Amount of bleeding

More than three soaked pads or six full regular-absorbency tampons a day for 3 or more days likely equates to greater than 80 mL of blood loss (Brown, 2005). A history of flooding, clots, or leaking, especially overnight, may be associated with a clotting disorder.

Bleeding disorder/anticoagulants

Severe acute uterine bleeding in a nonpregnant patient usually occurs as the result of a coagulopathy or from taking anticoagulants. Women with submucous fibroids can also present with profuse bleeding.

Pregnancy

A small amount of bleeding can occur at the time of implantation. The blastocyst burrows into the endometrium and invades the maternal blood supply; the formation and implantation of the placenta follow. If bleeding occurs from implantation, it happens about 1 week before the expected menstrual cycle. Regard women of childbearing age as pregnant until pregnancy is ruled out. It is estimated that up to 50% of all fertilized eggs die and are aborted spontaneously, usually before the woman knows she is pregnant. About 20% of pregnant women have some vaginal bleeding during the first trimester.

Recent delivery

If the patient has recently delivered a baby, the abnormal vaginal bleeding is likely from retained placenta, infection of the uterus (endometritis), or a laceration.

Age

The risk for spontaneous abortion is higher in women older than age 35 years. Most ectopic pregnancies occur in women ages 25 to 34 years. However, women older than age 35 have a higher rate of death from ectopic pregnancy.

Weeks of gestation

Among known pregnancies, the rate of spontaneous abortion is approximately 10% and usually occurs between the seventh and twelfth weeks of pregnancy. An estimated 10% to 15% of clinically recognized pregnancies result in first trimester loss. The patient experiencing an ectopic pregnancy typically presents at about 6 to 8 weeks of gestation.

Chronic health conditions

The risk for spontaneous abortion is higher in women with systemic diseases, such as diabetes or thyroid problems.

Pain

Low back pain or abdominal pain that is dull, sharp, or cramping may indicate spontaneous abortion or ectopic pregnancy. If there is pain associated with ectopic pregnancy, it will usually be described as “crampy,” pelvic pressure, or “soreness” in the lower abdomen. In ectopic pregnancy, the pain may lateralize to one side. Severe, sharp, and sudden pain in the lower abdominal area may indicate rupture of the ectopic pregnancy. Ruptured ectopic pregnancy is a surgical emergency.

Passing tissue

The passage of tissue from the vagina suggests spontaneous abortion. Ectopic pregnancies can be accompanied by sloughing material.

Other symptoms

Pain referred to the shoulder is suggestive of ectopic pregnancy rupture with peritoneal free fluid and significant hemorrhage. Other symptoms of rupture include feeling dizzy or faint, or actually fainting.

Sexually transmitted infection

Sexually transmitted infections (STIs) that have been unnoticed, untreated, or inadequately treated can cause scarring of the fallopian tubes, which is associated with greater risk for ectopic pregnancy. Ectopic pregnancy occurs in about 1 of every 200 pregnancies (Box 33-1). However, if the woman has had PID, the rate is as high as 1 of every 40 pregnancies.

Previous pregnancies

The risk for spontaneous abortion is higher in women older than age 35 and in women with a history of three or more prior spontaneous abortions.

Age

Knowing a woman’s age can help focus the differential diagnosis. The majority of adolescents with abnormal bleeding experience anovulatory cycles caused when estrogen stimulates the uterine lining with no opposing progesterone. This condition leads to a thicker, more vascular, and less stable endometrium, predisposing the adolescent to dyssynchronous bleeding. A young woman’s bleeding is most frequently caused by pregnancy, contraceptive methods, or infection. Women over age 40 are more likely to have problems related to polyps, fibroids, or ovarian dysfunction.

Postmenopause

If a woman is postmenopausal, the origin of bleeding irregularities is often hormone therapy (HT), endometrial hyperplasia, or endometrial cancer (see section on postmenopausal bleeding).

Symptom analysis

Determine the amount of flow and its duration to establish if there is menorrhagia, metrorrhagia, or menometrorrhagia. Menorrhagia is considered to be 80 mL of menses, which is estimated as saturating a sanitary pad hourly, over several hours. Metrorrhagia is defined as bleeding at irregular intervals or intermenstrual bleeding. When the menstruation has an unpredictable schedule and lasts for a prolonged time, it is termed menometrorrhagia.

Associated complaints

Patients may experience postcoital bleeding with cervical infections, cervical polyps, or cervical cancer. Accompanying dyspareunia may indicate endometriosis. Dysmenorrhea can be caused by an intrauterine device (IUD) or adenomyosis. Pelvic pressure or pain is suspicious for persistent corpus luteum cyst. Uterine prolapse causes pelvic pressure, which is subjectively described as “something falling out of the vagina.” Fever is associated with a pelvic infection. Menorrhagia, accompanied by fatigue, weight gain, hair loss, cold intolerance, decreased libido, and constipation, is a symptom of hypothyroidism. Bleeding disorders may become apparent for the first time in the teenager, with severe menorrhagia accompanied by bruising, petechiae, and gingival bleeding.

Irregular menses

In anovulatory cycles, the endometrium proliferates under the influence of high estrogen levels until it can no longer be supported—then bleeding occurs. This results in a menstrual pattern that is longer than 28 days with a very heavy flow that lasts 7 to 14 days. If the patient’s estrogen levels are fluctuating, she may have two periods a month. Both of these patterns are consistent with DUB. However, organic problems with any component of the reproductive tract must be ruled out.

Acute bleeding

One episode of acute bleeding in a woman with normally regular menstrual cycles suggests uterine fibroids or a complication of pregnancy, such as threatened abortion. In a postmenopausal woman with an intact uterus, an episode of vaginal bleeding is indicative of endometrial hyperplasia and is suspicious for endometrial cancer.

Chronic bleeding

Chronic, irregular menstrual cycles coupled with obesity are likely to be caused by polycystic ovary syndrome (PCOS), also known as Stein-Leventhal syndrome. Chronic midcycle spotting can occur secondary to the normal midcycle drop in estrogen levels and usually is not bothersome to the patient because the amount of vaginal bleeding is very scant and the duration is short.

Birth control

Menorrhagia from IUD contraception is accompanied by increased cramping and pain. If spotting or cramping is not of a usual pattern, ectopic pregnancy or infection must be considered. Displacement or perforation of the uterus by the IUD can be verified by pelvic ultrasound. Women who have recently discontinued the use of oral contraceptive (OC) pills after several years of use may experience heavier menstrual bleeding than when they were on OC pills. Breakthrough bleeding caused by OC pills may occur in the first 2 weeks of the cycle because of low estrogen level or in the last 2 weeks because of low progesterone level. Long-acting progestin contraceptives (Norplant) may cause irregular heavy menses because there is a lack of estrogen to stabilize the endometrium. Changes in bleeding patterns for progestin users necessitate ruling out pregnancy.

Pediatric vaginal bleeding

In the United States, the average age of menarche is 12 years old. Vaginal bleeding before age 9 is abnormal and may indicate foreign body or injury. The presence of secondary sexual characteristics indicates sexual precocity. Newborn girls may experience breast bud enlargement, galactorrhea, and a small amount of vaginal bleeding from maternal exogenous hormones. These symptoms resolve without intervention within a few weeks.

Although uncommon, malignant genital tract tumors in girls can cause vaginal bleeding. Vaginal adenosis and adenocarcinoma are the most common tumor types.

Bleeding problems

A family history of bleeding problems or a positive review of systems and physical examination indicating the presence of petechiae or bruises suggests a bleeding tendency. Platelet counts or clotting studies are indicated.

Accompanying symptoms

Vulvovaginitis is the most common pediatric gynecological problem. Vaginal discharge, vaginal itching, vulvar erythema, and lesions often accompany vulvovaginal bleeding. A foul-smelling discharge is noted with bacterial vaginosis, trichomoniasis, and a foreign body. Wet mounts and cultures should be taken for all vaginal discharges of a child, including cultures for gonorrhea and Chlamydia. If a sexually transmitted infection (STI) or sexual abuse is suspected, syphilis and human immunodeficiency virus (HIV) testing should be done. Throat and rectal cultures for gonorrhea and Chlamydia should also be obtained.

Trauma to the perineum is more common in children because there is less subcutaneous fat of the vulva. Large lacerations and hematomas warrant referral for examination and repair under anesthesia.

Prolapse of the urethra may cause bleeding. It is accompanied by pain at the meatus and pain with urination.

Irregular menstrual cycles

Anovulatory cycles are the most common cause of irregular bleeding patterns among females beginning (adolescent) or ending (perimenopausal) their menstrual cycles. It is estimated that 80% of young adolescents will be anovulatory during the first year of menstruation. Regular ovulatory cycles are usually established by the second year of menses but may take up to 5 years.

Menopause symptoms

The hot flash is the most commonly experienced symptom of menopause. It is a sensation of increased upper body warmth that begins in the chest area and progresses upward to the neck and face. Sweating, which can be so profuse as to leave clothing wet, follows the hot flash. Hot flashes often lead to disturbed sleep patterns, insomnia, and fatigue. Vaginal atrophy is experienced by the patient as vaginal dryness, dyspareunia, and atrophic vaginitis (see Chapter 34). Atrophic changes can affect the urinary system, causing urinary frequency, urgency, and exacerbation of stress incontinence.