Vaginal bleeding is any bleeding through the vagina. PV is shorthand for blood loss per vaginam (Latin for "through the vagina".

• 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

• 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

• 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
    • Trauma
    • Neoplasm
  • Cervical bleeding:
    • Cervicitis
    • Cervical neoplasm
    • Cervical polyp
  • Dysfunctional uterine bleeding (see page)
  • STI
  • In pregnancy:
    • Threatened miscarriage (see page), <24 weeks
    • Antepartum bleeding (see page), >24 weeks
    • Postpartum bleeding (see page), >birth
  • Postmenopausal bleeding (see page), >menopause
• Non-genital tract bleed:
  • GI bleed:
    • Hemorrhoids
    • IBD
  • Urinary tract bleed (aka hematuria):
    • UTI
• Predisposition, due to coagulopathy

• 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

• Directed at the cause
• COCP, for hormonal bleeding problems during the reproductive years, if bothersome to the woman

• Hypovolemia, in an emergency or acute setting

• Can occur at any age, but always requires Ix when encountered in female children, pregnant women, or postmenopausal women - when menstruation is NOT expected

• Menstruation (includes Mx of period w/ pads/tampons)
• Vaginal discharge
• Intermenstrual bleeding
• Post-coital bleeding