Vaginal bleeding is defined as any bleeding that occurs through the vagina.
Abnormal vaginal bleeding is any vaginal bleeding unrelated to normal menstruation. Menstrual periods that are heavier or last longer than usual or last more than seven days are also considered abnormal.
The origin of bleeding could be from the uterus, cervix, vulva, or vagina itself. When vaginal bleeding originates in the uterus, it is called abnormal uterine bleeding (AUB) or dysfunctional uterine bleeding (DUB).
The most common causes of abnormal vaginal bleeding include hormonal imbalance, anovulation, benign growths like fibroids or polyps, etc. In a few cases, cancer of the genital tract is the cause of vaginal bleeding. Hence all cases should be thoroughly investigated and treated accordingly.
What is Abnormal Vaginal Bleeding?
Normal vaginal bleeding is defined as the periodic flow of blood from the uterus. It is also called menorrhea, menstruation, menses, or periods. The menstrual cycle usually occurs every 21 to 35 days and lasts for two to seven days.
Menarche is the first occurrence of menses that occurs in girls at the time of puberty. The age of menarche is mostly between 10 to 13 years. Menopause is the time when menstrual cycles permanently stop. It usually occurs around 50 years of age.
Abnormal vaginal bleeding is bleeding from the vagina that occurs:
- between periods (including spotting)
- during menstruation, but is heavier than normal or that lasts longer than normal, ie., more than seven days
- before menarche
- after sex
- during early or late pregnancy
- after menopause
Commonly Used Medical Terms For Abnormal Vaginal Bleeding
- Excessive bleeding during menses – Menorrhagia or Hypermenorrhea
- Menses that are too frequent – Polymenorrhea
- Bleeding that occurs irregularly between the expected menses – Metrorrhagia
- Bleeding that is excessive during menses and occurs irregularly between menses – Menometrorrhagia
- Bleeding that occurs in young girls before menarche – Premenarchal bleeding
- Bleeding that occurs after menopause – Postmenopausal bleeding
Causes of Abnormal Vaginal Bleeding
The causes of abnormal vaginal bleeding are different in various age groups.
- Precocious puberty
- Foreign body in the vagina
- Sexual abuse
- Vaginal infection
- Vulval ulcers
- Primary hypothyroidism
- Vaginal tumors (benign or malignant)
- Hormone producing ovarian tumors
The causes of abnormal vaginal bleeding in premenopausal women who are not pregnant have been categorized using the FIGO (International Federation of Gynecology and Obstetrics) PALM-COEIN system. This acronym stands for Polyp, Adenomyosis, Leiomyoma, Malignancy and Hyperplasia, Coagulopathy, Ovulatory Disorders, Endometrial Disorders, Iatrogenic Causes, and Not Classified.
- Pelvic inflammatory disease (PID)
- Chlamydia trachomatis
- Ureaplasma vaginitis
Benign tumors or growths
- Endometrial polyps
- Cervical polyps
- Endometrial hyperplasia
- Cervical cancer
- Endometrial cancer (uterine cancer)
- Ovarian cancer
- Vaginal cancer
- Von Willebrand disease
- Other blood clotting or bleeding disorders
- Abnormal uterine bleeding (AUB) due to ovulatory dysfunction [anovulation ie., failure to ovulate]
- Polycystic ovary syndrome (PCOS)
- Hyperthyroidism (overactive thyroid)
- Hypothyroidism (underactive thyroid)
- Eating disorders including anorexia nervosa or bulimia
- An imbalance between exercise and caloric intake
- Stopping or changing birth control pills (withdrawl bleeding)
- Midcycle bleeding associated with ovulation
- Foreign object in the vagina
- Forgotten (retained) tampon
- Intrauterine device (IUD)
- Tamoxifen side effect
- Blunt trauma or penetrating injury to the vagina or cervix
- Sexual abuse
- Extreme emotional stress
Mostly abnormal vaginal bleeding during pregnancy occurs during the initial weeks of pregnancy when the woman is not even aware of the pregnancy. Hence any new and irregular bleeding that occurs in a woman of childbearing age may be a sign of very early pregnancy.
A very scant amount of bleeding may occur in the first two weeks of pregnancy, usually around the time of the expected menstrual period. This is called implantation bleeding and occurs due to the fertilized egg implanting in the uterine wall.
Other causes of bleeding during pregnancy include:
- Ectopic pregnancy
- Threatened or incomplete miscarriage
- Placenta previa (placenta partially or completely overlying the cervix)
- Placental abruption
- Post-partum hemorrhage
- Retained products of conception following pregnancy or abortion
During or after sexual intercourse
- Injuries to the vaginal wall or introitus
- Infections ( Gonorrhea, Chlamydia, Yeast infections)
- Tumors or polyps on the cervix or vagina
- Endometrial atrophy
- Vaginal atrophy
- Uterine fibroids
- Hormone replacement therapy
- Endometrial cancer
- Cervical cancer
The cause of the bleeding is determined on the basis of the bleeding history, signs and symptoms, and a detailed physical examination. Other medical tests and investigations may be considered as appropriate.
It includes visualizing the cervix with a speculum, a bimanual exam, and a rectovaginal exam. Abdominal examination is carried out by palpating the abdomen.
Hormone tests including estrogen, progesterone, FSH, LH if hormonal imbalance or PCOD is suspected.
Urine pregnancy test in women of childbearing age.
Ultrasonography of the pelvic area will detect any structural changes in the uterus and the ovaries like the presence of fibroids, polyps, endometrial thickness, ovarian cysts, etc. It will also detect ectopic pregnancy, miscarriage, or abnormalities of the placenta.
A thin tube with a tiny camera in it is put into the uterus. It enables the doctor to see the inside of the uterus. It can help to detect structural changes within the uterus. If anything abnormal is detected, a biopsy can be obtained.
Read more about Types of Biopsies and their Applications
In this test, a small sample of the endometrium is removed and then examined under a microscope. It helps to diagnose endometrial hyperplasia or endometrial cancer.
Pap smear examination
In this test, the cells from the cervix are scraped off and examined under a microscope. It can detect a variety of cervical infections, precancerous conditions, and cancer of the cervix.
Read more about Pap Smear- Indications, Method, and Significance
A small part of the cervix is removed and examined for cervical cancer or precancerous conditions.
Complications of Abnormal Vaginal Bleeding
Hypovolemia and Shock
Severe acute bleeding may lead to hypovolemia (the loss of blood from the circulation), which may progress to shock in severe cases. This is a medical emergency that requires admission to the hospital with intravenous fluid therapy and/or blood transfusion.
Read more about Blood transfusion- Indications and Procedure
Iron deficiency anemia
Prolonged heavy blood loss may lead to iron deficiency anemia. Such patients may require oral or injectable iron therapy or blood transfusions in severe cases.
Read more about Iron Deficiency Anemia: Causes, Lab Diagnosis, and Treatment
- Maintain a healthy weight. Both overweight and underweight women have a greater likelihood of having abnormal vaginal bleeding. There is a greater likelihood of hormonal imbalances in such individuals. Obese women are also at a greater risk of developing endometrial hyperplasia as well as uterine cancer.
Read about 10 Cancer Prevention Tips You Should Follow
- Oral contraceptives or birth control pills should be taken strictly according to directions and at the same time every day.
- If you are taking hormone replacement therapy, the medicines should be taken as directed.
- Reduce stress. You can opt for various relaxation techniques like yoga, meditation, music therapy, etc to reduce and cope with stress.
- A non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen can be used to reduce menstrual bleeding since they decrease the production of substances called prostaglandins in the body. The medicine should be started on the first day of the periods and continued until the menstrual bleeding stops.
It depends on the cause of bleeding.
Treatment of the underlying cause
In the case of an underlying thyroid, liver, kidney, or blood clotting problems, treatment is aimed at treating these disorders.
For endocrinal abnormalities, appropriate hormones like progesterone or oral contraceptives, etc may be given to achieve hormonal balance.
Hormonal therapy may also be given for treating endometriosis.
Read more about Endometriosis – Causes, Symptoms, Tests, and Treatment
If the cause of abnormal vaginal bleeding is not clear even after all the investigations (dysfunctional uterine bleeding), oral contraceptives may be given to improve cycle control and reduce abnormal bleeding.
In the case of infections, proper antibiotic therapy is required.
Surgical removal of benign tumors or growths
Conditions like polyps and fibroids need to be removed surgically. The surgical removal of fibroids is called a myomectomy.
Uterine fibroid embolization (UFE)
In this procedure, tiny particles are injected through a catheter into uterine arteries that deliver blood to fibroids. This blocks the blood flow and causes the fibroids to shrink.
The lining of the uterus is destroyed using a laser or other instruments that produce heat, freezing, or electrical currents. A narrow tube with a viewing device on the end (a hysteroscope) is used to guide during the procedure.
Dilation and curettage (D&C)
If medical treatment fails to control abnormal uterine bleeding, a surgical procedure called dilation and curettage (D&C) may be carried out. This procedure will reduce the excessive bleeding and also provide tissue that can be examined microscopically to detect any abnormalities of the endometrial lining of the uterus.
Treatment of uncontrolled heavy bleeding
Hypovolemia and shock due to uncontrolled acute bleeding are treated with intravenous fluid therapy and/or blood transfusion.
Read more about Blood transfusion- Indications and Procedure
Uterine artery embolization (occlusion of the blood vessels which supply the uterus) may be performed to treat uncontrolled life-threatening bleeding,
Iron therapy for prolonged blood loss
Iron deficiency anemia due to prolonged and heavy blood loss is treated by oral or injectable iron therapy or blood transfusions in severe cases.
Occasionally hysterectomy (removal of the uterus) may be necessary when all other methods fail to control excessive bleeding.
Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol 120 (1):197-206, 2012. doi: 10.1097/AOG.0b013e318262e320.
Management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol 122 (1):176-185, 2013. doi: 10.1097/01.AOG.0000431815.52679.bb.