Vaginal bleeding

The underlying cause of abnormal vaginal bleeding is dependent on age.

Vaginal bleeding refers to any expulsion of blood from the vagina. 

Such bleeding may originate from the uterus, vaginal wall, or cervix.

It may be, either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system.

The causes of abnormal vaginal bleeding vary by age.

Vaginal bleeding during pregnancy can be normal, especially early pregnancy, or  may indicate a pregnancy complication.

During pregnancy bleeding is usually, but not always, related to the pregnancy itself.

Regular monthly vaginal bleeding during the reproductive years, is termed menstruation.

Menstruation is a normal physiologic process. 

Vaginal bleeding that is excessively heavy, menorrhagia,  that occurs between monthly menstrual periods, intermenstrual bleeding, occurs more frequently than every 21 days, occurs too infrequently, oligomenorrhea, or occurs after vaginal intercourse, postcoital bleeding, should be evaluated.

The causes of abnormal vaginal bleeding vary by age.

Specific medical conditions ranging from hormone imbalances or anovulation to malignancy (cervical cancer, vaginal cancer or uterine cancer) can cause vaginal bleeding.

In young children, or elderly adults with cognitive impairment, the source of bleeding may not be obvious.

Most adult women can identify the site of bleeding.

When vaginal bleeding occurs in prepubertal children or in postmenopausal women, it always needs medical evaluation..

Bleeding before the onset of pubertal development deserves evaluation: could result from local causes or from hormonal factors.

In children, the source of bleeding may actually arise from the bladder or urethra, or from the rectum.

Vaginal bleeding in the first week of life after birth is a common observation.

During childhood possible causes of Vaginal bleeding include:  the presence of a foreign body in the vagina, trauma (accidental or non accidental), urethral prolapse, vaginal infection, vulvar ulcers, vulvar skin conditions such as lichen sclerosus, and rarely, a tumor or hormone-producing ovarian tumors.

 Childhood hormonal causes include central precocious puberty, or peripheral precocious puberty (McCune-Albright syndrome), or primary hypothyroidism.

 Childhood vaginal leading is alarming to parents, but most causes are benign, although sexual abuse or tumor are particularly important to exclude, by

examination under anesthesia or hysteroscopy.

In premenopausal women, bleeding can be from the uterus, from vulvar, vaginal lesions, or from the cervix: gynecologic examination can be performed to determine the source of bleeding. 

Premenopausal bleeding may also occur as a result of a pregnancy complication, such as a spontaneous abortion, ectopic pregnancy, or abnormal growth of the placenta.

10% of premenopausal women with abnormal vaginal bleeding have an associated malignant tumor, while 75% of women over the age of 70 with postmenopausal vaginal bleeding have cancer.

The risk of abnormal vaginal bleeding to be associated with malignancy increases with age in postmenopausal women.

Postmenopausal vaginal bleeding is the most common manifestation of carcinosarcoma.

Causes of abnormal uterine bleeding in premenopausal women who are not pregnant include: fibroids, polyps, hormonal disorders such as polycystic ovary syndrome (PCOS), blood clotting disorders, cancer, infections such as cervicitis or pelvic inflammatory disease (PID), postcoital bleeding is bleeding that occurs after sexual intercourse, and 

birth control induced vaginal spotting or bleeding.

PALM-COEIN system classifies the causes of abnormal uterine bleeding.

This acronym stands for Polyp, Adenomyosis, Leiomyoma, Malignancy and Hyperplasia, Coagulopathy, Ovulatory Disorders, Endometrial Disorders, Iatrogenic Causes, and Not Classified. 

The PALM causes are related to uterine structural, anatomic, and histolopathologic causes.

Assessment of PALM causes with imaging techniques such as ultrasound or biopsy to view the histology of a lesion.

The COEIN causes of abnormal bleeding are not related to structural causes.

Endometrial polyps are benign growths that are typically detected during gynecologic ultrasonography and confirmed using saline infusion sonography or hysteroscopy, often in combination with an endometrial biopsyproviding histopathologic confirmation. 

Endocervical polyps are visible at the time of a gynecologic examination using a vaginal speculum.

Adenomyosis is a condition in which endometrial glands are present within the muscle of the uterus (myometrium), and the pathogenesis and mechanism by which it causes abnormal bleeding have been debated.

Uterine leiomyoma, commonly termed uterine fibroids, are common, and most fibroids are asymptomatic.

Leiomyomas may not be the cause of abnormal bleeding, although fibroids that are submucosal are the most likely to cause abnormal bleeding.

The Malignancy and Hyperplasia category of the PALM-COEIN system includes malignancies of the genital tract, including cancers of the vulva, the vagina, the cervix, and the uterus. 

Endometrial hyperplasia, is more common in women who are obese or who have a history of chronic anovulation. 

When endometrial hyperplasia is associated with atypical cells, it can progress to cancer or occur concurrently with it.

Most patients with endometrial cancer have abnormal bleeding, and thus the diagnosis must be considered in women during the reproductive years.

Heavy menstrual bleeding can be related to coagulopathies.

Von Willebrand disease is the most common coagulopathy. and most women with von Willebrand disease have heavy menstrual bleeding.

Up to 20% of women with heavy menstrual have a bleeding disorder, Andy bleeding disorders have been found in up to 62% of adolescents with heavy menstrual bleeding.

Ovulatory dysfunction or anovulation is a common cause of abnormal  vaginal bleeding.

Ovulatory dysfunction may lead to irregular and unpredictable bleeding, as well as variations in the amount of flow including heavy bleeding. 

Endocrine causes of ovulatory disorders include polycystic ovary syndrome (PCOS), thyroid disorders, hyperprolactinemia, obesity, eating disorders including anorexia nervosa or bulimia, or to an imbalance between exercise and caloric intake.

Endometrial causes of abnormal  aginal bleeding include: endometritis, fallopian tubes or pelvis generally termed pelvic inflammatory disease (PID). 

The most common Iatrogenic cause of abnormal bleeding relates to treatment with hormonal medications such as birth control pills, patches, rings, injections, implants, and intrauterine devices (IUDs). 

Hormone therapy for treatment of menopausal symptoms can also cause abnormal bleeding: Breakthrough bleeding.

Breakthrough bleeding may result from inconsistent use of hormonal treatment.

Vaginal bleeding occurs during 15-25% of first trimester pregnancies.

Of first trimester pregnancies with vaginal bleeding half go on to miscarry and half bring the fetus to term.

Vaginal bleeding in pregnancy: 

complications to the placenta, such as placental abruption and placenta previa, miscarriage, ectopic pregnancy, molar pregnancy, incompetent cervix, uterine rupture, and preterm labor.

Common causes of postmenopausal vaginal bleeding: Endometrial atrophy, uterine fibroids, and endometrial cancer.

About 10% of cases of postmenopausal bleeding are due to endometrial cancer.

Women with fibroids do not always have symptoms, but some experience vaginal bleeding between periods.

The cause of the bleeding can often be discerned on the basis of the bleeding history, physical examination, and other medical tests.

The physical examination for evaluating vaginal bleeding typically includes visualization of the cervix with a speculum, a bimanual exam, and a rectovaginal exam. 

Typically a pregnancy test is performed.

Abnormal endometrium may have to be investigated by a hysteroscopy with a biopsy or a dilation and curettage.

In postmenopausal vaginal bleeding, the primary goal of any diagnostic evaluations is to exclude endometrial hyperplasia and malignancy. 

Transvaginal ultrasonography and endometrial sampling are common methods for an initial evaluation of postmenopausal bleeding.

Endometrial sampling is indicated if having the following findings and/or symptoms: 

Endometrial thickness greater than 4 mm

Diffuse or focal increased echogenicity

Failure to visualize the endometrium

Persistent or recurrent bleeding regardless of endometrial thickness.

Complications of vaginal bleeding:

Severe acute bleeding, as with ectopic pregnancy and post-partum hemorrhage, leads to hypovolemia and possibly shock.

Severe acute  vaginal bleeding

is a medical emergency and requires hospitalization.

Uncontrolled life-threatening bleeding may require uterine artery embolization,

laparotomy occasionally leading to hysterectomy.

A complication from protracted vaginal blood loss is iron deficiency anemia.

The most common cause of prepubertal vaginal bleeding is usually considered to be a foreign body inserted into the vaginal canal, which is frequently associated with pelvic pain, foul discharge, or recurrent genitourinary infections.

Foreign bodies  inserted into the vaginal canal can be due to normal self-exploration or can be indicative of sexual abuse.

Genitourinary injury is also a common cause of vaginal bleeding.

Genitourinary injury is often the most common cause of hospitalization or emergency department visits for prepubertal vaginal bleeding, comprising up to 45% of such cases: straddle injury, which often occurs during a fall, often on a sharp edge, and can cause lacerations between the labial folds.


Hormonal management is usually the first option used to treat acute abnormal uterine bleeding: birth control pills, medroxyprogesterone acetate and conjugated equine estrogen.

Long-term treatments include hormonal IUD insertion, birth control pills, progestin pills or progestin shots and NSAIDs such as ibuprofen.

Surgical treatments may also be considered:  dilation & curettage, endometrial ablation, and hysterectomy.


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