Vaginal Bleeding

What is Vaginal Bleeding?

Vaginal bleeding is a common problem that has many possible causes. This type of bleeding can happen suddenly or over a long period, and it can happen to women of all ages. This article discusses how a doctor would examine a patient with vaginal bleeding and the initial steps they would take to treat it.

In this context, “vaginal bleeding” means any unexpected bleeding from the vagina. This could include:

* Bleeding at any time other than during a regular menstrual period
* A period that is heavier or lasts longer than usual
* Any bleeding during pregnancy
* Bleeding in people who have gone through menopause or in girls who have not yet started menstruating.

What Causes Vaginal Bleeding?

Vaginal bleeding can be a worrying symptom for many women. It can occur as a result of a problem somewhere within the female reproductive system, including the external female genitals (vulva), the vagina, cervix, womb, and adjoining structures. The bleeding could be due to a range of conditions related to women’s health, pregnancy-related causes, or non-reproductive health issues. It’s important to bear in mind that bleeding could sometimes be a sign of cancer so it’s always worth seeing a doctor to investigate.

Let’s break down some of the most common causes of vaginal bleeding:

Health issues related to the womb can often lead to vaginal bleeding. For example, abnormal uterine bleeding (AUB) is a common cause in teenagers and adults. AUB can be categorized into two main groups: “PALM” and “COEIN”.

The “PALM” group includes structural causes of AUB:

Polyps – growths that develop in the lining of the womb
Adenomyosis – a condition where the inner lining of the uterus breaks through the muscle wall of the uterus
Leiomyomas – noncancerous growths in the uterus, also known as fibroids
Malignancy or hyperplasia – cancer or abnormal increase in cells in the womb lining

The “COEIN” group include causes that are related to the body’s physiology or system:

Coagulopathy – a condition that affects the blood’s ability to clot
Ovulatory dysfunction – problems with ovulation, often due to hormonal changes or extremes of reproductive age, such as polycystic ovary syndrome (PCOS), thyroid issues, overproduction of the hormone prolactin, or the periods around the start of menstruation or menopause
Endometrial abnormalities – problems with the lining of the womb, such as inflammatory or infectious conditions, or changes related to aging
Iatrogenic causes – side effects of medical treatment, such as hormonal contraceptives or certain medications
Not otherwise classified – other causes such as from an abnormal connection between an artery and a vein, or a rare type of inflammation in the womb called uterine sarcoidosis

Newborn babies may also experience a little bleeding during the first week after birth when the mother’s hormones in the baby’s blood decrease. This doesn’t require treatment and will go away on its own.

It’s not always the womb that’s the issue; common causes of bleeding can also come from the vulva and the vagina. These can be due to injuries, ulcers, tumors, aging, and damage from childbirth or surgery. Foreign items left inside, like a tampon or condom, can also cause bleeding. The cervix can also be a source of bleeding, whether due to infections, tumors, growths, or a condition called cervical ectropion where the cells on the inside of the cervix spread to the outside. Sometimes, a condition called endometriosis can cause bleeding. This is when tissue that normally lines the inside of your uterus grows outside your uterus.

If you’re pregnant, vaginal bleeding might be due to conditions related to the pregnancy, such as a hematoma (a localized collection of blood), miscarriage, ectopic pregnancy (a pregnancy that occurs outside the womb), or gestational trophoblastic disease, a rare condition where a tumor forms in the cells that would normally become the placenta. Later on in the pregnancy, bleeding could be due to a problem with the placenta, when the womb starts to open too soon before the baby is due, or a tear in the womb.

If you’ve just given birth, heavy bleeding (postpartum hemorrhage) is usually caused by a womb that doesn’t tighten properly after childbirth. It can also occur if there are remaining fragments of the placenta inside the womb, if there were injuries during birth, a womb inversion where the womb turns inside out, or a severe blood clotting disorder.

Risk Factors and Frequency for Vaginal Bleeding

Vaginal bleeding can occur in anyone with female anatomy, including those with a neovagina, at any stage of their life. It’s difficult to spot any patterns in vaginal bleeding when it is a standalone symptom. However, when considering specific causes or groups of people, certain patterns emerge. For instance, about 25% of people experience vaginal bleeding in the early stage of pregnancy. Postmenopausal bleeding occurs in 5% to 10% of cases, typically in the first year after the last period.

The causes of vaginal bleeding vary with age.

In children before puberty, the causes could be inflammation of the vulva and vagina (often due to stuck foreign bodies), physical injury (accidental or abusive), a protruding urethra, functioning follicular cysts, estrogen-releasing tumors (like ovarian granulosa cell tumors), McCune-Albright syndrome, or unintentional exposure to estrogen.
In people of reproductive age, the most frequent causes of abnormal uterine bleeding (AUB) are ovulatory dysfunction and leiomyomas. Cases of AUB linked to cancer are more likely to be seen in older individuals within this age group.
In postmenopausal individuals, the rates of cancer are highest, so cancer should always be ruled out when a patient in this age group presents with vaginal bleeding.

Signs and Symptoms of Vaginal Bleeding

When a patient is having abnormal bleeding, their past and present condition needs to be assessed carefully. This evaluation includes asking about their reproductive health status and any potential pregnancy. For example, a patient could be a young girl who hasn’t started menstruating, a teenager or a woman who has regular periods, a woman going through or past menopause, a person with diverse gender identity, or a person who has had a hysterectomy (removal of the uterus). If a patient is menstruating, the date of their last period should be asked for. Similarly, it should also be inquired whether they or their partner use any contraceptive methods and whether they could be pregnant. However, in women of reproductive age, a pregnancy test should always be done.

After that, the nature of the bleeding should be assessed by asking about the onset, frequency, duration, and severity of the bleeding. These factors can help identify any potential instigators such as trauma, changes in the use of hormonal contraceptives, and if bleeding occurs mainly after physical contact, indicating potential frailty or instability of the cervix or lining of the uterus. Other symptoms that may hint towards possible causes should also be asked about, including:

Pelvic pressure, discomfort during intercourse, constipation, or urinary frequency (may suggest a tumor)
Painful menstruation (suggests fibroids or adenomyosis)
Unintentional weight loss (may suggest cancer or hyperthyroidism)
Unchecked milk production (which may suggest high levels of prolactin) or hairiness (which indicates high androgen levels, PCOS, or congenital adrenal hyperplasia)
Heavy bleeding since the start of menstruation, a history of excessive bleeding from surgeries, dental procedures or childbirth, frequent bruising, nosebleeds, or a family history of bleeding symptoms (may suggest a bleeding disorder)
Pelvic pain, abnormal or foul-smelling vaginal discharge, or vaginal itching (suggests an infection)

A person who is in their second or third trimester of pregnancy should be asked whether this bleeding comes with pain or contractions, as painful bleeding could mean placental abruption, uterine rupture, or labor, while painless bleeding implies placenta or vasa previa. A decrease in the baby’s movement, any fluid loss, and the nature of recent childbirth or miscarriage should also be discussed. Risk factors for gynecologic cancer such as prolonged exposure to estrogen, a family history, and a person’s history of cervical cancer screens should be taken into account. It should be noted whether a person’s medications could affect their bleeding patterns. A comprehensive history that includes obstetric, gynecological, medical, surgical, and family information should be obtained for a complete evaluation and treatment plan.

Upon physical examination, the following should be assessed:

The person’s wellness
Visible signs of the bleeding source
Signs of trauma or foreign bodies
Signs of infection (abnormal discharge, ulcers, increased pain in the pelvis) and samples should be taken where needed
Signs of tumors (visible lesions, palpable mass) and biopsies should be made where necessary
Signs of endocrine disorders (such as an enlarged thyroid or hirsutism)

In pregnant people, the dilation of their cervix, the condition of the cervix’s coverings (membranes), and the heart rate of the fetus should also be assessed. Note that a cervical examination should not be performed in pregnant individuals until it has been confirmed through an ultrasound that the placenta or placental vessels are not blocking the cervical opening, as such an exam may result in serious harm. In people who have recently given birth, manually exploring the uterus could reveal retained placental fragments.

For pre-menstruating children, the mother’s age at the onset of menstruation, any potential trauma including abuse, weight loss, excessive thirst or urination, and other signs of early puberty should be looked for. An external examination of the vaginal opening should be performed to look for signs of potential trauma, tumors, and foreign bodies, preferably in the “knee-chest” position for children rather than the traditional lithotomy position. Usually, for children, a speculum examination is not necessary; however, if required, it should typically be done under anesthesia.

Postmenopausal women should be carefully examined since cancer could be a possibility. Their evaluation should focus on other signs and symptoms that could indicate a tumor, such as weight loss, easy bruising, a palpable mass, or a visible lesion. Atrophy of the vagina is often present unless the person is using hormone replacement therapy, hence speculum exams could potentially be discomforting or painful.

In the case of transgender and gender diverse individuals, they should be asked their preferred names, pronouns, and the terminology they use for their body parts. If these persons present with vaginal bleeding, it is important to know what organs they have and whether they are taking any hormones. Like with other adults who have vaginal bleeding, a speculum exam is usually done; however, sensitivity and judgement should be used as these individuals might have higher anxiety and fear regarding this procedure, especially if they do not identify as women. Further, testosterone usage can cause atrophy of the vagina, making speculum examinations more physically painful.

Testing for Vaginal Bleeding

If you’re experiencing vaginal bleeding, the method that doctors use to check you may depend on your age and whether you are able to conceive. In all cases, it is important to try to figure out from your personal history how much blood has been lost.

For women who can become pregnant, the first check is often a pregnancy test. If there is a positive result, the doctor will likely use an ultrasound to figure out three things:
1. Where the pregnancy is located – an ectopic pregnancy is when the pregnancy is outside the uterus and can be dangerous.
2. If the pregnancy seems healthy or not – a heartbeat can indicate the pregnancy is viable.
3. An estimated guess of how old the pregnancy is – this can be done by measuring certain features on the ultrasound.

Sometimes, if early signs of pregnancy are not visible on the ultrasound, a hormone called beta-human chorionic gonadotropin (hCG) may disclose the presence of a pregnancy.

In the later part of pregnancy, there are some conditions, including placental issues, that may cause bleeding. Clinicians will usually use an ultrasound examination and a non-stress test (NST) to check the baby’s condition. The ultrasound can also help to locate the exact position of the placenta and confirm other findings.

Post-delivery, heavy bleeding can be controlled with medications that cause the uterus to contract. Tests that evaluate the blood cell count, the ability to form clots, and blood typing may be required if bleeding does not subside.

The focus of testing for women who are not pregnant will be on evaluating the health of the reproductive tract. Pelvic ultrasound and blood tests may be ordered, including specialized tests for certain conditions. Doctors might also sample the lining of the uterus if there are other risk factors.

For younger women who have not started menstruating, tests will depend on the cause suspected after a medical history review and physical examination. Doctors may check for sexually transmitted infections (STIs) if abuse is suspected, hormone-related conditions like diabetes or thyroid issues, issues with blood clotting, or may plan an exam under anesthesia.

Women who are already through menopause and who are bleeding need to be evaluated using an ultrasound of the uterus and might have tissue samples taken in case there is a risk of cancer. Although often the cause for post-menopause bleeding is not serious, cancer must be ruled out since it can occur in some cases. Doctors might also check for cervical cancer or consider infections. If any lesions are visible, they should be biopsied even if no other signs of cancer are indicated.

Treatment Options for Vaginal Bleeding

When dealing with sudden, heavy vaginal bleeding, healthcare providers will first stabilize the patient, focusing on ensuring they can breathe and have proper blood circulation. If the bleeding is severe, the doctor might pack the vagina to slow down the bleeding and in some cases, a blood transfusion might be necessary.

If significant blood loss has led to iron-deficiency anemia, iron supplements can be used to treat this. Other treatments will be decided based on the cause of the bleeding.

If a nonpregnant patient experiences intense uterine bleeding, it’s usually managed with medication first, with hormonal therapy being the first choice. Surgical approaches are reserved for more serious cases. Some options include medication with equine estrogen, oral progestins, birth control pills and tranexamic acid. If a patient has a known or suspected bleeding disorder, they may need to consult with a hematologist.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are typically avoided in these cases. If bleeding doesn’t stop with initial treatments and the patient is exhibiting signs of a coagulation issue — that is, their blood isn’t clotting normally — other approaches may be needed.

Surgical treatment might be needed for some patients, especially those with severe or uncontrolled bleeding or those who aren’t responding to medication. Some options include dilation and curettage (D&C), a procedure where the uterine lining is scraped to reduce bleeding, hysteroscopy, endometrial ablation, uterine artery embolization, or hysterectomy.

If a young child, teenager or adult experiences non-uterine vaginal bleeding, the treatment will depend on the cause. For example, vaginal lacerations might need to be stitched, while bleeding from an infected cervix may improve with suitable antibiotic treatment. Lesions from a mesh used for bladder leakage are often treated topically with estrogen.

If a patient miscarries, treatments can range from patiently waiting for the body to expel the pregnancy tissue to taking medication that helps the miscarriage process. On occasion, a procedure to remove the pregnancy tissue might be needed. This can be done through uterine aspiration (a type of suction procedure) or a suction D&C. Emergency cases of sudden, heavy bleeding in pregnant patients could require a caesarean section.

Postpartum hemorrhage, or heavy bleeding after giving birth, can be treated with medications such as oxytocin and methylergonovine, amongst others. A healthcare provider may use techniques such as bimanual uterine massage (using hands to stimulate uterine contractions) or a uterine tamponade balloon to stop the bleeding. However, in certain circumstances, surgery may be necessary.

If further treatment is necessitated by bleeding disorders like gestational trophoblastic disease (GTD), this may involve uterine evacuation and chemotherapy. A hysterectomy (removal of the uterus) may also be an option for certain patients who do not wish to have more children.

Vaginal bleeding in adults and adolescents can be caused by many different things, which can be grouped into several categories:

Structural changes in the womb:

Polyps
Adenomyosis
Leiomyomas
Malignancy or hyperplasia

Non-structural changes in the womb:

Coagulopathy
Ovulatory dysfunction (often due to conditions like thyroid disorders or the extremes of reproductive age)
Iatrogenic causes
Endometrial dysfunction (including endometritis and estrogen-deficient atrophy)
Other causes not yet classified

Problems in the vulva or vagina:

Trauma
Infections
Ulcers
Neoplasia
Atrophy
Injury from a foreign body or prolapse
Vaginal endometriosis

Issues with the cervix:

Infectious cervicitis
Neoplasia
Polyps
Fibroids
Ectropion

Problems with the adnexa:

Neoplasia
Ruptured hemorrhagic cysts
Salpingitis

Pregnancy-related causes:

Ectopic pregnancy
Early pregnancy loss
Subchorionic hematoma/hemorrhage
GTD/GTN
Placental abruption
Placenta previa
Uterine rupture
Cervical dilation/labor
Postpartum uterine atony
Retained placenta
Obstetric lacerations

Vaginal bleeding in children has a different set of possible causes:

Vulvovaginitis (usually due to retained things like toilet paper)
Trauma (accidental or abuse)
Urethral prolapse
Estrogen-secreting tumors (like ovarian granulosa cell tumors)
Excessive exposure to estrogen
In newborn babies, bleeding in the first week of life often happens as a “withdrawal bleed” when the mother’s hormone levels drop in the baby’s bloodstream

What to expect with Vaginal Bleeding

The outcome of vaginal bleeding can be different for everyone and largely depends on its underlying cause. More severe or heavy bleeding, particularly when it’s causing instability in the patient’s overall condition or is linked to cancer, generally has a less positive outlook compared to light bleeding caused by a less dangerous condition.

In pregnant individuals, the stage of pregnancy and the severity of the bleeding are also key in determining the likely health outcome for the baby. For instance, the outlook is typically better for a person at 38 weeks into their pregnancy who has light bleeding due to a minor partial tear at the edge of the placenta, as compared to someone needing an emergency caesarean delivery at 28 weeks because of severe tearing of the placenta with heavy bleeding following a car accident.

Possible Complications When Diagnosed with Vaginal Bleeding

If a nonpregnant woman experiences acute vaginal bleeding, the complications can be severe due to the sudden loss of blood. These issues can include anemia (low levels of healthy red blood cells), acute kidney injury (sudden damage to the kidneys), instability in blood circulation, reactions to blood transfusions, and complications following emergency surgery, like organ injury, infection, and loss of fertility.

In terms of medical treatment for sudden bleeding in the uterus, the use of higher doses of hormone therapy can increase the chances of thromboembolic events, such as blood clots moving to the lungs.

Pregnant women who suffer from bleeding during the second half of their pregnancy may face serious issues. Risks include delivering the baby too early (preterm delivery), needing a cesarean section, excessive bleeding after delivery (postpartum hemorrhage), and harm to the baby due to prematurity, blood loss, and poor oxygen levels in the womb.

Lastly, a condition known as a ‘ruptured ectopic pregnancy’, where the fetus is growing outside of the uterus, can endanger the mother, resulting in internal bleeding and can lead to the mother’s death if it is not treated promptly.

List of complications from acute vaginal bleeding:

Anemia
Acute kidney injury
Hemodynamic instability
Transfusion reactions
Organ injury, infection, loss of fertility from emergency surgery
Risk of thromboembolic events from hormone therapy
Preterm delivery
Cesarean delivery
Postpartum hemorrhage
Adverse fetal/neonatal outcomes
Internal hemorrhage and maternal death from ruptured ectopic pregnancy

Preventing Vaginal Bleeding

If a young girl, pregnant woman, or woman who has stopped menstruating (gone through menopause) has vaginal bleeding, it’s important she gets checked by a healthcare professional. This is to make sure there are no serious health issues causing the bleeding.

Using a condom during sexual intercourse can help stop the spread of sexual infections that may cause inflammation of the cervix (this is called cervicitis).

Regular screenings for cervical cancer can help find if a woman has human papillomavirus (HPV) and/or abnormal changes in the cells of her cervix (this is called cervical dysplasia) before these change into cancer. It’s crucial because early detection can significantly increase the chances of successful treatment.

Frequently asked questions

The prognosis for vaginal bleeding depends on its underlying cause and severity. Generally, more severe or heavy bleeding, especially when it is causing instability or is linked to cancer, has a less positive outlook compared to light bleeding caused by a less dangerous condition. In pregnant individuals, the stage of pregnancy and the severity of the bleeding also play a role in determining the likely health outcome for the baby.

Vaginal bleeding can occur as a result of various factors, including health issues related to the womb, such as abnormal uterine bleeding (AUB), which can be caused by polyps, adenomyosis, leiomyomas, malignancy, or hyperplasia. Other causes include coagulopathy, ovulatory dysfunction, endometrial abnormalities, iatrogenic causes, and not otherwise classified causes. Vaginal bleeding can also be caused by injuries, ulcers, tumors, aging, damage from childbirth or surgery, foreign items left inside, or conditions like cervical ectropion or endometriosis. In pregnancy, vaginal bleeding can be due to conditions like hematoma, miscarriage, ectopic pregnancy, gestational trophoblastic disease, problems with the placenta, or a tear in the womb. Postpartum hemorrhage can cause heavy bleeding after childbirth. Vaginal bleeding can occur in anyone with female anatomy, including those with a neovagina, at any stage of their life. The causes of vaginal bleeding vary with age, such as inflammation, physical injury, tumors, or exposure to estrogen in children before puberty, ovulatory dysfunction and leiomyomas in people of reproductive age, and cancer in postmenopausal individuals.

Signs and symptoms of vaginal bleeding include: - Abnormal bleeding, which may be heavy, prolonged, or irregular - Bleeding between periods - Bleeding after sexual intercourse - Bleeding after menopause - Pain or discomfort during intercourse - Pelvic pain or pressure - Abnormal or foul-smelling vaginal discharge - Vaginal itching or irritation - Unintentional weight loss - Unchecked milk production - Excessive hairiness - Heavy bleeding since the start of menstruation - History of excessive bleeding from surgeries, dental procedures, or childbirth - Frequent bruising or nosebleeds - Family history of bleeding symptoms It is important to note that these signs and symptoms may vary depending on the underlying cause of the vaginal bleeding. Therefore, a comprehensive evaluation and examination should be conducted to determine the cause and appropriate treatment.

The types of tests that may be needed for vaginal bleeding depend on the individual's age, pregnancy status, and suspected cause of the bleeding. Some possible tests that a doctor may order to properly diagnose this condition include: - Pregnancy test - Ultrasound examination - Non-stress test (NST) - Blood tests (including blood cell count, clotting ability, blood typing) - Pelvic ultrasound - Specialized tests for certain conditions - Sampling of the uterine lining - Tests for sexually transmitted infections (STIs) - Hormone-related tests (e.g., diabetes, thyroid issues) - Exam under anesthesia - Uterine ultrasound - Tissue samples (biopsy) - Iron-deficiency anemia evaluation - Hematologist consultation (for bleeding disorders) - Medication trials (e.g., hormonal therapy, equine estrogen, oral progestins, birth control pills, tranexamic acid) - Surgical treatments (e.g., dilation and curettage, hysteroscopy, endometrial ablation, uterine artery embolization, hysterectomy) - Stitching of vaginal lacerations - Antibiotic treatment for infected cervix - Topical treatment with estrogen for lesions from a mesh - Uterine aspiration or suction D&C for miscarriage - Caesarean section for emergency cases of heavy bleeding in pregnant patients - Medications and techniques for postpartum hemorrhage - Uterine evacuation and chemotherapy for gestational trophoblastic disease (GTD) - Hysterectomy for patients who do not wish to have more children.

The doctor needs to rule out the following conditions when diagnosing Vaginal Bleeding: - Polyps - Adenomyosis - Leiomyomas - Malignancy or hyperplasia - Coagulopathy - Ovulatory dysfunction - Iatrogenic causes - Endometrial dysfunction - Trauma - Infections - Ulcers - Neoplasia - Atrophy - Injury from a foreign body or prolapse - Vaginal endometriosis - Infectious cervicitis - Neoplasia - Fibroids - Ectropion - Neoplasia - Ruptured hemorrhagic cysts - Salpingitis - Ectopic pregnancy - Early pregnancy loss - Subchorionic hematoma/hemorrhage - GTD/GTN - Placental abruption - Placenta previa - Uterine rupture - Cervical dilation/labor - Postpartum uterine atony - Retained placenta - Obstetric lacerations - Vulvovaginitis - Trauma - Urethral prolapse - Estrogen-secreting tumors - Excessive exposure to estrogen - Withdrawal bleed in newborn babies.

The side effects when treating vaginal bleeding can include: - Anemia (low levels of healthy red blood cells) - Acute kidney injury (sudden damage to the kidneys) - Hemodynamic instability (instability in blood circulation) - Transfusion reactions - Organ injury, infection, and loss of fertility from emergency surgery - Risk of thromboembolic events from hormone therapy - Preterm delivery - Cesarean delivery - Postpartum hemorrhage (excessive bleeding after delivery) - Adverse fetal/neonatal outcomes - Internal hemorrhage and maternal death from ruptured ectopic pregnancy

You should see a doctor specializing in gynecology or obstetrics for vaginal bleeding.

Vaginal bleeding can occur in anyone with female anatomy, including those with a neovagina, at any stage of their life.

When dealing with vaginal bleeding, the treatment depends on the cause and severity of the bleeding. For sudden, heavy vaginal bleeding, healthcare providers will first focus on stabilizing the patient's breathing and blood circulation. In severe cases, the doctor might pack the vagina to slow down the bleeding or a blood transfusion may be necessary. Iron supplements can be used to treat iron-deficiency anemia caused by significant blood loss. Nonpregnant patients with intense uterine bleeding are usually managed with medication, such as hormonal therapy, with surgical approaches reserved for more serious cases. Nonsteroidal anti-inflammatory drugs (NSAIDs) are typically avoided. If initial treatments don't stop the bleeding or if there are coagulation issues, other approaches may be needed. Surgical treatment, such as dilation and curettage (D&C), hysteroscopy, endometrial ablation, uterine artery embolization, or hysterectomy, may be necessary for some patients. Treatment for non-uterine vaginal bleeding depends on the cause, such as stitching vaginal lacerations or antibiotic treatment for bleeding from an infected cervix. In cases of miscarriage, treatment can range from waiting for the body to expel the pregnancy tissue to medication or a procedure to remove the tissue. Postpartum hemorrhage can be treated with medications, uterine massage, or a uterine tamponade balloon, but surgery may be necessary in certain circumstances. Bleeding disorders like gestational trophoblastic disease (GTD) may require uterine evacuation, chemotherapy, or a hysterectomy.

Vaginal bleeding refers to any unexpected bleeding from the vagina, which can occur at any time other than during a regular menstrual period, during pregnancy, or in people who have gone through menopause or girls who have not yet started menstruating. It can happen suddenly or over a long period and can affect women of all ages.

Women's Health