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vaginal bleeding; abnormal uterine bleeding; anovulatory bleeding

Etiology: === prepubertal === 1) vulvovaginitis 2) vaginal trauma a) accidents from a fall on a sharp object b) foreign bodies c) sexual abuse 3) urological abnormalities: urethral prolapse 4) ovarian tumors (2/3 benign) a) follicular cysts b) juvenile granulosa cell tumor c) carcinomas (i.e. embryonal cell carcinoma) rare 5) vaginal a) tumors, generally benign b) polyps c) hymenal tags 6) hormonal stimulation a) menstruation secondary to precocious puberty b) exogenous estrogen exposure - oral contraceptive ingestion 7) bleeding disorder === reproductive age === 1) pregnancy a) early - spontaneous abortion, ectopic pregnancy, gestational trophoblastic disease, lesions of the cervix or vagina b) late - placenta previa (generally bright red, painless), abruptio placentae (generally dark red, painful) 2) hormonal abnormalities a) dysfunctional uterine bleeding - endometriosis b) endocrine diseases 1] ovarian tumor or dysfunction 2] hyperthyroidism 3) hypothyroidism 4] diabetes mellitus 5] pituitary dysfunction 6] adrenal tumor or dysfunction 3) infections 4) uterine pathology a) polyps (3% of women < 35, 23% of women > 35 [2]) b) fibroids (common) - intracavitary & intramural 5) cervical polyps, lacerations or cervical carcinoma - high risk of cervical cancer in patients with HIV1 infection, including those taking antiretroviral therapy [22] 6) vaginal trauma, neoplasia, or atrophy 7) vulvar atrophy or neoplasia 8) systemic disease a) coagulopathies 1] thrombocytopenia 2] von Willebrand's disease 3] vitamin K deficiency b) liver disease c) renal disease 9) medications - steroids, anticoagulants, oral contraceptives, anti-inflammatory agents, major tranquilizers & neuroleptics, chemotherapeutic agents, antihistamines, alcohol, local anesthetics 10) nutritional factors - obesity, iron-deficiency, vitamin C deficiency === perimenopausal === - endometrial cancer - irregular menses for 9 months with period lasting 15 days is anovulatory bleeding warranting endometrial biopsy without transvaginal ultrasound [19,21] - short-term (9 months) exposure to unopposed estrogen would place these women at sufficient risk for endometrial cancer to justify endometrial biopsy [19] === post-menopausal === 1) hormonal disturbances a) atrophic vaginitis/ genitourinary syndrome of menopause (most common) [7] b) estrogen withdrawal bleeding with cessation or interruption of HRT 2) cervical lesions a) cervical carcinoma b) cervicitis c) cervical polyp 3) endometrial lesions (generally benign) a) polyps (23% of women > 35 have endometrial polyps [2]) b) fibroids c) endometrial cancer (9% of postmenopausal vaginal bleeding) [16] d) endometrial atrophy, endometrial hyperplasia [7] 4) ovarian neoplasm (functioning) [7] 5) vaginal a) vaginitis b) vaginal neoplasm c) vaginal ulceration 6) vulvar a) vulvar carcinoma b) laceration or ulceration 7) other a) coagulation disorder b) rectal lesion (rectal polyp) [7] c) urinary tract infection [7] d) urethral mucosal prolapse [7] e) urethral caruncle [7] f) foreign body (pessary) [7] Epidemiology: - >75% of middle-aged women have vaginal bleeding considered abnormal [13] History: - pattern of bleeding: onset, duration, intensity, clots, pads/day, last menstrual period, contraceptives, sexual history, sexual abuse, drug history, vasomotor flushing, pain, fever/chills, lightheadedness, coagulopathy, thyroid, renal or hepatic disease Clinical manifestations: 1) hirsuitism or striae suggest adrenal disease 2) petechiae or ecchymoses suggest bleeding disorder 3) cervical abnormalities may be found 4) enlarged uterus may suggest fibroids or pregnancy Laboratory: 1) pregnancy test first line [3] a) urine pregnancy test b) beta-chorionic gonadotropin in serum 2) complete blood count (CBC) 3) other testing as indicated a) thyroid function tests (serum TSH, free T4) b) serum prolactin c) serum follicle-stimulating hormone (serum FSH) d) serum luteinizing hormone (serum LH) e) renal function tests f) liver function test (LFTs) g) Pap smear Special laboratory: 1) hysteroscopy if endometrial thickness cannot be visualized on ultrasound [10] 2) endometrial biopsy (in office) - premenopausal women > 45 years or obese (BMI >= 30) with anovulatory vaginal bleeding [3,19] or other risk factors for endometrial cancer* - if < 35 years of age & no risk factors for endometrial cancer* hormonal therapy is appropriate [3] - postmenopausal women with endometrial thickness > 5 mm [15,18] - endometrial thickness determined by pelvic or transvaginal ultrasound - endometrial biopsy may not be necessary in postmenopausal women without vaginal bleeding [15] - postmenopausal women treated with tamoxifen* [17] - failure of medical management [20] 3) dilatation & curettage * risk factors for endometrial cancer - prolonged unapposed estrogen stimulation of endometrium - obesity (BMI >= 30), polycystic ovary syndrome - genetic syndromes: Lynch syndrome, Cowden syndrome * irregular menstrual cycles suggests anovulatory vaginal bleeding [19] Radiology: 1) pelvic or transvaginal ultrasound a) mean endometrial thickness correlates with endometrial cancer in postmenopausal women [3] - cutoff level of < 4 mm [12,15] b) sensitivity for endometrial cancer is 95% if thickness set for false-positive rate of 50%; 63% if thickness set for false-positive rate of 10% [3] c) not useful in premenopausal or perimenopausal women due to variation in endometrial thickness with hormonal levels [19] 2) computed tomography 3) magnetic resonance imaging 4) hysterosalpingography Management: 1) any vaginal bleeding in postmenopausal women is abnormal a) further evaluation indicated b) pelvic examination [7] c) endometrial biopsy to evaluate for endometrial cancer as indicated (see Diagnostic procedures/Special laboratory above) 2) perineal hygiene 3) antibiotics if indicated 4) hormonal therapy a) combination oral contraceptives - 4 pills daily for 4 days - 3 pills daily for 3 days - 1 pill daily for 1st 25 days of month for several months b) oral progestins - 10 mg medroxyprogesterone for 1st 10-21 days of month [3] - medroxyprogesterone for the 2nd 1/2 of the month will restore cyclic menses [3] c) levonorgestrel-releasing intrauterine system 1] most effective hormonal treatment [5] 2] approved in US only for contraception d) danazol (gonadotropin-releasing hormone agonist) e) intravenous estrogen 25 mg every 4-6 hours for 4-6 doses - generally stops bleeding within 24 hours 5) transfusion if indicated 6) non-steroidal anti-inflammatory agents 7) Pap Smear & endometrial biopsy a) anovulatory bleeding in premenopausal women - menstrual abnormalities taking oral contraceptives b) post-menopausal bleeding (beyond the initial months of beginning hormone replacement therapy) 8) surgery a) dilatation & curretage (all post-menopausal women [3]) b) endometrial ablation c) hysterectomy - uterine fibroids, endometrial hyperplasia, refractory anemia or bleeding

Related

endometrial biopsy hemorrhage (bleeding) Papanicolaou (Pap) smear

Specific

antepartum hemorrhage dysfunctional uterine bleeding (DUB) menometrorrhagia menorrhagia metrorrhagia polymenorrhagia

General

sign/symptom mucosal bleeding vaginal disorder

References

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