gynecology and obstetrics
Vaginal Bleeding
Evaluation of Vaginal Bleeding
The first priority is determining whether the patient has persistent major bleeding or is at risk of it (eg, due to Ectopic Pregnancy ). Unrecognized pregnancy must be suspected and diagnosed in women of reproductive age because some causes of vaginal bleeding during pregnancy (eg, ectopic pregnancy) are life threatening. History of present illnessshould include quantity (eg, by number of pads used per day or hour) and duration of bleeding, as well as the relationship of bleeding to menses and sexual activity. Clinicians should ask about the following: Menstrual history, including date of last normal menstrual period, age at menarche and menopause (when appropriate), cycle length and regularity, quantity and duration of typical menstrual bleeding, and the frequency of dysmenorrhea Previous episodes of abnormal bleeding, including frequency, duration, quantity, and pattern (cyclicity) of bleeding Sexual history, including possible history of sexual assault Review of systemsshould seek symptoms of possible causes, including the following: Missed menses, breast swelling, and nausea: Vaginal Bleeding During Early Pregnancy None Abdominal pain, sometimes with light-headedness or syncope: Ectopic Pregnancy or ruptured Chronic pelvic or abdominal pain, bloating, change in bowel habits, or weight loss: Introduction to Gynecologic Tumors None Easy bruising and excessive bleeding during toothbrushing, minor lacerations, or venipuncture: A Excessive Bleeding None should identify disorders known to cause vaginal bleeding, including a recent spontaneous or induced abortion or structural disorders (eg, Uterine Fibroids , cervical or endometrial polyps). Clinicians should identify risk factors for: Drug historyshould include specific questions about use of hormonal contraceptives, other hormones, and other drugs that may cause AUB (eg, anticoagulants, nonsteroidal anti-inflammatory drugs). Family historyof bleeding problems or gynecologic cancers should be queried. If sexual abuse of a child is suspected, a structured forensic interview based on theNational Institute of Child Health and Human Development (NICHD) Protocolcan be used. It helps the child report information about the experienced event and improves the quality of information obtained. Vital signs are reviewed for signs of hypovolemia (eg, tachycardia, hypotension). During the general examination, clinicians should look for signs of anemia (eg, conjunctival pallor) and evidence of possible causes of abnormal uterine bleeding, including the following: Hirsutism, acne, obesity, and enlarged ovaries: Polycystic Ovary Syndrome (PCOS) None Warm and moist or dry skin, eye abnormalities, tremor, abnormal reflexes, or goiter: A Overview of Thyroid Function None Nipple discharge: Etiology None Low body mass index: Possibly hypothalamic Pathophysiology None Hepatomegaly, jaundice, asterixis (flapping tremor of the wrist), or splenomegaly: A Evaluation of the Patient With a Liver Disorder None Easy bruising, petechiae, purpura, or mucosal (eg, gingival) bleeding: A Excessive Bleeding None Abdominal mass or ascites: Cancer, including Introduction to Gynecologic Tumors None In children, breast development and presence of pubic and axillary hair at a younger age than is typical for puberty: Puberty None In children, difficulty walking or sitting; bruises or tears around the genitals, anus, or mouth; and/or vaginal discharge or pruritus: Sexual abuse None The abdomen is examined for distention, tenderness, and masses (particularly an enlarged uterus). A Physical Examination is done. External inspection and speculum examination help identify lesions of the vulva, vagina, cervix, and urethra. Bimanual examination is done to evaluate uterine size and ovarian enlargement. If abdominal examination suggests a late-stage pregnancy, digital cervical examination is contraindicated until placental position is determined. If no blood is present in the vagina, rectal examination is done to determine whether bleeding is gastrointestinal in origin. If a child cannot tolerate a pelvic examination or if the source if the child's bleeding is undetermined, the child may be given an anesthetic before the examination; vaginoscopy is done if necessary to examine the vagina and cervix. The following findings are of particular concern: Excessive bleeding Hemodynamic instability (tachycardia, hypotension) Premenarchal or postmenopausal vaginal bleeding Vaginal bleeding in pregnant patients In children, difficulty walking or sitting; bruises or tears around the genitals, anus, or mouth; and/or vaginal discharge or pruritus suggestive of sexual abuse. Significant hypovolemia or hemorrhagic shock is unlikely except with ruptured ectopic pregnancy or, rarely, a ruptured ovarian cyst. Inchildren,breast development and pubic or axillary hair before the typical age range for puberty suggest precocious puberty and premature menses. In those without such findings, the possibility of sexual abuse should be investigated unless an explanatory lesion or foreign body is obvious. Inwomen of reproductive age,examination may detect a causative gynecologic lesion or other findings suggesting a cause. If younger patients taking hormonal contraceptives have no apparent abnormalities during examination and bleeding is spotty, bleeding may be related to the hormones. If the problem is excessive menstrual bleeding only, a uterine disorder or bleeding diathesis should be considered. Inherited bleeding disorders may initially manifest as heavy menstrual bleeding beginning at menarche or during adolescence. Inpostmenopausal women,gynecologic cancer should be suspected. All patients of reproductive age require A urine or blood pregnancy test During early pregnancy (before 5 weeks), a urine pregnancy test may not be sensitive enough. A quantitative serum betahuman chorionic gonadotropin(beta-hCG) test should be done if the urine test is negative and pregnancy is suspected. Vaginal bleeding during pregnancy requires a specific approach (see Vaginal Bleeding During Early Pregnancy and Blood testsinclude a complete blood count (CBC) if bleeding is unusually heavy (eg,>1 pad or tampon/hour) or has lasted > 7 days or if findings suggest anemia or hypovolemia. If anemia is identified and is not obviously due to iron deficiency (eg, based on microcytic, hypochromic red blood cell [RBC] indices), iron studies are done. Thyroid-stimulating hormone and prolactin levels are usually measured, even when galactorrhea is absent. If a bleeding disorder is suspected,von Willebrand factor, platelet count, prothrombin time (PT), and partial thromboplastin time (PTT) are determined. If polycystic ovary syndrome is suspected,testosteroneand dehydroepiandrosterone sulfate (DHEAS) levels are measured. Imagingincludes transvaginal ultrasonography if women have any of the following: A suspected structural lesion (based on history or examination) Etiology None Focal thickening of the endometrium that is detected during screening ultrasonography may require hysteroscopy or saline-infusion sonohysterography to identify small uterine masses (eg, endometrial polyps, submucous myomas). Other testingincludes endometrial sampling if examination and ultrasonography are inconclusive in patients with any of the following: Age > 45 exposure (as occurs in women with a high body mass index or Polycystic Ovary Syndrome (PCOS) ) Risk factors for gynecologic cancer Endometrial thickening > 4 mm in postmenopausal patients Sampling can be done by endometrial biopsy or, if the cervical canal requires dilation, by dilation and curettage (D & C). 