CHAPTER 94
Vaginal Bleeding
Presentation
A menstruating woman complains of greater-than-usual bleeding, which is either off of her usual schedule (metrorrhagia), lasts longer than a typical period, or is heavier than usual (menorrhagia), perhaps with crampy pains and passage of clots. Prolonged bleeding is longer than 7 days duration. Profuse bleeding is generally defined as soaking a large sanitary pad or tampon every hour or two and continuing for more than 2 hours. Excessive menstrual bleeding is quantified typically as greater than 80 mL, with normal menstrual losses over a 5- to 7-day cycle on average of 30 to 45 mL.
What To Do:
Establish whether or not there is hemodynamic instability, clearly identify the source of bleeding, and evaluate the volume of blood loss.
Obtain orthostatic pulse and blood pressure measurements, a complete blood count, and pregnancy test (urine or serum beta human chorionic gonadotropin [hCG]). Measurement of beta hCG is required in all menstruating women, except when there are positive fetal heart tones, a known pregnancy, or a definite history of hysterectomy. All others should have beta hCG measured, including those with tubal ligation, Norplant, and claims of celibate lifestyle, as well as those whose doctors have told them they cannot get pregnant. (To avoid unintentionally insulting a patient, inform them that pregnancy testing is routinely required on all cases of vaginal bleeding.) Although less reliable than hemoglobin and hematocrit measurements, try to quantify the amount of bleeding by the presence of clots and the number of saturated pads used. In the United States, regular to super plus tampons hold 6 to 15 mL of blood.
If the patient is deemed hemodynamically unstable, arrange for rapid transport to an acute care setting, such as an emergency department by ambulance. Start an IV line of normal saline or lactated Ringer solution and have blood ready to transfuse on short notice if there is significant bleeding—demonstrated by pallor, lightheadedness, tachycardia, orthostatic pressure changes, a pulse increase of more than 20 per minute on standing, or a hematocrit below 30%. Consider intrauterine tamponade by packing the uterus with Kerlix. Uterine curettage is first-line therapy for the unstable patient with acute or prolonged uterine bleeding. Uterine artery embolization is first-line therapy for those with uterine arteriovenous malformation. Hysterectomy is recommended when all other treatments have failed.
If the patient is hemodynamically stable, go ahead and begin to get your patient’s history, including a menstrual, sexual, and reproductive history. Are her periods usually irregular, occasionally this heavy? Does she take oral contraceptive pills, and has she missed enough to produce estrogen withdrawal bleeding? Is an intrauterine device (IUD) in place and contributing to cramps, bleeding, and infection? Was her last period missed or light, or is this period late, suggesting an anovulatory cycle, a spontaneous abortion, or an ectopic pregnancy? Ask about bruising, petechiae, or other signs suggestive of coagulopathy. Ask about use of anticoagulants, such as aspirin or warfarin (Coumadin). Ask about any history of thyroid, renal, or hepatic disease, and determine if the patient is involved in high-risk sexual activity (e.g., unprotected sexual intercourse, new and/or multiple sexual partners, trauma). Also inquire about any known structural abnormalities, such as a history of fibroid uterus.
Determine the source of bleeding by inspecting the vulva, vagina, cervical surface/os, uterus, and anus.
Perform a speculum and bimanual vaginal examination, looking particularly for signs of pregnancy, such as a soft, blue cervix, enlarged uterus, or passage of fetal parts with the blood. Ascertain that the blood is coming from the cervical os and not from a laceration, polyp, cervical lesion, or other vaginal or uterine disease or infection. Test for gonorrhea and chlamydia when infection may be a factor. Especially consider the young sexually active patient with intermenstrual spotting and/or prolonged menses (see Chapters 83, 93 and 95). Feel for adnexal masses as well as pelvic tenderness. Spread any questionable products of conception on gauze or suspend in saline to differentiate from organized clot. Gently press sterile ring forceps against the cervix to see whether they enter the uterus, indicating that the internal os is open (an inevitable, complete, or incomplete abortion) or closed (not pregnant or a threatened abortion, the fetus having roughly even odds of survival, which is generally treated with bed rest alone).
Obtain a transvaginal ultrasonogram and quantitative beta hCG level if the urine beta hCG is positive, or there is any uterine or adnexal abnormality on pelvic examination. A sonogram will help assess the age and viability of the fetus in an intrauterine pregnancy. An ectopic gestational sac may be seen. A sonogram showing an empty uterus, despite a positive pregnancy test, is consistent with either a very early intrauterine pregnancy, an ectopic pregnancy, or a recent complete abortion. When the beta hCG result is positive and the patient’s condition remains stable, repeat the level measurement in 48 hours.
With incomplete spontaneous abortions, deliver any products of conception that protrude from the cervical os using steady gentle traction with sponge forceps while compressing and massaging the uterus. If bleeding continues, start an IV infusion of oxytocin (Pitocin), 20 mU/min, to diminish the rate of hemorrhage. Alternatively, place 10 to 20 IU of oxytocin in 1 L of 0.9% normal saline and run it at 200 to 500 mL/hr, or give methylergonovine (Methergine), 0.2 mg IM (contraindicated in the hypertensive patient). Obtain gynecologic consultation to consider performing a dilation and curettage (D&C) for emergent termination of the uterine bleeding. With all bleeding while pregnant, test the mother’s Rh status, and, if negative, administer Rh immunoglobulin (RhoGAM), 50 µg IM if the uterus was less than 12 weeks’ size, 300 µg IM if larger.
Send the stable patient with a threatened abortion home, as determined by an ultrasonogram positive for an intrauterine pregnancy, unless there is severe pain or hemorrhage. Bed rest has not been shown to improve the outcome for a threatened abortion but is still usually part of the regimen.
Begin treatment for dysfunctional uterine bleeding when the patient is hemodynamically stable and any anatomic lesions, systemic disease, infection, and pregnancy have been ruled out. This is usually not feasible on the patient’s first visit. When it is necessary to help control vaginal bleeding in the nonpregnant patient who has moderate hemorrhage, oral conjugated estrogen (Premarin), 2.5 mg PO qid can be given until the bleeding subsides. Typically, bleeding will stop within 10 to 24 hours. For mild to moderate bleeding, the dose can be bid, but is not to be continued for more than 21 to 25 days. After the estrogen, a progestin should be given, medroxyprogesterone acetate, 5 to 10 mg orally, daily for 5 to 10 days, start on day 16 or 21 of cycle. Warn the patient that after the initial reduction of bleeding, there will be an increase in hemorrhage when the uterine lining is sloughed.
If bleeding does not subside, consider a structural problem. Conjugated estrogen (Premarin), 25 mg, can be given IV and repeated every 4 to 6 hours (per manufacturer, every 6 to 12 hours; per ACOG [American College of Obstetricians and Gynecologists] 2000, every 4 hours for 24 hours if needed). It will take several hours to have an effect. When available, this treatment should be coordinated with a consulting gynecologist. Estrogens cause nausea and vomiting in high doses; therefore an antiemetic should also be prescribed.
Use the more convenient regimen of oral contraceptive pills with at least 35 µg ethinyl estradiol (Necon 10/11 or Ortho Novum 10/11), administered at a dose of one pill qid tapered for 3 to 5 days until the bleeding stops, and then decreased to one pill per day until the month’s pack is completed. Provide the patient with an antiemetic, and prepare her for withdrawal bleeding at the end of this new cycle. The vaginal rings and contraceptive patches have no role in treating profuse or prolonged bleeding.
Treat simple menorrhagia and mild dysfunctional uterine bleeding with standard regimens of oral contraceptives plus nonsteroidal anti-inflammatory drugs (NSAIDs) given on the first 3 days of the menstrual period.
If the cause of the uterine bleeding was missed oral contraceptive pills, advise the patient to resume the pills but use additional contraception for the first cycle to prevent pregnancy.
If the cause is a new IUD, the patient may elect to have it removed and use another contraceptive technique.
In most cases, the patient should be referred for follow-up to a gynecologist for definitive diagnosis, adjustment of medications, or further treatment. She may be evaluated by hysteroscopy, ultrasonography, and endometrial biopsy. Endometrial ablation is an option for those for whom medical therapy has been unsuccessful or is contraindicated because of thrombosis risks. This procedure is also recommended, rather than D&C, for those patients bleeding from polyps or intracavitary leiomyomas.
D&C is still recommended for removing retained products of conception and for those women wishing to maintain fertility.
Medical evaluation may reveal liver disease, hypothyroidism (even when there is a minimally high thyroid-stimulating hormone [TSH] level, there may be a response to treatment), or a bleeding disorder (especially thrombocytopenia and von Willebrand disease).
What Not To Do:
Do not prescribe estrogen therapy to women at risk for intravascular thrombosis. In these women, use progestins or provide surgical intervention.
Do not leap to a diagnosis of dysfunctional uterine bleeding without ruling out pregnancy.
Do not rule out pregnancy or venereal infection in patients who are not at risk on the basis of a negative sexual history—confirm with physical examination and laboratory tests.
Do not give aspirin for menorrhagia. It is not effective and may increase bleeding.
Do not attempt to use methylergonovine in the nonpregnant patient. It has no effect.
Discussion
The patient’s age should direct you to the most likely cause of her vaginal bleeding. Vaginal bleeding in a newborn may be the result of withdrawal of maternal hormones. In prepubertal girls, look for anatomic lesions, urethral prolapse, vulvovaginal infections, endocrinopathies, neoplasia, rectal fissures, trauma, or foreign bodies, and consider abuse. Scratching prompted by dermatoses may also cause bleeding. In postmenarchal adolescents and women of reproductive age, consider pregnancy-related problems first, then dysfunctional uterine bleeding (anovulatory cycles), infection with sexually transmitted diseases, anatomic lesions (fibroids, cervical polyps), and systemic illnesses (hypothyroidism, bleeding disorders). In nonpregnant adolescents, 50% of severe menorrhagia at the first menses is result of coagulopathy (i.e., thrombocytopenia, immune thrombocytopenic purpura, platelet dysfunction, and von Willebrand disease). In perimenopausal and postmenopausal women, strongly consider the possibility of malignant disease, and then evaluate for atrophic vaginitis, fibroids, polyps, anovulatory dysfunctional uterine bleeding, liver disease, anticoagulation therapy, and bleeding disorders. A third of postmenopausal bleeding is associated with common premalignant or malignant conditions of the endometrium (e.g., hyperplasia and atypia).
Dysfunctional uterine bleeding is a diagnosis of exclusion. It is usually hormonal in etiology and can be the result of abnormal endogenous hormone production or the result of problems with the administration of prescribed synthetic sex hormones, such as oral contraceptive pills. During an anovulatory cycle, there is no progesterone, which results in a chaotic estrogen-stimulated endometrial proliferation. The uterine lining, therefore, hypertrophies and sloughs erratically, resulting in excessive or irregular uterine bleeding. This occurs most commonly around the time of menarche in girls and menopause in women. Other causes include a severely restricted diet, prolonged exercise, and significant emotional stress. Breakthrough bleeding is a form of estrogen withdrawal while taking low-dose estrogen oral contraceptives. Changing to a higher-dose pill will generally eliminate this problem. Also consider drug interactions with certain anticonvulsants and antibiotics.
The essential steps in the emergency evaluation and management of vaginal bleeding are fluid resuscitation of shock, if present; recognition of any anatomic lesion, infection, or pregnancy; and complications of pregnancy, such as spontaneous abortion or ectopic pregnancy. Treatment of the more chronic and less severe dysfunctional uterine bleeding usually consists of iron replacement and optional use of oral contraceptives to decrease menstrual irregularity (metrorrhagia) and volume (menorrhagia).
Warn the patient that after the initial reduction of bleeding, there will be an increase in hemorrhage when the uterine lining is sloughed on hormone withdrawal.
The half-life of beta hCG after the end of pregnancy is 1.5 days, and a sensitive pregnancy test may remain positive for 2 to 4 weeks after a miscarriage or abortion.
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