hemodynamic stability
− Difficult to assess hemodynamic stability over the phone
− HOWEVER, this patient reported small amounts of
bleeding. If indeed there is little bleeding, hemodynamic
instability is less of a concern.
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Assessment: POSTMENOPAUSAL
WOMEN
Trauma
(Any precipitating factors? Atrophy?)
Bleeding pattern
(When did it start? Temporal pattern, duration,
postcoital, quantity?)
Associated symptoms
(Pain, fever, changes in bladder/bowel function?)
Medications/supplements
(Hormones, anticoagulants, soy-containing herbal
or dietary supplements?)
Family history
(Breast, colon, endometrial cancer?)
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Postmenopausal Bleeding
Possible Causes
Atrophy
Cancer
Polyps/Fibroids/Adenomyosis
Medications
(HRT, herbal or dietary supplements)
Infections
Other
(diseases in adjacent organs, post-radiation)
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Primary goal of evaluating postmenopausal
bleeding is to exclude malignancy
Physical exam,
pelvic exam, Pap
History
Different approach
may be used for
patients on hormone
replacement therapy
Ultrasound and/or
endometrial
biopsy*
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Key Points for Vaginal Bleeding
Multiple causes of abnormal bleeding;
evaluation depends on bleeding pattern, patient
age, other factors
Two main issues for women of childbearing age:
• Hemodynamic stability • Pregnancy
Main issue for postmenopausal women is to rule
out malignancy
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Authors
Laure Veet, MD
Women’s Health Services, Office of Patient Care Services, VHA
Central Office
Deborah Ingram, PhD, ARNP-BC
Malcom Randall VAMC, Gainesville, FL
Melissa McNeil, MD, MPH
VA Pittsburgh Health Care System
Linda Baier Manwell, MS
Univ of Wisconsin-Madison Division of General Internal Medicine
Molly Carnes, MD, MS
Univ of Wisconsin-Madison Center for Women’s Health Research
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