Vaginal bleeding

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Vaginal bleeding
ICD-10 N92-N93

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Vaginal bleeding refers to bleeding in females that are either a physiologic response during the non-conceptional menstrual cycle or caused by hormonal or organic problems of the reproductive system. Vaginal bleeding may occur at any age, but always needs investigation when encountered in female children or postmenopausal women. Vaginal bleeding during pregnancy may indicate a possible pregnancy complication that needs to be medically addressed.

Anatomy

Blood loss per vaginam (Latin: from the vagina) typically arises from the lining of the uterus (endometrium), but may arise from uterine or cervical lesions, the vagina, and rarely from the Fallopian tube. During pregnancy it is usually but not always related to the pregnancy itself. Rarely, the blood may actually arise from the urinary tract (hematuria), although the vast majority of women can identify the difference. It can also be a sign of vaginal cancer.

Causes

Life Threatening Causes

Common Causes

Causes by Organ System

Cardiovascular Hereditary hemorrhagic telangiectasia , Placenta vein rupture
Chemical/Poisoning Medroxyprogesterone acetate, Ulipristal
Dental No underlying causes
Dermatologic Actinomycosis 
Drug Side Effect Clomiphene, Dicoumarol, Dienogest, Estradiol valerate , Ganirelix, Hormonal contraception, Mifepristone, Misoprostol, Oral contraception, Phenprocoumon, Progestagens, Spironolactone, Tamoxifen, Tiagabine, Trimethadione, Warfarin
Ear Nose Throat No underlying causes
Endocrine Anovulation, Autoimmune thyroid diseases , Decreased menses , Exogenous hormonal preparations, Graves disease , Hormonal contraception, Hormonal disorder, Hormonal imbalance, Hyperoestrogenic states, Hyperthyroidism, Hypothyroidism, Low estrogen levels, Neuroendocrine carcinoma of the cervix , Precocious puberty, Primary cortisol resistance , Thyroid disorders 
Environmental Smoking , Tampon
Gastroenterologic Abdominal cancer , Peritoneum cancer , Peritoneum disorders 
Genetic Von willebrand disease, Y chromosome pericentric inversion 
Hematologic Anemia, Ante-partum hemorrhage, Autoimmune thrombocytopenia , Bleeding tendency, Blood clotting disorders, Clotting disorder, Dysfunctional uterine bleeding, Hereditary hemorrhagic telangiectasia , Thinning vaginal lining, Thrombocytopenia , Thrombocytopenic purpura, Tubal ligation syndrome , Von willebrand disease
Iatrogenic No underlying causes
Infectious Disease Actinomycosis , Bladder infection, Cervix infection, Chlamydia, Endometrial infection, Endometriosis , Endometritis, Lichen sclerosis , Ovary infection, Puerperal fever , Sexually transmitted diseases, Uterine infection, Uterine polyps, Vaginal infection, Vaginitis
Musculoskeletal/Orthopedic Cervical cancer, Cervical dysplasia, Pelvic cancer , Uterine atony
Neurologic No underlying causes
Nutritional/Metabolic Vitamin a embryopathy 
Obstetric/Gynecologic Abortion, Abruptio placentae , Adenomyosis, Amniocentesis, Anovulation, Ante-partum hemorrhage, Asherman syndrome , Cervical ectropion, Cervical polyps, Cervical smear, Cervicitis , Cervix cancer, Cervix disorder, Cervix infection, Choriocarcinoma , Chorionic villus sampling, Contraceptive implants, Decreased menses , Dysfunctional uterine bleeding, Ectopic pregnancy, Endometrial cancer, Endometrial hyperplasia, Endometrial infection, Endometrial stromal sarcoma , Endometriosis , Endometritis, Endometrium atrophy, Estrogen withdrawal, Fallopian tube cancer , Fibroids, Fibromyoma, Foreign body, Genital tract tumors, Glassy cell carcinoma of the cervix , Hydatidiform mole , Iucd, Malignant mixed mullerian tumor , Menopause , Menstruation, Miscarriage, Mittelschmerz , Oral contraception, Ovarian cancer , Ovarian cyst, Ovary infection, Pelvic inflammatory disease , Perimenopause , Placenta previa , Placenta vein rupture, Placental abruption, Placental hypertrophy, Polycystic ovary syndrome, Precocious puberty, Pregnancy complications , Pregnancy, Premature menarche, Primary dysmenorrhoea, Primary fallopian tube cancer, Primary malignant melanoma of the cervix , Progestagens, Puerperal fever , Sarcoma botryoides , Secondary fallopian tube cancer , Spontaneous abortion, Thinning vaginal lining, Threatened miscarriage, Tubal ligation syndrome , Urethral caruncle, Urethral prolapse, Uterine atony, Uterine cancer , Uterine disorder, Uterine fibroids, Uterine growths, Uterine infection, Uterine polyps, Uterine sarcoma , Vaginal cancer, Vaginal foreign body, Vaginal infection, Vaginal injury, Vaginitis, Vitamin a embryopathy , Vulva disorder, Vulva injury, Vulval squamous cell carcinoma, Vulvovaginitis
Oncologic Abdominal cancer , Adenocarcinoma, Cervical cancer, Cervix cancer, Choriocarcinoma , Endometrial cancer, Endometrial stromal sarcoma , Fallopian tube cancer , Fibroids, Fibromyoma, Genital tract tumors, Glassy cell carcinoma of the cervix , Malignant mixed mullerian tumor , Myoma , Neuroendocrine carcinoma of the cervix , Ovarian cancer , Pelvic cancer , Peritoneum cancer , Primary fallopian tube cancer, Primary malignant melanoma of the cervix , Sarcoma botryoides , Secondary fallopian tube cancer , Trophoblastic cancer , Tumors, Uterine growths, Uterine sarcoma , Vaginal cancer, Vulval squamous cell carcinoma
Ophthalmologic No underlying causes
Overdose/Toxicity Amphetamine abuse , Smoking 
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal/Electrolyte Bladder bleeding, Bladder infection
Rheumatology/Immunology/Allergy Condyloma acuminate, Granuloma inguinale , Graves disease , Uterine fibroids
Sexual Chlamydia, Condyloma acuminate, Gonorrhea , Granuloma inguinale , Molestation , Sexual intercourse, Sexually transmitted diseases
Trauma Abortion, Miscarriage, Molestation , Trauma, Urethral prolapse, Vaginal injury, Vulva injury
Urologic Urethral caruncle
Miscellaneous No underlying causes

Causes in Alphabetical Order

Investigation

The diagnosis can often be made on the basis of the bleeding history, physical examination, and other medical tests as appropriate. Typically a pregnancy test and additional hormonal tests, a Pap smear, a transvaginal ultrasound are needed. If bleeding was excessive or prolonged, a CBC may be useful to check for anemia. Abnormal endometrium may have to be investigated by a hysteroscopy with a biopsy or a dilation and curettage.

Differential Diagnosis

In alphabetical order. [1] [2]

  • Abortion
  • Adherent placental residue
  • Adnexitis
  • Adrenal disease
  • Atonic secondary bleeding
  • Carcinoma
  • Cervical Cancer
  • Cervical ectopia
  • Cervical erosion
  • Cervical neoplasms
  • Cervical polyp
  • Cervicitis
  • Chorionepithelioma
  • Colpitis Senilis
  • Corpus luteum deficiency syndrome
  • Ectopic Pregnancy
  • Endometrial polyps
  • Endometriosis
  • Endometritis
  • Estrogen-progestogen therapy
  • Estrogen breakthrough bleeding
  • Fibrinogen deficiency
  • Follicle persistence
  • Granulosa cell tumor
  • Hydatidiform mole
  • Hypothalamic or pituitary lesion
  • Inadequate corpus luteum
  • Injuries
  • Intrauterine device (IUD)
  • Lacerated placenta
  • Midcycle ovulatory bleeding
  • Myoma
  • Neoplasms
  • Placenta Previa
  • Postcoital hemorrhage
  • Premature placental abruption
  • Prolapsed uterus
  • Rupture hemorrhage
  • Ruptured uterus
  • Stress/psychogenic factors
  • Thyroid disease
  • Trauma
  • Uterine adenomytosis
  • Uterine leiomyomas
  • Vaginal Cancer
  • Vaginal infections
  • Vaginal varices
  • Varicosis of the vagina
  • Velamentous insertion
  • Vulvar Cancer

Treatment

The treatment will be directed at the cause. Hormonal bleeding problems during the reproductive years, if bothersome to the woman, are frequently managed by use of combined oral contraceptive pills.

Contraindicated medications

Vaginal Bleeding is considered an absolute contraindication to the use of the following medications:

Complications

A possible complication from protracted vaginal blood loss is iron deficiency anemia, which can develop insidiously. Eliminating the cause will resolve the anemia, although some women require iron supplements or blood transfusions to improve the anemia.

References

  1. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X

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