Vaginal bleeding
Encyclopedia
Vaginal bleeding refers to bleeding in females that is either a physiologic response during the non-conceptional menstrual cycle
or caused by hormonal or organic problems of the reproductive system
. Vaginal bleeding may occur at any age, but always needs investigation when encountered in female children or postmenopausal women. Vaginal bleeding during pregnancy
may indicate a possible pregnancy complication that needs to be medically addressed.
Blood loss per vaginam (Latin
: through the vagina
) (PV) typically arises from the lining of the uterus (endometrium
), but may arise from uterine
or cervical
lesions, the vagina
, and rarely from the Fallopian tube
. During pregnancy
it is usually but not always related to the pregnancy itself. Rarely, the blood may actually arise from the urinary tract (hematuria
), although the vast majority of women can identify the difference. It can also be a sign of vaginal cancer.
could be a sign of precocious puberty
. Other possible causes include the presence of a foreign body
in the vagina, molestation, vaginal infection (vaginitis
), and rarely, a tumor.
. Of these, half go on to miscarry
and half bring the fetus to term. There are a number of causes including rupture of a small vein on the outer rim of the placenta
. It can also herald a miscarriage
or ectopic pregnancy
, which is why urgent ultrasound
is required to separate the two causes. Bleeding in early pregnancy may be a sign of a threatened or incomplete miscarriage.
In the second or third trimester a placenta previa (a placenta partially or completely overlying the cervix) may bleed quite severely. Placental abruption
is often associated with uterine bleeding as well as uterine pain.
is:
and additional hormonal tests, a Pap smear
, a transvaginal ultrasound are needed. If bleeding was excessive or prolonged, a CBC may be useful to check for anemia
. Abnormal endometrium may have to be investigated by a hysteroscopy
with a biopsy
or a dilation and curettage
.
The treatment will be directed at the cause. Hormonal bleeding problems during the reproductive years, if bothersome to the woman, are frequently managed by use of combined oral contraceptive pills.
(the depletion of blood from the circulation), progressing to shock. This is a medical emergency
and requires hospital attendance and intravenous fluids
, usually followed by blood transfusion
. Once the circulating volume has been restored, investigations are performed to identify the source of bleeding and address it. Uncontrolled life-threatening bleeding may require Uterine artery embolization
(occlusion of the blood vessels supplying the uterus), laparotomy
(surgical opening of the abdomen), occasionally leading to hysterectomy
(removal of the uterus) as a last resort.
A possible complication from protracted vaginal blood loss is iron deficiency anemia
, which can develop insidiously. Eliminating the cause will resolve the anemia, although some women require iron
supplements or blood transfusion
s to improve the anemia.
Menstrual cycle
The menstrual cycle is the scientific term for the physiological changes that can occur in fertile women for the purpose of sexual reproduction. This article focuses on the human menstrual cycle....
or caused by hormonal or organic problems of the reproductive system
Reproductive system
The reproductive system or genital system is a system of organs within an organism which work together for the purpose of reproduction. Many non-living substances such as fluids, hormones, and pheromones are also important accessories to the reproductive system. Unlike most organ systems, the sexes...
. Vaginal bleeding may occur at any age, but always needs investigation when encountered in female children or postmenopausal women. Vaginal bleeding during pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
may indicate a possible pregnancy complication that needs to be medically addressed.
Blood loss per vaginam (Latin
Latin
Latin is an Italic language originally spoken in Latium and Ancient Rome. It, along with most European languages, is a descendant of the ancient Proto-Indo-European language. Although it is considered a dead language, a number of scholars and members of the Christian clergy speak it fluently, and...
: through the vagina
Vagina
The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the...
) (PV) typically arises from the lining of the uterus (endometrium
Endometrium
-Function:The endometrium is the innermost glandular layer and functions as a lining for the uterus, preventing adhesions between the opposed walls of the myometrium, thereby maintaining the patency of the uterine cavity. During the menstrual cycle or estrous cycle, the endometrium grows to a...
), but may arise from uterine
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
or cervical
Cervix
The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall...
lesions, the vagina
Vagina
The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the...
, and rarely from the Fallopian tube
Fallopian tube
The Fallopian tubes, also known as oviducts, uterine tubes, and salpinges are two very fine tubes lined with ciliated epithelia, leading from the ovaries of female mammals into the uterus, via the utero-tubal junction...
. During pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
it is usually but not always related to the pregnancy itself. Rarely, the blood may actually arise from the urinary tract (hematuria
Hematuria
In medicine, hematuria, or haematuria, is the presence of red blood cells in the urine. It may be idiopathic and/or benign, or it can be a sign that there is a kidney stone or a tumor in the urinary tract , ranging from trivial to lethal...
), although the vast majority of women can identify the difference. It can also be a sign of vaginal cancer.
Bleeding in Children
Bleeding before the expected time of menarcheMenarche
Menarche is the first menstrual cycle, or first menstrual bleeding, in female human beings. From both social and medical perspectives it is often considered the central event of female puberty, as it signals the possibility of fertility....
could be a sign of precocious puberty
Precocious puberty
As a medical term, precocious puberty describes puberty occurring at an unusually early age. In most of these children, the process is normal in every respect except the unusually early age, and simply represents a variation of normal development. In a minority of children, the early development is...
. Other possible causes include the presence of a foreign body
Foreign body
A foreign body is any object originating outside the body. In machinery, it can mean any unwanted intruding object.Most references to foreign bodies involve propulsion through natural orifices into hollow organs....
in the vagina, molestation, vaginal infection (vaginitis
Vaginitis
Vaginitis is an inflammation of the vagina. It can result in discharge, itching and pain, and is often associated with an irritation or infection of the vulva. It is usually due to infection. The three main kinds of vaginitis are bacterial vaginosis , vaginal candidiasis, and trichomoniasis. A...
), and rarely, a tumor.
Premenopausal women
- MenstruationMenstruationMenstruation is the shedding of the uterine lining . It occurs on a regular basis in sexually reproductive-age females of certain mammal species. This article focuses on human menstruation.-Overview:...
. Exceptionally heavy bleeding during periods is termed menorrhagiaMenorrhagiaMenorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals. Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus...
or hypermenorrhea, while light bleeding is called hypomenorrhea. - If bleeding occurs between periods, this is not necessarily pathological, but it is termed intermenstrual bleeding. If no period can be identified due to the unpredictable bleeding, metrorrhagiaMetrorrhagiaMetrorrhagia, also known as breakthrough bleeding or spotting, is uterine bleeding at irregular intervals, particularly between the expected menstrual periods.In some women, menstrual spotting between periods occurs as a normal and harmless part of ovulation...
is used. - Dysfunctional uterine bleedingDysfunctional uterine bleedingDysfunctional Uterine Bleeding is abnormal genital tract bleeding based in the uterus and found in the absence of demonstrable structural or organic pathology.usually due to hormonal disturbances....
is a common cause of menorrhagia and irregular bleeding. It is due to a hormonal imbalance, and symptoms can be managed by use of hormonal contraceptionHormonal contraceptionHormonal contraception refers to birth control methods that act on the endocrine system. Almost all methods are composed of steroid hormones, although in India one selective estrogen receptor modulator is marketed as a contraceptive. The original hormonal method—the combined oral contraceptive...
(although hormonal contraception does not treat the underlying cause of the imbalance). If it is due to polycystic ovary syndromePolycystic ovary syndromePolycystic ovary syndrome is one of the most common female endocrine disorders. PCOS is a complex, heterogeneous disorder of uncertain aetiology, but there is strong evidence that it can to a large degree be classified as a genetic disease....
, weight loss may help, and infertility may respond to clomifene citrate. - Uterine fibroids (leiomyoma) are benign tumorTumorA tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
s of the uterusUterusThe uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
. - Cervical cancerCervical cancerCervical cancer is malignant neoplasm of the cervix uteri or cervical area. One of the most common symptoms is abnormal vaginal bleeding, but in some cases there may be no obvious symptoms until the cancer is in its advanced stages...
may occur at premenopausal age, and often presents with "contact bleeding" (e.g. after sexual intercourse) - Uterine cancerUterine cancerThe term uterine cancer may refer to any of several different types of cancer which occur in the uterus, namely:*Uterine sarcomas: sarcomas of the myometrium, or muscular layer of the uterus, are most commonly leiomyosarcomas.*Endometrial cancer:...
will lead to irregular and often prolonged bleeding. - In recently pregnant women who have been delivered of a baby or who have had a miscarriage, vaginal bleeding may be a sign of endometritisEndometritisEndometritis refers to inflammation of the endometrium, the inner lining of the uterus. Pathologists have traditionally classified endometritis as either acute or chronic: acute endometritis is characterized by the presence of microabscesses or neutrophils within the endometrial glands, while...
or retained products of conception.
Pregnant women
Vaginal bleeding occurs during 15-25% of first trimester pregnanciesPregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
. Of these, half go on to miscarry
Miscarriage
Miscarriage or spontaneous abortion is the spontaneous end of a pregnancy at a stage where the embryo or fetus is incapable of surviving independently, generally defined in humans at prior to 20 weeks of gestation...
and half bring the fetus to term. There are a number of causes including rupture of a small vein on the outer rim of the placenta
Placenta
The placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply. "True" placentas are a defining characteristic of eutherian or "placental" mammals, but are also found in some snakes and...
. It can also herald a miscarriage
Miscarriage
Miscarriage or spontaneous abortion is the spontaneous end of a pregnancy at a stage where the embryo or fetus is incapable of surviving independently, generally defined in humans at prior to 20 weeks of gestation...
or ectopic pregnancy
Ectopic pregnancy
An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...
, which is why urgent ultrasound
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...
is required to separate the two causes. Bleeding in early pregnancy may be a sign of a threatened or incomplete miscarriage.
In the second or third trimester a placenta previa (a placenta partially or completely overlying the cervix) may bleed quite severely. Placental abruption
Placental abruption
Placental abruption is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth...
is often associated with uterine bleeding as well as uterine pain.
Postmenopausal women
All vaginal bleeding in postmenopausal women should be medically assessed. The differential diagnosisDifferential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
is:
- 30% unopposed estrogen
- 30% atrophic endometritis / vaginitis
- 15% endometrial cancerEndometrial cancerEndometrial cancer refers to several types of malignancies that arise from the endometrium, or lining, of the uterus. Endometrial cancers are the most common gynecologic cancers in the United States, with over 35,000 women diagnosed each year. The incidence is on a slow rise secondary to the...
- 10% endometrial polyps or cervical polyps
- 5% endometrial hyperplasia
- 10% other
Diagnostic approach
The diagnosis can often be made on the basis of the bleeding history, physical examination, and other medical tests as appropriate. Typically a pregnancy testPregnancy test
A pregnancy test attempts to determine whether or not a woman is pregnant.These markers are found in urine and blood, and pregnancy tests require sampling one of these substances. The first of these markers to be discovered, human chorionic gonadotropin , was discovered in 1930 to be produced by...
and additional hormonal tests, a Pap smear
Pap smear
The Papanicolaou test is a screening test used in to detect pre-cancerous and cancerous processes in the endocervical canal of the female reproductive system. Changes can be treated, thus preventing cervical cancer...
, a transvaginal ultrasound are needed. If bleeding was excessive or prolonged, a CBC may be useful to check for anemia
Anemia
Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...
. Abnormal endometrium may have to be investigated by a hysteroscopy
Hysteroscopy
Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention .-Method:...
with a biopsy
Biopsy
A biopsy is a medical test involving sampling of cells or tissues for examination. It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically...
or a dilation and curettage
Dilation and curettage
Dilation and curettage refers to the dilation of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping . It is a diagnostic gynecological procedure.D&C normally is referred to a procedure involving a curette, also called sharp...
.
The treatment will be directed at the cause. Hormonal bleeding problems during the reproductive years, if bothersome to the woman, are frequently managed by use of combined oral contraceptive pills.
Complications
Severe acute bleeding, such as caused by ectopic pregnancy and post-partum hemorrhage, leads to hypovolemiaHypovolemia
In physiology and medicine, hypovolemia is a state of decreased blood volume; more specifically, decrease in volume of blood plasma...
(the depletion of blood from the circulation), progressing to shock. This is a medical emergency
Medical emergency
A medical emergency is an injury or illness that is acute and poses an immediate risk to a person's life or long term health. These emergencies may require assistance from another person, who should ideally be suitably qualified to do so, although some of these emergencies can be dealt with by the...
and requires hospital attendance and intravenous fluids
Intravenous therapy
Intravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
, usually followed by blood transfusion
Blood transfusion
Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood...
. Once the circulating volume has been restored, investigations are performed to identify the source of bleeding and address it. Uncontrolled life-threatening bleeding may require Uterine artery embolization
Uterine artery embolization
Uterine artery embolization is a procedure where an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body...
(occlusion of the blood vessels supplying the uterus), laparotomy
Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...
(surgical opening of the abdomen), occasionally leading to hysterectomy
Hysterectomy
A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...
(removal of the uterus) as a last resort.
A possible complication from protracted vaginal blood loss is iron deficiency anemia
Iron deficiency anemia
Iron-deficiency anemia is a common anemia that occurs when iron loss occurs, and/or the dietary intake or absorption of iron is insufficient...
, which can develop insidiously. Eliminating the cause will resolve the anemia, although some women require iron
Iron
Iron is a chemical element with the symbol Fe and atomic number 26. It is a metal in the first transition series. It is the most common element forming the planet Earth as a whole, forming much of Earth's outer and inner core. It is the fourth most common element in the Earth's crust...
supplements or blood transfusion
Blood transfusion
Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood...
s to improve the anemia.