Vaginal Bleeding in the Non-Pregnant Patient

General Intro / Main Questions

Theoretical Case

18 yo F G0P0 presents with sudden onset vaginal bleeding after passing multiple large clots and three syncopal events on the toilet.  She has a history of polycystic ovarian syndrome and depression.  Home medications include fluoxetine and metformin.  She had a normal menstrual period 2 weeks ago.  Initial vital signs include blood pressure 101/52 and pulse 95.  She is pale, shivering, and continues to pass clots intermittently.  Urine pregnancy is negative, hemocue (point of care hemoglobin) is 9.9.

An hour later, her blood pressure is 75/30 and pulse is 97.  Hemocue is 5.4.  Your ob-gyn consultant is in an emergency C-section.  What is the differential diagnosis and how are you going to stabilize this healthy 18 year-old female who is bleeding out in front of you?

What’s New

PALM-COEIN for etiologies of vaginal bleeding introduced in 2011 by FIGO (International Federation of Gynecology and Obstetrics) and adopted by ACOG (American College of Obstetricians and Gynecologists):

PALM (Structural causes)
Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia
COEIN (Non-structural causes)
Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified

In addition, terminology has been simplified: menorrhagia is now heavy menstrual bleeding and metrorrhagia is intermenstrual bleeding.

Recap Basics

  • Anovulatory Bleeding: Irregular periods and unpredictable bleeding.
  • Ovulatory Bleeding: Heavy and prolonged menstrual periods.
Most common causes of vaginal bleeding by age
12-18y Immaturity of hypothalamic-pituitary-ovarian axis leading to persistent anovulation.  Other causes include pelvic infection and coagulopathy (up to 20% of girls presenting to ED with vaginal bleeding may have von Willebrand disease).
19-39y Structural lesions such as polyps and fibroids.  Fibroid is most common pelvic tumor; 20-50% incidence in reproductive age women with incidence increasing with age.  Bleeding occurs from disruption of submucosal blood supply surrounding fibroid, often during menstruation.  PCOS should be considered in pts with anovulatory bleeding and signs of androgen excess: acne, hirsutism, alopecia, and obesity.
>40y Endometrial atrophy is most common cause, however 10% diagnosed with endometrial carcinoma.  Etiology is cancer until proven otherwise.

Vaginal bleeding treatment in stable patients

  • Workup includes pregnancy test and CBCCoagulation studies if patient has symptoms of easy bruising or bleeding, or if taking anticoagulant(s).  Imaging of choice is pelvic ultrasound looking for structural causes such as polyps, fibroids, AV malformation, and endometrial thickness to assess for carcinoma.
  • Anovulatory bleeding is most effectively treated with hormonal treatment. Ovulatory bleeding is treated with non-hormonal treatments. Please see figure 1 for discussion of treatments.
Figure 1
Dose Contraindication The Data
Combination OCP 1 pill TID x 7 days > 35 yo F who smokes,Hx of DVT, PE, breast cancer, liver disease, thromboembolic disorder, ischemic heart disease, CVA, uncontrolled HTN Cochrane (2009): Not enough evidence to assess
Progestin-only 20 mg TID x 7 daysor10 mg Qd x 10 days Hx of DVT, PE, liver dz, or breast cancer
NSAIDs Ibuprofen 200-400 mg TID x 5 daysorNaproxen 500 mg then 250 mg TID x 5 days Advanced renal disease. Avoid in pts with known or suspected bleeding disorders Cochrane review of 18 small RCTs shows more effective than placebo
Tranexamic acid 1.3 g TID for up to 5 days Active intravascular clotting or SAH Cochrane: 4 small RCTs, superior to placebo, NSAIDs, and oral progestin
  • In pt with vWD, use desmopressin with tranexamic acid in the absence of massive hemorrhage.
  • If on anticoagulant therapy, administer prothrombin complex concentrate (PCC) rather than FFP in conjunction with vitamin K.
  • Platelet transfusion if < 50k.

Vaginal bleeding treatment in unstable patients

Aggressive fluid resuscitation and transfusion of blood products if needed.

First line treatment: conjugated estrogen.

  • Estrogen promotes rapid endometrial growth, covering areas that are denuded and bleeding.
  • Treat with 25 mg IV q4-6h until bleeding stops.  Contraindications are active or past thromboembolic disease, breast cancer, or liver disease.  Supporting data is a small randomized controlled trial in 1982 of 34 pts which showed cessation of bleeding in 72% of treatment group vs 38% in control group.

Second line treatment: tamponade.

  • Intrauterine tamponade with 26 Fr foley infused with 30 mL of saline or balloon for postpartum hemorrhage e.g. Bakri balloon.
  • Tamponade of os with pediatric foley.
  • Vaginal tamponade with gauze, using long strips for easier removal.

Surgical options

  • Dilation and curettage (D+C): Surgical treatment of choice in patients with acute bleeding resulting in hypovolemia. Maintains fertility. High need for recurrent procedures.
  • Endometrial ablation
  • Uterine artery ablation
  • Hysterectomy

Bottom Line/Pearls & Pitfalls

  • To estimate volume of blood; clenched fist is about 500 mL / 50 cm diameter floor spill is also about 500 mL.
  • PALM-COEIN separates differential for vaginal bleeding into structural and non-structural causes.
  • In unstable patient: resuscitate with fluid / blood and conjugated estrogen IV.  Consider tamponade.  Consult ob-gyn early for possible surgical intervention.
  • D+C is only surgical option which maintains fertility.  However if etiology is AV malformation, D+C can worsen bleeding.

Further Reading

  • Borhart, Joelle. “Emergency Department Management of Vaginal Bleeding in the Nonpregnant Patient.”  Emergency Medicine Practice. 2013 Aug;15(8):1-20. Epub 2013 Jul 10.
  • Cirilli, AR and Cipot SJ.  “Emergency evaluation and management of vaginal bleeding in the nonpregnant patient.” Emerg Med Clin North Am. 2012 Nov;30(4):991-1006.
  • “Committee Opinion.” Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. ACOG.
  • James, Andra et al.  “Evaluation and management of acute menorrhagia in women with and without underlying bleeding disorders: consensus from an international expert panel.”  European Journal of Obstetrics & Gynecology and Reproductive Biology. 2011; 158 (2): 124-134.
  • Selby ST, et al. Uterine arteriovenous malformation with sudden heavy vaginal hemmorhage. West J Emerg Med. 2013 Sep;14(5):411-4.
Edited by Alex Koyfman

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