Vaginal Bleeding Summary

Emergency Causes

  • Ectopic pregnancy
  • Placental abruption
  • Placenta praevia
  • Ruptured ovarian cyst

Intermenstrual Bleeding

  • STIs/Cervicitis
  • Cervical/endometrial polyps
  • Hormonal contraceptives
  • Gynecological cancers

Postcoital Bleeding

  • Cervical ectropion
  • Cervicitis
  • Cervical polyps/cancer
  • Trauma

Menorrhagia

  • Dysfunctional uterine bleeding
  • Uterine fibroids
  • Endometriosis
  • Coagulation disorders

Pregnancy Bleeding

  • 1st trimester: Miscarriage, ectopic
  • 2nd trimester: Placental issues
  • 3rd trimester: Abruption, praevia

Postmenopausal

  • Always abnormal
  • Urgent cancer referral
  • Endometrial cancer risk

Vaginal Bleeding

Comprehensive guide to causes, diagnosis, and management of abnormal vaginal bleeding

Emergency Warning Signs

Intermenstrual Bleeding

Bleeding between regular menstrual periods

Physiological

  • Ovulation bleeding
  • Hormonal fluctuations

Infectious

  • STIs with cervicitis
  • Endometritis/PID
  • Vaginal infections

Structural

  • Cervical or endometrial polyps
  • Cervical ectropion
  • Uterine fibroids
  • Endometrial polyps

Neoplastic

  • Vaginal cancer
  • Cervical cancer
  • Endometrial cancer
  • Oestrogen-secreting ovarian cancers

Hormonal

  • Breakthrough bleeding on contraceptives
  • Perimenopausal fluctuations
  • PCOS
  • Adenomyosis

Pregnancy-related

  • Ectopic pregnancy
  • Gestational trophoblastic disease
  • Early pregnancy complications

Postcoital Bleeding

Bleeding after sexual intercourse

Inflammatory

  • STIs/PID with cervicitis
  • Cervical ectropion
  • Atrophic vaginitis

Structural

  • Cervical or endometrial polyps
  • Uterine fibroids

Neoplastic

  • Vaginal cancer
  • Cervical cancer
  • Endometrial cancer

Traumatic

  • Trauma during intercourse
  • Sexual abuse
  • Vaginal dryness

Menorrhagia

Heavy menstrual bleeding

Gynecological

  • Dysfunctional uterine bleeding (DUB)
  • Uterine fibroids
  • Endometriosis/Adenomyosis
  • PID/endometritis
  • Endometrial polyps
  • Endometrial hyperplasia/carcinoma

Systemic

  • Coagulation disorders (von Willebrand)
  • Hypothyroidism
  • Diabetes mellitus
  • Hyperprolactinaemia
  • Liver or renal disease

Medication-related

  • Anticoagulant treatment
  • Chemotherapy
  • Herbal supplements (ginseng, ginkgo, soya)
  • Intrauterine contraceptive device

Bleeding in Pregnancy

Pregnancy Timeline

First Trimester

  • Spontaneous miscarriage
  • Ectopic pregnancy
  • Molar pregnancy

Second Trimester

  • Spontaneous miscarriage
  • Molar pregnancy
  • Placental abruption
  • Placenta praevia

Third Trimester

  • Placental abruption
  • Placenta praevia
  • Vasa praevia
  • Uterine rupture
Any bleeding in pregnancy requires urgent medical evaluation

Postmenopausal Bleeding

POSTMENOPAUSAL BLEEDING IS ALWAYS ABNORMAL

Refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer if they are aged 55 years and over with post-menopausal bleeding.

Common Causes

  • Atrophic vaginitis
  • Endometrial atrophy
  • Endometrial hyperplasia
  • Endometrial polyps

Neoplastic Causes

  • Endometrial cancer
  • Uterine fibroids
  • Cervical polyps
  • Cervical cancer

Other Causes

  • Ovarian cancer
  • Vaginal cancer
  • HRT-related bleeding

Referral Guidelines

  • Age ≥55: Suspected cancer pathway referral (2-week wait)
  • Age <55: Consider suspected cancer pathway referral
  • All cases require thorough investigation

Diagnostic Approach

Initial Assessment

History Taking
  1. Characterize bleeding pattern
  2. Associated symptoms (pain, fever)
  3. Contraceptive use
  4. Pregnancy status
  5. Medical and surgical history
  6. Medication review

Investigations

Test Indication
Pregnancy test All women of reproductive age
Pelvic ultrasound Structural assessment
Endometrial biopsy Postmenopausal bleeding
Colposcopy Abnormal cervical appearance
STI screening Suspected infection
Coagulation studies Heavy bleeding, personal/family history