Priority Topic: Vaginal Bleeding

Key Feature 3a: In a non-pregnant patient with vaginal bleeding: Do an appropriate work-up and testing to diagnose worrisome causes (ex: cancer), using an age-appropriate approach.
Skill: Clinical Reasoning
Phase: Investigation, Diagnosis

Key Feature 3b: In a non-pregnant patient with vaginal bleeding: Diagnose (and treat) hemodynamic instability.
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis, Treatment

Key Feature 3c: In a non-pregnant patient with vaginal bleeding: Manage hemodynamically stable but significant vaginal bleeding (ex: with medical versus surgical treatment).
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 4: In a post-menopausal woman with vaginal bleeding, investigate any new or changed vaginal bleeding in a timely manner (ex: with endometrial biopsy testing, ultrasonography, computed tomography, a Pap test, and with a pelvic examination).
Skill: Clinical Reasoning
​Phase: Investigation

The first thing to think about when starting an assessment on anyone with a complaint of bleeding, from anywhere, is the ABCs, and in particular with bleeding, if they are hemodynamically stable. If not, regardless of the etiology, your first priority is to start resuscitating them. The next thing to think about is whether the patient is premenarchal, premenopausal, or postmenopausal. In the patient who is premenopausal, the next step then is to rule out pregnancy. 

The following is my approach to a complaint of vaginal bleeding in a patient who is not pregnant. 

DDx for a premenarchal patient

• Estrogen withdrawal (most common cause of vaginal bleeding in a neonate)
• Trauma (and possible sexual abuse)
• Foreign body
• Infection
• Structural etiologies (ex: urethral prolapse, neoplasm)
• Precocious puberty

DDx for a premenopausal patient (here I am using the well-known PALM-COEIN mnemonic)

• Polyp
• Adenomyosis
• Leiomyomas (aka fibroids)
• Malignancy
• Coagulopathy
• Ovulatory dysfunction
• Endocrine dysfunction (ex: PCOS, thyroid, hyperprolactinemia)
• Infection/Iatrogenic
• Not yet classified (r/o trauma and/or sexual abuse, consider changes in weight, exercise, and stress)

DDx for a postmenopausal patient 

• Malignancy
• Medications (ex: HRT, anticoagulants)
• Systemic disease

History: On history, you want to try to identify the source of the bleed (ruling out bleeding from outside the genital tract, such as from the urinary or gastrointestinal system, and looking for clues that the bleeding is coming from the uterus vs other areas of the genital tract). Heavy bleeding is more likely to arise from the uterus, whereas lighter bleeding can be from anywhere, including the uterus. If the source of the bleed is seemingly from the uterus (aka abnormal uterine bleeding), then it is helpful to characterize the bleeding as fitting into 1 of 3 patterns:

1. Heavy menstrual bleeding: The woman is still having regular cycles, only they are heavy. If this is the case, the most common etiologies are adenomyosis, fibroids, and bleeding disorders.
2. Intermenstrual bleeding: The woman is still having regular cycles but is also having bleeding at other times in her cycle. If this is the case, the most common etiologies are polyps, malignancy, infection, and iatrogenic causes.
3. Irregular bleeding: The woman is having irregular cycles. If this is the case, think ovulatory dysfunction or endocrine dysfunction.

A further complete history is indicated, including an obstetrical/gynecology history, sexual history, and the other basic components of a thorough history. Asking about whether the patient is up to date on her Pap screening and if she has ever had any abnormal Pap screening results is also pertinent. 

Physical exam: On routine physical exam you want to be sure to assess vital signs (including orthostatic vital signs), perform a cardiovascular assessment that includes volume status, and perform a complete abdominal and pelvic exam. Make sure to examine the skin to look for petechia or purpura, which could suggest a coagulopathy.

Investigations: Routine investigations in any patient with a complaint of vaginal bleeding includes a B-hCG (this should be done already) and a CBC. If the woman is postmenopausal, initial investigations, regardless of the rest of the clinical picture, should include a gyne malignancy workup that includes a transvaginal ultrasound +/- endometrial biopsy, Pap test if indicated, and further imaging such as transabdominal ultrasound or CT or MRI if indicated.

Treatment: My general approach to treating vaginal bleeding is as follows:

1. Resuscitate and monitor the patient as indicated if there is ongoing bleeding
2. Address the underlying etiology (see below), and consider that there may be multiple things going on if the bleeding isn't fully resolved after treating the suspected cause
3. Treat the patient for anemia if the bleeding was sufficient to cause this
4. Always rule out sexual abuse, and report this and cousel/refer the patient to appropriate supports if indicated

For heavy menstrual bleeding: Next steps are to obtain a transvaginal US to look for adenomyosis or fibroids. Serum coags (INR, PTT) should be ordered to look for a coagulopathy, and liver function tests and creatinine can be ordered to screen for liver and kidney disease, respectively, as these end-organ diseases can lead to acquired coagulopathies. The treatment for adenomyosis and fibroids are similar, in that definitive treatment requires surgery and therefore a referral to a Gynecologist. Other non-definitive treatment options include the estrogen-progestin OCP, the levonorgestrel-containing IUD, and, to be used while menstruating, NSAIDs +/or tranexamic acid. If screening tests for a bleeding disorder come back positive, further investigations and possibly referral to a specialist such as a Hematologist may be warranted.

For intermenstrual bleeding: Next steps are again to obtain a transvaginal US if there is suspicion of an endometrial polyp. If there is suspicion for ovarian cancer, both a transvaginal and transabdominal US are warranted. If pelvic inflammatory disease (PID) is suspected, obtain vaginal +/or cervical swabs for chlamydia and gonorrhea, and also test for HIV and syphilis. If there is evidence of neoplasm, refer the patient to a Gynecologist for removal. If there is evidence of PID, the patient will need to be started on antibiotics. Consider a transvaginal ultrasound to rule out a tubo-ovarian abscess if there is focal adnexal tenderness/mass on exam. Iatrogenic causes of intermenstrual bleeding will be apparent on review of medications: Contraception methods, hormone replacement therapy, and medications that can cause hyperprolactinemia can all be culprits.

For irregular bleeding: Next steps are to rule out causes of intermenstrual bleeding, as these can also cause irregular bleeding on a backdrop of causes for irregular cycles, as well as to order an early-morning serum testosterone level, a TSH level, and a prolactin level. These are to look for evidence of hyperandrogenism, thyroid disease, and hyperprolactinemia. If any of these are elevated, they have a further DDx that requires working up. Other tests to consider looking for other etiologies of irregular bleeding, depending on the clinical picture, include FSH (for suspicion of premature ovarian failure), estrogen level (for suspicion of an oestrogen-secreting tumour), a fasting blood glucose (for suspicion of diabetes mellitus), liver function testing (for suspicion of liver disease), creatinine (for suspicion of kidney disease), and a late-night salivary cortisol (for suspicion of Cushing syndrome). In any case, in conjunction with treating the underlying etiology, estrogen-progestin OCPs can help improve symptoms but also protect against endometrial cancer, with patients who have irregular bleeding are at higher risk for.