Vaginal Bleeding (Non-Pregnant)

Background
  • This page is for the generalized approach to undifferentiated vaginal bleeding in non-pregnant women
  • Normal menstruation:
    • 28 +/- 7 day cycles
    • 3-7 days of bleeding
    • Usual amount bleeding per period 10-35 cc
    • Each normal sized tampon or pad holds 5 cc when soaked through

Vaginal Bleeding Definitions
  • Menorrhagia: >7 day (prolonged) or >80 mL/day (excessive) uterine bleeding at regular intervals
  • Metrorrhagia: irregular vaginal bleeding outside the normal cycle
  • Menometrorrhagia - Excessive irregular vaginal bleeding
  • Intermenstrual bleeding - variable amounts between regular menstrual periods
  • Midcycle spotting - spotting just before ovulation (due to decline in estrogen)
  • Postmenopausal bleeding - recurrence of bleeding after menopause
    • Never normal but usually not emergency, requires outpatient OB/GYN follow up
  • Polymenorrhea: Frequent and light bleeding
  • Postcoital bleeding: vaginal bleeding after intercourse, suggesting cervical pathology
  • Postmenopausal bleeding: Any bleeding that occurs >6 mo after cessation of menstruation
  • The International Federation of Gynecology and Obstetrics (FIGO) introduced a new classification system known by the acronym PALM-COEIN
  • PALM: structural causes
    • Polyp (AUB-P)
    • Adenomyosis (AUB-A)
    • Leiomyoma (AUB-L)
    • Malignancy and hyperplasia (AUB-M)
  • COEIN: nonstructural causes
    • Coagulopathy (AUB-C)
    • Ovulatory dysfunction (AUB-O)
    • Endometrial (AUB-E)
    • Iatrogenic (AUB-I)
    • Not yet classified (AUB-N)

Clinical Features
  • Vaginal bleeding in a non-pregnant woman

Differential Diagnosis

Nonpregnant Vaginal Bleeding

Systemic Causes

Reproductive Tract Causes

Evaluation

Work-Up
  • Urine pregnancy
  • hemoglobin
  • Coags (only if history of or suspect coaulopathy)
  • ?TSH, prolactin (only if suspect endocrine disorder)
  • Consider follow up for non-emergent pelvic ultrasound
    • No indication for emergent ultrasound in ED

Evaluation

Management

Mild Bleeding
  • Iron supplementation
    • 324mg ferrous sulfate tablet PO TID (each tab contains 65mg of elemental iron)
  • Ibuprofen
    • For cramps and can theoretically decreases intra-uterine bleeding
    • Reduces endometrial prostaglandin levels and promotes vasoconstriction in the uterus

Moderate continued bleeding

Patients can benefit from initiation of birth control or for acute cessation consider medroxyprogesterone therapy in the ED

  • Medroxyprogesterone
    • Give only if endocervical curettage/endometrial biopsy does not need to be performed (young patient) or has already been performed, since the hormone may alter the results
    • High Dose regimen: 150mg IM x 1 then 20mg PO Q8hrs x 3 days
    • In a trial of 48 patients all had cessation in 5 days.[1]
    • Alternative regimen: 10mg PO q8 x 7 days then 10mg daily x 3 weeks[2]

Life Threatening
  • Establish large bore IV access
  • Prepare for emergent blood transfusion uncrossmatched O-negative blood if typed blood is not available.
  • It is possible to temporize bleeding w/ intravaginal packing with kerlix soaked in with thrombin
  • If bleeding is due to a traumatic cause emergent surgical repair is necessary
  • Tranexamic acid [3]
    • Coordinate with OBGYN prior to administration due to the increased thrombotic risk
    • Acutely 10 mg/kg IV, max dose of 600 mg[4]
    • Then 1-1.5 g TID PO for 5 days

Pharmacologic Treatment Regimens For Acute Abnormal Uterine Bleeding[5][6]
Drug Suggested Dose Contraindications
Conjugated equine estrogen25 mg IV every 4-6 h until bleeding stops, up to 24 hActive or past thromboembolic disease, breast cancer, or liver disease
Combination oral contraceptive pills1 pill tid PO for 7 days or 1 pill bid PO for 5 days, then 1 pill qd until pack is finished> 35 y who smoke, hx of DVT or PE, breast cancer, liver disease, known thromboembolic disorders, pregnancy, ischemic heart disease, cerebrovascular disease, or uncontrolled hypertension
Progestin-only oral contraceptive pills (medroxyprogesterone acetate)20 mg tid PO for 7 days or 10 mg qd PO for 10 daysActive or past DVT or PE, liver disease, or breast cancer
NSAIDs: Ibuprofen200-400 mg 3-4 times/day PO for 5 daysAdvanced renal disease
Antifibrinolytic agents (tranexamic acid)1.3 g tid PO for up to 5 daysActive intravascular clotting or subarachnoid hemorrhage

Disposition
  • Most can be discharged home with OB/GYN follow-up
  • For severe anemia or persistent exceedingly heavy flow, consider admission and/or discussion with OB/GYN

References
  1. Ammerman SR, Nelson AL. A new progestogen-only medical therapy for outpatient management of acute, abnormal uterine bleeding: a pilot study. Am J Obstet Gynecol. 2013. 208(6):499.e1-e5.
  2. Aksu F, Madazli R et al. High-dose medroxyprogesterone acetate for the treatment of dysfunctional uterine bleeding in 24 adolescents. Aust N Z J Obstet Gynaecol. 1997;37(2):228–231.
  3. Leminen and Hurskainen. Tranexamic acid for the treatment of heavy menstrual bleeding: efficacy and safety. Int J Womens Health. 2012; 4: 413–421.
  4. Committee on Gynecological Practice. Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. April 2013. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Management-of-Acute-Abnormal-Uterine-Bleeding-in-Nonpregnant-Reproductive-Aged-Women
  5. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 557: management of acute abnormal uterine bleeding in nonpregnant reproductiveaged women. Obstet Gynecol. 2013;121(4):891-896
  6. Tibbles CD. Selected gynecologic disorders: abnormal uterine bleeding in the nonpregnant patient. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby-Elsevier; 2010: 1325-1332.

See Also
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