abnormal vaginal bleeding -- Gynecology

1. Abnormal vaginal bleeding
Lara Masri, 4th year
Sources: Kaplan, Ten teacher, Amboss

2. Outline
• Classification
• Definition
• Causes
• Diagnosis
• Management

3. Classification:
• Premenarchal vaginal bleeding
• Reproductive age vaginal bleeding
• Postmenopausal vaginal bleeding

4. Premenarchal vaginal bleeding
Bleeding that occurs before menarche (the average age of
menarche is age 12)
Possible causes :
 Foreign body that irritates the vaginal lining ( most common
cause )
 Estrogen withdrawal
 Ingestion of estrogen medication
 Cancer of the vagina or of the cervix (sarcoma botryoides)
 Tumor of the pituitary or adrenal gland, an ovarian tumor
 Sexual abuse
 Vulvovaginitis
 Idiopathic precocious puberty

7. ▪ The most common cause of vaginal bleeding and discharge
in the neonatal period is maternal withdrawal of estrogen.
▪ Similar to the follicular phase of menstruation, maternal
estrogen crosses the placenta during pregnancy and causes
growth of the fetal endometrial lining. Following delivery,
the neonatal endometrium may slough off causing self-
limited, mucoid, vaginal bleeding.
▪ This bleeding typically occurs within the first 2 weeks of
life and may last for several days. The effect of maternal
hormones may also lead to temporary breast bud and
external genitalia engorgement during the first month of
life.
▪ There is no required treatment, and parents should be
reassured that this brief bleeding is physiologic and normal.

10. Most menstrual cycles in the first one to two years
following menarche are anovulatory.
These cycles are typically irregular and may be
complicated by menorrhagia.
This is due to immaturity of the developing hypothalamic-
pituitary-gonadal axis that does not produce adequate
quantities and proportions of the hormones (LH and FSH)
required to induce ovulation.

11. Premenopausal vaginal bleeding
causes :
1)Pregnancy
2)Anatomic lesion
3)Inherited coagulopathy
4)Abnormal uterine bleeding

12. Pregnancy
• In a patient who has abnormal bleeding during the reproductive
age group, pregnancy or a complication must first be considered.
• Complications of early pregnancy that are associated with
bleeding include abortion , ectopic pregnancy, and molar
pregnancy.
• Diagnosis
1. Urine or serum β-hCG test.
2. If pregnancy is identified vaginal ultrasound and speculum
will help sort out which pregnancy complication is
operative.
• Management Varies with the individual diagnosis.

13. Anatomic lesion
• If the pregnancy test is negative, then an anatomic cause of vaginal bleeding
should be considered. The classic history is that of unpredictable bleeding
(without cramping).
• Causes
 Vaginal lesions: lacerations, varicosities, or tumors
 Cervical lesions: polyps, cervicitis, or tumors
 Endometrial lesions: submucous leiomyomas, polyps, hyperplasia, or
cancer
 Myometrial lesions: adenomyosis
• Diagnosis
 Lower genital tract: pelvic and speculum exam
 Upper genital tract: saline sonogram, endometrial biopsy, or hysteroscopy
• Management: varies according to the individual diagnosis.

15. Inherited Coagulopathy
• Up to 15% of patients with abnormal vaginal bleeding (especially in the
adolescent age group) have coagulopathies.
• Review of systems may be positive for other bleeding symptoms including:
epistaxis, gingival bleeding, easy bruising (>5 cm) and ecchymoses.
• Von Willebrand disease which arises from a deficiency of VWF is the most
common hereditary coagulation abnormality.
• Other Coagulopathies can be due to vessel wall disorders, platelet disorders,
coagulation disorders, and fibrinolytic disorders.
• Diagnosis
1. Positive family history and review of systems are helpful for screening.
2. Initial lab tests include CBC with platelet count, PT, and PTT.
3. The best screening test for Von Willebrand disease is a vWF antigen.
• Management: Consultation with a hematology specialist .

18. There are several types of abnormal bleeding and their
terminology should be known:
HMB: excessive menstrual blood loss
IMB: bleeding between periods, often seen with endometrial and
cervical polyps, endometriosis
PCB: bleeding after intercourse . Often associated with cervical
abnormalities
PMB: bleeding more than 1 year after cessation of periods. Exclude
endometrial pathology or vaginal atrophy
BEO: ‘bleeding of endometrial origin’, a diagnosis of exclusion, has
replaced the term ‘dysfunctional uterine bleeding’ (DUB)

20. Dysfunctional uterine bleeding (DUB)
• The classic history is that of bleeding that is unpredictable in amount,
duration and frequency without cramping occurring.
• The most common cause of DUB is anovulation. Anovulation results in
unopposed estrogen. With unopposed estrogen, there is continuous
stimulation of the endometrium with no secretory phase.
• An estrogen- dominant endometrium is structurally unstable as it increasingly
thickens. With inadequate structural support, it eventually undergoes random,
disorderly, and unpredictable breakdown resulting in estrogen breakthrough
bleeding.

23. Diagnosis
Anovulatory cycles can usually be diagnosed from a history of irregular,
unpredictable bleeding.
• Bleeding is usually without cramping since there is no PG release to cause
myometrial contractions.
• Cervical mucus will be clear, thin and watery reflecting the estrogen dominant
environment.
• Basal-body temperature (BBT) chart will not show a midcycle temperature rise
due to the absence of the thermogenic effect of progesterone.
• Endometrial biopsy will show a proliferative endometrium.

24. Progesterone trial involves administering progestin to stabilize the
endometrium, stop the bleeding and prevent random breakdown.
When the progestin is stopped, spiral arteriolar spasm results in PG
release, necrosis, and an orderly shedding of the endometrium.
• A positive progesterone trial confirms a clinical diagnosis of
anovulation.
• A negative progesterone trial rules out anovulation.

26. Correctable causes of anovulation
Anovulation can be secondary to other medical conditions. It is
important to identify and correct a reversible cause of anovulation if
present:
• Hypothyroidism is a common cause of anovulation
diagnosed by a high TSH
treated with thyroid replacement.
• Hyperprolactinemia
diagnosed by a serum prolactin test. An elevated prolactin
inhibits GnRH.
Treatment depends on the cause of the elevated prolactin.

27. Heavy Menstrual Bleeding (menorrhagia)
• HMB is the most common type of menstrual bleeding disorder.
• HMB is defined as a blood loss of greater than 80 ml per period.
• In reality, methods to quantify menstrual blood loss are both inaccurate (poor correlation
with haemoglobin level) and impractical, and so a clinical diagnosis based on the
patient’s own perception of blood loss is preferred.
Of women of reproductive age, 20–30% suffer from HMB.
The aetiology of HBM:
• Fibroids: 30% of HMB is associated with fibroids.
• Adenomyosis: 70% of women will have AUB/HMB.
• Endometrial polyps
• Coagulation disorders (e.g. von Willebrand disease).
• Pelvic inflammatory disease (PID).
• Thyroid disease.
• Drug therapy (e.g. warfarin).
• Intrauterine devices (IUDs).
• Endometrial/cervical carcinoma.

29. Light menstrual cycles (hypomenorrhea):
Regularly timed menses but an unusually light amount of flow
<25ml
Causes:
This is commonly caused by hypogonadotropic hypogonadism,
which is seen most commonly in anorexic patients and athletes.
Atrophic endometrium causes:
• Asherman syndrome (intrauterine adhesions or synechiae)
• Congenital malformations
• Infection
• Intrauterine trauma.
• Patients on ocps, depo-provera, and the progestin-containing
iuds
• Women who have undergone endometrial ablation.

30. Intermenstrual bleeding (metrorrhagia)
Imb is characterized by bleeding that occurs between regular menstrual
Periods. This bleeding is usually less than or equal to normal menstrual volume.
Primary causes include cervical lesions (polyps,ectropions, and carcinoma) and
endometrial polyps and carcinoma.
Heavy irregular bleeding (formerly menometrorrhagia)
Is excessive (>80 ml) or prolonged bleeding at irregular intervals.
The usual causes include uterine fibroids, adenomyosis, endometrial polyps,
Endometrial Intraepithelial Neoplasia, (EIN) and cancer.

31. Infrequent menstrual cycles (oligomenorrhea).
Periods greater than 35 days apart
the causes include:
• Disruption of the hypothalamic–pituitary–gonadal axis
• Systemic diseases, such as: hyperprolactinemia and thyroid
disorders
• The most common causes of oligomenorrhea are polycystic
ovarian syndrome (pcos),chronic anovulation, and
pregnancy.
When a patient has no period for 3-6 consecutive months,
secondary amenorrhea is diagnosed.

32. Regular menstrual cycles with increased frequency (polymenorrhea)
Describe regular periods that occur less than 21 days apart.
Frequent menstrual cycles can be confused with IMB . However, if all of the bleeding
episodes are similar in amount and fewer than 21 days apart, frequent menstrual cycles
should be considered. This is usually caused by anovulation.
Postcoital bleeding :
• Refers to spotting or bleeding that occurs after intercourse and is not related to
menstruation.
• The prevalence of postcoital bleeding ranges from 0.7 to 9.0 percent of menstruating
women.
• There are multiple etiologies for this common complaint in which most are benign such
as cervicitis or cervical polyps. However, the most serious cause of postcoital bleeding is
cervical cancer

33. Investigations for abnormal uterine bleeding
History:
 Questions about the timing, quantity, and amount of bleeding,
 Associated symptoms.
 Gyn, ob, menstrual, sexual, surgical, and contraceptive history
 Family history of bleeding disorders, particularly, if HMB occurs at menarche
Physical examination
 Look for sequelae of PCOS (hirsutism, acne, truncal obesity, acanthosis nigricans),
 Thyroid examination (thyromegaly, thyroid nodule, skin changes, diaphoresis,
increased pulse.
 Bleeding disorders symptoms (bruising, petechiae, skin pallor).
 Pelvic examination, rectal, urethral, vaginal, and cervical causes of bleeding should be
ruled out.
 Bimanual examination may reveal uterine or adnexal masses consistent with
fibroids, adenomyosis, pregnancy, or cancer.
1) Full history and physical examination

34. Initial laboratory evaluation:
• Tests would include a pregnancy test, TSH,
prolactin , FSH levels and CBC.
• For primary bleeding disorder: evaluation for
these women might include a CBC , including
platelet count , ,PTT, factor viii, and Vwf antigen
and activity.
• Pap smear test : with or without high-risk human
papillomavirus (hpv) screening as indicated, is used
to screen for cervical neoplasia and cancer.
• Cervical cultures: to rule out infection.
• Testing for chlamydia trachomatis : is indicated for
those at high risk of infection.
• Tumor markers: ca125 , ca19-9 if there is masses

35. Pelvic / vaginal ultrasound:
• To identify endometrial polyps, fibroids, EIN, cancers, and adnexal masses.
• If intrauterine pathology is suspected on pelvic ultrasound, a 3d ultrasound,
saline-infused sonohysterogram (SIS), or hysterosalpingogram can be
performed to show intrauterine defects.
• MRI is expensive but useful in distinguishing adenomyosis from uterine
fibroids.
• Hysteroscopy : for direct visualization of the intrauterine cavity.
• Dilation and curettage (D&C) provides tissue for diagnosis and sometimes
treatment of AUB.

37. Endometrial biopsy

40. Management
These methods help regulate the menstrual flow and prevent endometrial
hyperplasia, but do not reestablish normal ovulation:
1. Mefenamic acid and other NSAIDS:
Associated with a reduction in mean menstrual blood loss of 20–25 per cent.
• Benefits: effective analgesia, hence often the firstline treatment of choice where
dysmenorrhoea coexists.
• Disadvantages: contraindicated with a history of duodenal ulcer or severe asthma.
• Recommended dose: 500 mg p.O. Tds to be taken when menstruation is particularly heavy
or painful.
• There are some recent concerns that long-term usage of NSAIDS may cause reversible
difficulties in conceiving

41. 2. Tranexamic acid
This is associated with a mean reduction in menstrual blood loss (MBL) of
about 50%
• Benefits: Only requires to be taken on days when the bleeding is particularly heavy.
• Disadvantages: Theoretical concerns have been raised that tranexamic acid may be
associated with an increased risk of venous thrombosis, but this has not been borne
out by the studies that have investigated it to date
• Recommended dose: 1 g p.o. qds to be taken when menstruating heavily.

42. 3. Combined oral contraceptive pill
Benefits: Doubles up as a very effective contraceptive when taken properly.
Disadvantages:
(1) It is contraindicated for patients who have risk factors for thromboembolism.
(2) It is unsuitable for patients over 35 years old who smoke.
(3) It is unsuitable if there is a personal or family history of breast cancer.
(4) It is unsuitable for patients who are grossly overweight.
4. Norethisterone
This cyclical progestin is effective taken in a cyclical pattern from day 6 to day 26 of the
menstrual cycle.
Benefits: It is a safe and effective oral preparation, which can regulate bleeding pattern.
Disadvantages: It is not a contraceptive and can cause break-through bleeding.
Recommended dose: 5–10 mg tds on days 6–26 of the menstrual cycle.

43. 5. Levonogestrel intrauterine system
Mean reductions in MBL of around 95 % by one year after LNGIUS insertion have been
demonstrated.
Benefits:
• It provides contraceptive cover comparable with sterilization.
• Recent evidence proves it is effective for associated dysmenorrhoea.
• Around 30 per cent of women are amenorrhoeic by one year after insertion.
Disadvantages: Irregular menses and break-through bleeding for the first three to
nine months after insertion

44. 6. GnRH agonists
These drugs act on the pituitary to stop the production of estrogen which results in
amenorrhea. These are only used in the short term due to the resulting hypooestrogenic
state which predisposes to osteoporosis.
Benefits: They are effective for associated dysmenorrhea.
Disadvantages:
• They can cause irregular bleeding
• They can be associated with flushing and sweating.
• Only suitable for short-term usage (six months)
Dose:
1. Goserelin (Zoladex™) 3.6 mg monthly subcutaneous implant
2. Decapeptyl (Triptorelin™) 3 mg monthly or 11.25 mg three-monthly subcutaneous or
intramuscular injection
3. Buserelin (Suprecur™) 300 mg nasal spray tds.

45. Surgical management:
1. Endometrial ablation: procedure destroys the endometrium by
heat, cold or microwaves. It leads to iatrogenic Asherman
syndrome and minimal or no menstrual blood loss. Fertility will be
affected.
2. Umbilical artery embolization
3. Myomectomy
4. Transcervical resection of fibroids
5. Hysterectomy: is a last resort and performed only after all other
therapies have been unsuccessful.

46. Undiagnosed AUB is a contraindication to
endometrial ablation because it can prevent
evaluation of the endometrium in patients with
possible endometrial hyperplasia/cancer
Undiagnosed AUB is a contraindication to
hysterosalpingogram because the procedure
could spread the cancerous endometrial cells into
the abdomen

47. • Polyps :removed via hysteroscopic resection. If multiple or recurrent polyps
management with hysterectomy
• Adenomyosis :is occasionally responsive to hormonal medical treatment.
Endometrial ablation in symptomatic adenomyosis. In patients with refractory
pain and/or bleeding, hysterectomy after ruling out EIN and endometrial cancer
• Leiomyomata :can be managed medically surgically with hysteroscopic resection
for submucosal fibroids (AUB-LSM). endometrial ablation, uterine artery
embolization, and uterine myomectomy or hysterectomy
• Benign endometrial hyperplasia :progestin therapy if no cytologic atypia is
present
The treatment of choice for EIN is total hysterectomy. Endometrial ablation and
supracervical hysterectomy are not acceptable for patients with EIN or endometrial
cancer

48. • Coagulopathies :to hematologist. They can generally be managed with hormonal
contraception, levonorgestrel-containing IUD, or global endometrial ablation.
Rarely, hysterectomy may be indicated.
• Ovulatory disorders :the primary cause should be addressed when possible. After
this, menstrual regulation can often be achieved with the use of hormonal
contraceptives or cyclic progestins/ levonorgestrel-containing IUD .
• Nonstructural endometrial sources according to the underlying source.
Contraceptives, levonorgestrel-containing IUD, and endometrial ablation offer
symptom management. Rarely, hysterectomy is indicated.
• Iatrogenic etiologies. The most common cause is unscheduled bleeding, or so
called “break-through-bleeding,” due to the use of contraceptives. In most cases,
medications adjustments will resolve the symptoms. When endometrial atrophy is
suspected, high-dose NSAIDs (ibuprofen 800 mg TID for 5 days), combination
hormonal contraception, or an estradiol patch (0.1 mcg for 1 month) may be used
to stabilize the endometrium.
• Not yet been classified :treatment should be geared toward the specific etiology

49. Postmenopausal vaginal bleeding
• Menopause is marked by 12 months of amenorrhea after the
final menstrual Period .
• Postmenopausal bleeding :is any vaginal bleeding that occurs
more than 12 months after the last menstrual period.
• Any postmenopausal bleeding is abnormal.
• The most common cause of postmenopausal bleeding is
endometrial and/or vaginal atrophy, not cancer .Premalignant
and malignant endometrial disease is responsible for only 10%
to 15% of all postmenopausal vaginal bleeding (PMVB).

50. Common causes of postmenopausal bleeding
Uterine causes Cervical causes Vaginal causes
1. Endometrial cancer
2. Endometrial polyp
3. Endometrial hyperplasia
4. Atrophic endometritis
5. Submucosal leiomyoma
6. Tamoxifen therapy
7. Hormone replacement
therapy
1. Cervical cancer
2. Cervical polyp
1. Vaginal cancer
2. Atrophic vaginitis

51. Diagnosis:
• A careful history is important.
• Physical examination should include a careful inspection of the external
anus, urethra, vulva, vagina, and cervix.
• Pap test
• Laboratory tests might include a CBC, TSH, prolactin, and FSH levels.
• If an ovarian mass is identified, tumor markers (ca-125, LDH, Hcg, AFP,
CEA , inhibin, and estradiol should also be considered.
• Pelvic ultrasound, saline infusion sonohystrograph SIS, and MRI
• EMB this is done to rule out EIN and cancer even if there is another
identifiable source of postmenopausal bleeding.
• Hysteroscopy
• D&C can be both diagnostic and therapeutic for some lesions of the
uterus and cervix.

53. Treatment
• Lesions of the vulva and vagina should be biopsied and treated accordingly.
• Lacerations of the vaginal mucosa should be repaired.
• Genital urinary syndrome of menopause can be treated with low-dose
topical or vaginal estrogen preparations (cream, pill, ring).
• Endometrial polyps may be removed by hysteroscopic resection or D&C.
• Benign endometrial hyperplasia can be treated with progestin therapy if no
atypia is present.
• Hysterectomy is the treatment of choice for EIN.
• Endometrial cancer is usually treated by total hysterectomy and bilateral
salpingo-oophorectomy (TAHBSO) performed in conjunction with radiation
if indicated.