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C3 - Non Pregnant Vaginal Bleeding - History

Mel Herbert, MD MBBS FAAEM, Stuart Swadron, MD, FRCPC, Mizuho Spangler, DO, and Jessica Mason, MD
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C3 - Non Pregnant Vaginal Bleeding Written Summary 420 KB - PDF

Important points are found in the history and physical.

Non-pregnant Vaginal Bleed - History

Stuart Swadron MD, Mizuho Spangler DO, and Mel Herbert MD

 

* Drug doses are a guide only, always check second source and follow local practice guidelines


History and Physical

      Important things to know about menstrual history:

      Last period, length of cycle, regularity, duration, pattern, and volume of bleeding

      Women with heavy or prolonged uterine bleeding generally complain of vaginal bleeding that may soak through clothing or onto bedding +/- passing blood clots

      For volume: do you change pads/tampons at ≥3 hour intervals (still not that consistent among patients), do you need to change the pad/tampon during the night?

      Prolonged bleeding is defined as longer than seven days

 

      Important terms (that help narrow down the DDx)

      Menorrhagia = heavy bleeding

      Common causes

      Structural (fibroids, adenomyosis)

      Non-structural (thyroid disease, coagulopathy)

      Metrorrhagia = bleeding between menstrual periods

      Common causes

      Structural (uterine polyps)

      Non-structural (ovarian dysfunction)

      Menometrorrhagia = a combination of heavy and irregular menses

      Common causes

      Structural (uterine polyps)

      Non-structural (ovarian dysfunction)

      When bleeding is irregularly irregular and extremely heavy at times, it is most likely due to anovulation (failure of ovulation)

      Anovulation occurs for many reasons, including:

      Anorexia

      Polycystic ovary syndrome (associated with obesity)

      Ovulation is key to setting the orderly pattern of the menstrual cycle with endometrial lining build-up (the proliferative estrogen stage) followed by ovulation and the stabilization of the uterine lining in preparation for a possible pregnancy (the secretory progestin stage)

      Without ovulation, the patient essentially remains in the proliferative stage, with disorderly and unchecked proliferation of the endometrium

      This can result in massive and uncontrolled bleeding as the “unstabilized” overgrown endometrium periodically slough off 

      Post-menopausal bleeding

      Common causes

      Hyperplasia (pre-cancer)

      Endometrial cancer 

      Post-coital bleeding

      Cervical pathology (cervical polyps, cancer, infection)

      Cervical/vaginal laceration (e.g. from traumatic intercourse)

      Vaginal bleeding associated with abnormal bruising and bleeding (e.g. with routine dental work) , and/or a family history of excessive bleeding

      Anticoagulant medications

      Coagulation disorders (e.g. von Willebrand’s disease is most common)

      Liver disease

      Chemotherapy drugs

 

Physical Examination:

      General exam

      Does the patient look sick or not sick?

      Do they appear pale (anemia), any signs of liver disease (e.g. jaundice, ascites)

      Are their signs of coagulation/platelet disorder?

      multiple spontaneous bruises - deep bleeding usually from prolonged clotting time

      petechiae - non-blanching purple dots that represent hemorrhage into the superficial layers of skin in platelet disorders

      Look for petechiae on the soft palate and flexor surfaces (e.g. popliteal fossa, back of the knees)

      Any signs of thyroid disease?

      Both hyper- and hypothyroidism can lead to abnormal uterine bleeding

      signs include thyroid gland enlargement/tenderness, tremor/lethargy, heat/cold intolerance, abnormal reflexes

      Abdominal exam:

      Note any peritoneal signs, signs of surgical disease

      May occasionally  feel very enlarged uterus with fibroids/adenomyosis above pubic symphysis

      The Pelvic exam is critical:

      Confirming the source - first make sure that it is not rectal bleeding

      Need to look at the vagina (foreign body or traumatic injury, tears usually go to OR)

      The cervix is critical to inspect visually if possible - it may reveal bleeding polyps, friability and bleeding from infection or lesions suspicious for cervical cancer

      Most abnormal bleeding arises from the cavity of the uterus, even if you don’t happen to see this directly (e.g. blood actually streaming from the os) either because the bleeding is intermittent or so heavy that visualization is difficult

      In cases of overwhelming bleeding, in addition to resuscitation and an immediate call for assistance, local measures such as vaginal packing and insertion of a Foley catheter into the uterus to tamponade the bleeding may be attempted

 

Tests:

      For sick patients (e.g. with signs of shock) and those with uncontrolled severe bleeding:

      CBC

      Coagulation tests (e.g PT/INR)

      Type and cross (for blood transfusion)

      TSH

      For well appearing/hemodynamically stable patients :

      Selective testing only

      In most cases, not much required beyond point of care hemoglobin

      Most will require a pelvic ultrasound, but this can usually be deferred to outpatient setting

 

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C3 - Non Pregnant Vaginal Bleeding Full episode audio for MD edition 49:18 min - 57 MB - M4AC3 - Non Pregnant Vaginal Bleeding Written Summary 420 KB - PDFC3 - October MP3s 62 MB - ZIPC3 - October - Non Pregnant Vaginal Bleeding - Board Review Answers 174 KB - PDFC3 - October - Non Pregnant Vaginal Bleeding - Board Review Questions 132 KB - PDF