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Abnormal vaginal bleeding in the non-pregnant patient


Essentials

  • 1

    Start the assessment of any patient with vaginal bleeding by excluding pregnancy.

  • 2

    Locate the anatomical site of bleeding and assess the severity looking for signs of hypovolemia and shock.

  • 3

    Familiarize yourself with the PALM-COEIN classification system.

  • 4

    Consider coagulopathy as a cause of heavy uterine bleeding in all patients, especially adolescents.

Introduction

Vaginal bleeding is often divided into two major categories: bleeding which occurs in a pregnant patient and bleeding in the non-pregnant patient. Therefore, in conjunction with determining hemodynamic stability, the first step for a patient presenting with vaginal bleeding is to exclude pregnancy. See Chapters 19.4 and 19.5 if the woman is pregnant.

In this chapter, we will deal exclusively with bleeding in non-pregnant women. Abnormal vaginal bleeding is the most common reason women seek gynaecologic care. Bleeding may be from the uterus, lower genital tract (vulva, vagina, cervix) or from systemic causes. The PALM-COEIN acronym was introduced in 2011 by the International Federation of Gynecology and Obstetrics (FIGO) with a goal of avoiding confusing or poorly defined terminology in the classification of acute abnormal uterine bleeding. With this system, aetiologies are classified as structural or nonstructural: PALM for structural (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia) and COEIN for nonstructural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not otherwise classified).

Physiological uterine bleeding

Physiological uterine bleeding is associated with ovulatory menstrual cycles, which occur at regular intervals every 21 to 35 days, and last for 3 to 7 days. The average volume of blood loss is 30 to 40 mL (each normal sized tampon or pad holds 5cc when soaked through) with>80 mL being defined as menorrhagia.

The menstrual cycle is controlled by the hypothalamic–pituitary–ovarian (HPO) axis. During the first 14 days, oestrogen is produced by the developing follicle, leading to proliferation of the endometrium, which reaches a thickness of 3 to 5 mm. Oestrogen acts on the pituitary gland to cause the release of follicle stimulating hormone (FSH) and luteinizing hormone (LH), which result in ovulation. The corpus luteum then releases progesterone in excess of oestrogen.

Progesterone causes stabilization of the endometrium during the secretory phase of the menstrual cycle. In the absence of fertilization, there is involution of the corpus luteum and a fall in oestrogen and progesterone levels. This results in vasoconstriction within the endometrium, which consequently becomes ischaemic and is shed as normal menstrual bleeding.

Pathological uterine bleeding

Pathological causes include infection, structural abnormalities, such as polyps, fibroids, arteriovenous malformations (AVM) or malignancy, drugs, hyperprolactinaemia, coagulopathy and thyroid endocrinopathy. Terms associated with abnormal uterine bleeding are inconsistently defined, but may be broadly considered as abnormal uterine bleeding with ovulatory menstrual cycles and abnormal uterine bleeding with anovulatory menstrual cycles.

Abnormal uterine bleeding with ovulatory menstrual cycles

The most common cause of abnormal uterine bleeding is menorrhagia occurring in ovulatory menstrual cycles. This presents as regular heavy bleeding and may result in anaemia. In these women, the menstrual blood has been shown to have increased fibrinolytic activity and/or increased prostaglandins.

Abnormal uterine bleeding with anovulatory menstrual cycles

Abnormal uterine bleeding or metrorrhagia due to anovulatory menstrual cycles, sometimes referred to as dysfunctional uterine bleeding (DUB), presents as irregular bleeding of variable volume. In anovulatory menstrual cycles and other high oestrogen states, there is a relative lack of progesterone to oppose the oestrogenic stimulation of the endometrium. This results in excessive proliferation and occasionally hyperplasia/metaplasia of the endometrium. The endometrium also becomes ‘unstable’ and prone to erratic sloughing.

Clinically, this presents as irregular, often heavy, menstrual bleeding. Anovulatory cycles are due to immaturity or disturbance of the normal HPO axis. This is seen at the extremes of reproductive ages, in the first decade after menarche and in premenopausal women, as well as in polycystic ovary syndrome (PCOS) and during times of either physical or emotional stress.

causes of Abnormal Vaginal Bleeding

It is essential initially to review all the possible causes of vaginal bleeding which may be considered by pathophysiology and/or pathological location ( Box 19.3.1 ).

Box 19.3.1
Differential diagnosis of abnormal vaginal bleeding

  • Ovulatory bleeding ‘ menorrhagia’

    • Anovulatory bleeding: sometimes known as dysfunctional uterine bleeding (DUB)

  • Uterine and ovarian pathology:

    • uterine fibroids (pelvic pain, dysmenorrhoea)

    • endometriosis; adenomyosis (dysmenorrhoea, dyspareunia, pelvic pain, infertility)

    • pelvic inflammatory disease and pelvic infection (fever, vaginal discharge, pelvic pain, intermenstrual and postcoital bleeding)

    • endometrial polyps (intermenstrual bleeding)

    • endometrial hyperplasia; endometrial carcinoma (pelvic pain, abnormal bleeding, postcoital bleeding)

    • polycystic ovary syndrome (irregular bleeding, infertility and hirsutism)

  • Systemic disease:

    • coagulation disorder; bleeding diathesis such as von Willebrand disease

    • liver or renal disease

    • hypothyroidism (fatigue, constipation, coarse features, alopecia)

  • Iatrogenic cause:

    • anticoagulation

    • intrauterine device

    • chemotherapy

    • sex steroids

History

A careful menstrual history helps determine the cause of the vaginal bleeding. A history of vaginal trauma may indicate vulval or vaginal wall bleeding. The vaginal trauma may be associated with either consensual or non-consensual intercourse or a vaginal foreign body. Exposure in utero to diethyl stilboestrol (DES) should raise suspicion of vaginal malignancy.

The patient’s estimate of the amount of vaginal bleeding is often inaccurate and has limited use in diagnosis, other than the presence of clots, which is abnormal and suggests heavy bleeding. Ask about additional information, including known gynaecological cancer, a known bleeding disorder or a family history of a bleeding diathesis and exogenous sex steroid use. Up to 13% of women with heavy menstrual bleeding have some variant of von Willebrand disease, and up to 20% of women may have an underlying coagulation disorder.

Postcoital or intermenstrual bleeding

Postcoital or intermenstrual bleeding may be symptomatic of cervical or uterine pathology. Common causes include ectropion or polyps on the cervix, infection or malignancy causing bleeding from the vagina, cervix or uterus.

Postmenopausal bleeding

Postmenopausal bleeding is related to vaginal or uterine conditions, which include infection, atrophy, trauma or malignancy. All postmenopausal bleeding is abnormal and requires follow-up evaluation for endometrial cancer. Risk factors for uterine malignancy include obesity, age >40 years, nulliparity, tamoxifen use, infertility and chronic anovulatory cycles.

Anovulatory bleeding

A diagnosis of anovulatory bleeding is classically made from the history of irregular menses with periods of amenorrhoea followed by heavy bleeding, in the absence of features suggesting a structural or a histological uterine abnormality. A menstrual cycle of less than 21 days or more than 35 days, even if regular, is usually anovulatory.

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