Abnormal Vaginal Bleeding - Causes, Diagnosis, and Treatment

Last Updated on June 21, 2020

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.

In children

Precocious puberty
Foreign body in the vagina
Trauma
Sexual abuse
Vaginal infection
Vulval ulcers
Primary hypothyroidism
Vaginal tumors (benign or malignant)
Hormone producing ovarian tumors

Premenopausal

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.

Infections

Endometritis
Pelvic inflammatory disease (PID)
Cervicitis
Vaginitis

- Chlamydia trachomatis
- Gonorrhea
- Ureaplasma vaginitis

Benign tumors or growths

Polyps
- Endometrial polyps
- Cervical polyps
Leiomyoma

Endometrial disorders

Endometrial hyperplasia
Adenomyosis
Endometriosis

Malignancy (cancers)

Cervical cancer
Endometrial cancer (uterine cancer)
Ovarian cancer
Vaginal cancer

Coagulopathy

Von Willebrand disease
Other blood clotting or bleeding disorders

Ovulatory Disorders

Abnormal uterine bleeding (AUB) due to ovulatory dysfunction [anovulation ie., failure to ovulate]

Endocrine causes

Polycystic ovary syndrome (PCOS)
Hyperthyroidism (overactive thyroid)
Hypothyroidism (underactive thyroid)
Hyperprolactinemia
Obesity
Eating disorders including anorexia nervosa or bulimia
An imbalance between exercise and caloric intake

Iatrogenic causes

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

Pregnancy

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

Postmenopausal

Endometrial atrophy
Vaginal atrophy
Uterine fibroids
Hormone replacement therapy
Endometrial cancer
Cervical cancer

Diagnosis

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.

Physical examination

It includes visualizing the cervix with a speculum, a bimanual exam, and a rectovaginal exam. Abdominal examination is carried out by palpating the abdomen.

Blood tests

Complete blood counts, peripheral blood smear examination, and iron studies to diagnose hemoglobin levels and iron deficiency anemia in case of heavy bleeding.

Thyroid function tests, liver function tests, kidney function, tests to detect coagulation disorders (PT/ INR) may be carried out depending upon the patient’s signs and symptoms.

Hormone tests including estrogen, progesterone, FSH, LH if hormonal imbalance or PCOD is suspected.

Pregnancy test

Urine pregnancy test in women of childbearing age.

Ultrasound

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.

Hysteroscopy

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.

Endometrial biopsy

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.

Cervical biopsy

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.

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.

Prevention

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.

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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.

Treatment

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.

Hormonal therapy

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.

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.

Antibiotic treatment

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.

Endometrial ablation

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.

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.

Hysterectomy

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.