Vaginal bleeding is any bleeding through the vagina. PV is shorthand for blood loss per vaginam (Latin for "through the vagina".
Patient information
What is vaginal bleeding?
It's bleeding through the vagina.
What is a vagina?
The vagina is a muscular tube which is part of the female reproductive system.
Pathophysiology
Commonly caused by bleeding from another location of the female reproductive system. Can also be caused by bleeding from the vaginal wall itself
Typically arises from lining of the uterus (endometrium), but may arise from lesions of the uterine, cervix, vagina, and rarely from the Fallopian tube
Classification
Minimal vaginal bleeding (aka spotting), involving few drops of blood → metorrhagia
Mild bleeding, soaking <1 pad/tampon in >3 hours
Moderate bleeding, soaking >1 pad/tampon in 3 hours
Severe vaginal bleeding, soaking 1-2 pads/tampons in 1-2 hours, unless it is normal for the Pt. It may also involve passing clots of blood from the vagina. The exception is if the Pt is pregnant, and there is a single gush of blood, or passing of a clot, that is not considered severe
Cause
In children, before menarche:
Precocious puberty
Foreign body in the vagina
Molestation
Vaginitis (vaginal infection)
Tumor, rarely
Genital tract bleed:
Vaginal bleeding:
Physiological, during menstrual cycle (shedding when a woman is not conceiving)
Bleeding relating to OCP use, including breakthrough bleeding and/or withdrawal bleeding
Hormonal/organic problems of the reproductive system
Why would a woman bleed through her vagina?
So in kids, before a girl has her 1st period, it could be... well, early puberty. It could be a foreign body, molestation, vaginal infection, even a cancer. Then, we divide the bleed into genital, or non-genital. And, just general predisposition into bleeding.
Wait... non-genital? We said woman bleeding through her vagina... ?
Strictly speaking, it should be her vagina, but... it could be a GI bleed. Or, it could be a urinary bleed. So, we just want to be sure
Alright. So genital, big one, I'm guessing, given we are strictly talking about bleeding from the vagina?
So we can still divided, into vaginal bleeding, bleeding from the opening to the womb, bleeding from the womb itself. Then there's special situations, like STI's, during and after pregnancy, and bleeding after menopause, when it's supposed to have stopped.
Ix
Hx:
Characterization, including when it started, duration, pattern/regularity, amount (number of pads and tampons), frequency
Pain → trauma
Children → trauma from childbirth
Drugs, including OCT, HRT → estrogen causing thickening of endometrium/uterine lining → uterine cancer
PMH, including of bleeding, anemia → coagulopathy
SH → STI
Diet, especially of estrogen (e.g. from soy) → endometrial hyperplasia, uterine cancer
Smoking → risk factor for cervical cancer
O/E, focused on finding the source of bleeding, and looking for any abnormalities that could cause bleeding:
Visualization of the cervix with a speculum
Bimanual exam
Rectovaginal exam
Abdominal examination and palpation, to ascertain if the bleeding is abdominal in origin
Pregnancy test
FBC, if bleeding is excessive or prolonged, to check for anemia
Hysteroscopy w/ biopsy or D&C, to Ix an abnormal endometrium
Transvaginal U/S, which is 1st line procedure to identify which women are at higher risk of endometrial cancer. A cut off threshold of <=3mm of endometrial thickness should be used for in women with PMB, in a woman not having used HRT for 1yr+, or usage of continuous HRT consisting of both an estrogen and progestagen
Tx
Directed at the cause
COCP, for hormonal bleeding problems during the reproductive years, if bothersome to the woman
Complications
Hypovolemia, in an emergency or acute setting
Epidemiology
Can occur at any age, but always requires Ix when encountered in female children, pregnant women, or postmenopausal women - when menstruation is NOT expected
See also
Menstruation (includes Mx of period w/ pads/tampons)
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