GU

Vaginal Bleeding

Abnormal vaginal bleeding is a very common cause of concern for adolescent girls and their families.  Many times, however, the symptoms causing alarm are actually just variations of normal.  One of the main reasons for these false alarms is that many adolescents, as well as their families, are unaware of what a "normal" menstrual cycle is.  A normal ovulatory cycle can occur anywhere between 21 to 35 days and menstruation can last up to 8 days, with an average blood loss of 30 to 80mL (more than 3 soaked pads or 6 full regular-absorbency tampons a day for 3 or more days is equal to, or greater than, 80mL of blood loss).  It is, however, important to keep in mind that it is normal for menstrual cycles to be irregular for the first 1 – 2 years after menarche (by the third year of menarche, 95% of menstrual cycles fall within normal limits).  Regardless, evaluation of abnormal vaginal bleeding is important, and warranted, as it could be a symptom of serious underlying pathology.

 

Differential Diagnosis

  • Anovulation
  • Endocrine
    • Adrenal disorders
    • Hyperprolactinemia
    • Ovarian failure
    • Polycystic ovarian syndrome
    • Thyroid disorders
  • Hematologic
    • Coagulation Defects
    • Factor Deficiencies
    • Platelet Dysfunction
    • Thrombocytopenia
    • vonWillebrand disease
  • Infections
    • Condyloma of the cervix/vagina
    • Pelvic inflammatory disease
    • Vaginitis/cervicitis (trichomonas/gonorrhea)
  • Medications
    • Anticoagulants
    • Antipsychotics
    • Chemotherapy
    • Danazol
    • Exogenous steroids
    • Oral contraceptives
    • Platelet inhibitors
    • Progestins (e.g. Depo-Provera)
    • Spirinolactone
  • Ovarian Failure
  • Pathology involving the reproductive tract
    • Cervical dysplasia
    • Congenital malformation of the uterus
    • Endometrial fibroid
    • Endometrial hyperplasia/carcinoma
    • Endometrial polyp
    • Endometriosis
    • Myoma
  • Pregnancy Related
    • Abortion (threatened or incomplete)
    • Ectopic pregnancy
    • Implantation
    • Placenta Accreta
    • Retained products of conception
  • Systemic Diseases
    • Adrenal insufficiency
    • Chronic renal disease
    • Cushing syndrome
    • Diabetes mellitus
    • Late-onset congenital adrenal hyperplasia
    • Liver disease
    • Polycystic ovary syndrome
    • Systemic lupus erythematosis
    • Thyroid abnormalities
  • Trauma
  • Tumor
    • Ovarian cyst or tumor
    • Sarcoma botryoides
  • Other
    • Eating disorders
    • Excessive exercise
    • Intrauterine device
    • Stress
    • Systemic disease

 

The Visit

When evaluating a patient who is experiencing abnormal vaginal bleeding, a thorough history, review of systems and physical exam should be done – laboratory studies may also be required.

  • History
    • Medical and Surgical History
      • Previous diagnosis of anemia
      • Previous abortions or dilatation and curettage
      • Current and previous medication use
      • Prior chemotherapy
    • Menstrual History
      • Age at menarche – patients who experience menarche at an older age are more prone to experiencing a longer period of "irregular" cycles; this should also include the quality of the first period(a heavy first period may point to a bleeding diathesis)
      • Length of cycles – it is recommended that a patient record their periods on a calendar so that the data can be accurately discussed and reviewed with her physician
      • Timing, duration, and quantity of uterine bleeding – it is often recommended that these be recorded on the calendar as well
      • Number of pads/tampons used in 24 hours (and for how many days)
      • Presence of cramping
      • Presence of clots
    • Sexual History
      • Risk factors for sexually transmitted diseases
        • Age of sexual debut
        • Number of lifetime partners
        • Date of last sexual activity
        • Use of condoms
        • History of sexually transmitted infections – this should include the number and types of STIs as well as STI history of partners
        • History of sexual abuse
    • Social History
      • Diet and exercise – may point to eating disorders or excessive physical activity as the root cause
      • Illicit drug use
      • Stress – this can also cause anovulation and dysfunctional uterine bleeding
    • Family History
      • Relatives with heavy periods or hysterectomy after childbirth because of bleeding – may be indicative of vonWillebrand disease
      • Relatives with other clotting problems – including after circumcision, dental or surgical procedures
      • Autoimmune diseases
      • Endocrine disorders
      • History of Cancer
  • Review of Systems
    • General – include questions that cover fatigue, weight change, night sweats, and hot flashes
    • HEENT – ask about abnormal bleeding in gums or throat
    • CV – inquire about palpitations or tachycardia
    • Pulmonary – ask about episodes of dyspnea/dyspnea on exertion
    • GI – inquire about diarrhea and constipation
    • GU – include questions that cover dysuria, vaginal discharge, dyspareunia
    • Heme – discuss symptoms of easy bleeding or bruising
    • Neurologic – ask about headaches, double vision, or loss of vision
    • Skin – ask about abnormal hair growth, acne, or hair loss
    • Other – inquire about nipple discharge
  • Physical Exam
    • Vital signs – always start with vital signs and ensure that the patient is hemodynamically stable.  Ensure that the patient is not tachycardic or hypotensive and that they are not experiencing orthostatic changes.
    • General – ensure that the patient looks stable.  Do they look like they may be suffering from anemia (e.g. pale or tired looking)?  Is their mental status altered?  Also note their general body habitus – do they look extremely thin or, conversely, obese?
    • HEENT – verify that there are no signs of anemia (conjunctival pallor) or excessive bleeding (epistaxis or gum bleeding)
    • Neck – look for signs of thyroid dysfunction (enlarged thyroid) or lymphadenopathy
    • Breast – look for signs of galactorrhea or other nipple discharge
    • Heart – listen to for signs of anemia (specifically, for a flow murmur)
    • Abdomen – examine for hepatosplenomegaly and note if pain is elicited during exam
    • GU
      • External exam – look for signs of trauma (inflammation or lacerations) as well as discharge.  Also examine the size of the clitoris.
      • Internal exam – look for foreign bodies (including a retained tampon); examine the cervix and look for pain upon movement of the cervix, adenexa or uterus.
    • Skin – keep an eye out for signs of bleeding diatheses (burises or petichiae) or endocrine abnormalities – most specifically PCOS (acne, hirsutism, acanthosis nigricans, and striae)
    • Neurologic – examine the patient for evidence of visual field deficits
  • Labs
    • The initial laboratory workup should include a pregnancy test and a CBC – a pelvic ultrasound may also be considered.
    • If the bleeding is severe and/or if the history or examination point to an underlying bleeding disorder, the following may also be ordered:
      • PT and PTT
      • Bleeding time and platelet aggregation
      • vonWillebrand panel
      • Factor levels and activity
    • If an endocrine disorder (thyroid dysfunction, PCOS, prolactinoma, or adrenal tumor) seems more likely, the following should be ordered:
      • TSH
      • Prolactin
      • Free & Total Testosterone
      • Dehydroepiandrosterone sulfate
      • LH and FSH
    • If, given the history and examination, STIs are at the top of the differential, it is important to get the following labs:
      • Wet mount of discharge
      • Gonorrhea and Chlamydia tests

 

Treatment

The management of abnormal vaginal bleeding depends entirely on the underlying etiology – however, the prevention of the development of anemia and the restoration of a regular menstrual cycle are important in almost every case.  In some cases (when the etiology of the abnormal bleeding is found to be related to endocrine or systemic dysfunction or by a bleeding disorder), the patient will be referred to a specialist for management and resolution.  However, in patients suffering from vaginal bleeding with no clear etiology (idiopathic), management will depend on the patient�s hemodynamic stability and hemoglobin levels:

  • Hemoglobin: > 12mg/dL
    • Considered Mild Uterine Bleeding
    • Treatment consists of observation and reassurance
    • Patients should keep a menstrual calendar
    • Follow-up should occur in 3-6 months unless symptoms worsen
    • Multivitamin with Iron may be recommended
  • Hemoglobin: 10 – 12mg/dL
    • Considered Moderate Uterine Bleeding
    • Characterized by moderately prolonged or frequent menses every 1 – 3 weeks
    • Usually no signs of hypovolemia or hemodynamic instability are present given the mild anemia
    • Treatment involves hormone therapy (OCPs)
      • Agent of choice and regimen depends on the amount of bleeding
        • Estrogen and progestin pills can be used in one of two ways:
          • 1 pill per day for the entire course
          • 3 times per day until bleeding stops (usually 48 hours), followed by taper to 2 times daily for 5 days, and then 1 daily to complete 21 days of hormone therapy.  Once this is done, the patient starts a new pack by taking one pill per day.
          • Antiemetics can be given to avoid nausea caused by high-dose estrogen therapy
        • Progestin only pills
          • For patients with more moderate bleeding or for those who cannot tolerate, dislike, or have contraindications to estrogen therapy
    • Iron supplementation is important in these patients
  • Hemoglobin:  <10mg/dL
    • Considered Severe Uterine Bleeding/Menorrhagia
    • If the patient has no signs of hemodynamic instability, and has a hemoglobin between 8 and 10mg/dL, it may not be necessary to hospitalize the patient
      • However, it is necessary to hospitalizae those patients who do have signs or symptoms of hemodynamic instability or have a hemoglobin < 7mg/dL
    • The decision to transfuse blood should be made on an individual basis and should take into account the amount of bleeding, the initial blood count, the patient's symptoms as well as any other comorbidities
    • Patients who are hospitalized should be evaluated for bleeding disorders
      • Coagulation disorders are the second most common cause of menorrhagia in adolescents and have been noted in 20% of adolescents hospitalized with menorrhagia (DeSilva, 27)
    • For patients who can tolerate PO intake and estrogen, therapy includes:
      • OCP with 50mcg estradiol and 0.5mg norgesterel or 50mcg estradiol and 1mg norethindrone
      • Possible schedule:
        • Take 4 pills daily until bleeding stops
        • Then take 3 pills daily for 3 days
        • Then take 2 pills to complete 21 day cycle
        • Patient then starts new pack (without taking placebos)
    • For patients who can tolerate PO intake but cannot tolerate estrogen, therapy includes:
      • Progestin 5 to 10mg daily or micronized progesterone 200mg at night
    • For patients who cannot tolerate PO intake and require IV treatment:
      • Conjugated equine estrogen (Premarin) may be used
    • In cases where the patient is unresponsive to therapy for 24 hours – or in the case where the patient has severe platelet dysfunction – nonhormonal hemostatic drugs can be used (usually for 8 hours or until bleeding stops).
      • These include
        • Antifibrinolitic compounds
        • Aminocaproic Acid or Tranexamic aid
        • Desmopressin
      • Once bleeding stops and patient can tolerate PO, they should be transitioned to oral therapy
    • If bleeding persists, dilation and curettage may be indicated as well

After bleeding is controlled, and the patient is tolerating their medications, therapy should continue for about 6 months.  During this time, the patient should be seen at regular intervals to evaluate for efficacy of therapy and ensure that no complications arise.  Even after therapy is discontinued, the patient should continue to be seen regularly to ensure that regular menstruation is maintained.

 

References

  1. Gray, Susan Hayden, and S. Jean Emans. Abnormal vaginal bleeding in adolescents. Pediatrics in Review 28.5 (2007): 175-182.
  2. DeSilva, Nirupama K. Abnormal Uterine Bleeding in the Adolescent Patient. The Female Patient. July 2010.
  3. Gray, Susan Hayden. Menstrual Disorders. Pediatrics in Review 34.1 (2013): 6-18.
  4. Goldstein, Mark A. Menstrual Irregularities: Abnormal Vaginal Bleeding. The MassGeneral Hospital for Children Adolescent Medicine Handbook. Springer New York, 2011. 91-94.