0071643192.pdf

OBSTETRICS AND GYNECOLOGY

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VAGINAL BLEEDING

Gynecologic causes of abnormal vaginal bleeding in nonpregnant, reproduc-

tive age females include: (1) ovulatory bleeding, (2) anovulatory bleeding, or

(3) nonuterine bleeding. (See Table 12.8.)

SYMPTOMS/EXAM

■ Ovulatory bleeding is associated with menses and preceded by breast ten-

derness, abdominal bloating, and dysmenorrhea.

■ Anovulatory bleeding is seen mostly in perimenarchal or perimenopausal

women. In adolescents physical exam is usually normal. If blood loss is con-

siderable or lasting >9 days check coagulation studies. In perimenopausal

women, atrophic vaginitis is a common cause.

■ Nonuterine bleeding is vaginal bleeding. Bleeding from nose or gums sug-

gests systemic etiology. Vaginal lacerationsoccur following penile or foreign

body penetration and typically require suturing.

DIFFERENTIAL

■ Ovulatory bleeding is due to pelvic diseases (PID, endometriosis, ovarian

neoplasm) or uterine causes (leiomyomas, polyps, endometrial malignancy,

or hyperplasia).

■ Anovulatory bleeding in adolescents is mostly due to immature hypothalamic-

pituitary-ovarian axis; in reproductive age, is usually due to fluctuating levels

or estrogen that go below a critical level needed to maintain the endo-

metrium. In menopausal patients, malignancy needs to be ruled out with an

endometrial biopsy.

■ Nonuterine bleeding can be from cervix or vagina. Consider also lower

urinary tract or GI bleeding.

TABLE 12.8. Definitions of Vaginal Bleeding

Abnormal vaginal bleeding Occurs outside menstrual cycle

Menorrhagia Menses > 7 days, or> 60-mL blood loss oroccurring

< every 21 days

Metrorrhagia Bleeding at irregular times

Menometrorrhagia Heavy irregular vaginal bleeding

Dysfunctional uterine bleeding Abnormal vaginal bleeding due to anovulation

Postcoital bleeding Vaginal bleeding after intercourse suggesting cervical

pathology

Postmenopausal bleeding Any bleeding that occurs > 6 months after cessation of

menses