Vaginal bleeding

One of the main problems involving the female reproductive organs is vaginal bleeding. Its causes range from hormonal imbalance to cancer, and various investigations may be used to differentiate between these causes. While hysterectomy (surgical removal of the uterus) has classically been the treatment for uncontrollable bleeding, other modalities are now becoming more common.

Anatomy

Blood loss per vaginam (Latin: from the vagina) may arise from the Fallopian tubes (rare), the uterus, the cervix or the vagina. Rarely, the blood may actually arise from the urinary tract (hematuria), although the vast majority of women can identify the difference.

Causes

Physiological causes of vaginal bleeding include menstruation. Exceptionally heavy bleeding during periods is termed menorrhagia. If bleeding occurs between periods, this is not necessarily pathological, but it is termed intermenstrual bleeding. If no period can be identified due to the unpredictable bleeding, metrorrhagia is used.

Premenopausal women:

• Dysfunctional bleeding is a common cause of menorrhagia and intermenstrual blood loss. It is due to a hormonal imbalance, and usually resolves on the contraceptive pill. If it is due to polycystic ovary syndrome, weight loss may help, and infertility may respond to clomifene citrate.
• Fibroids (leiomyoma) are benign tumors of the uterus.
• Cervical cancer may occur at premenopausal age, and often presents with "contact bleeding" (e.g. after sexual intercourse)

During pregnancy: mild to moderate blood loss may be due to rupture of a small vein on the outer rim of the placenta. It can also herald a miscarriage, which is why urgent ultrasound is required to separate the two causes. Finally, placenta previa (a placenta partially or completely overlying the cervix) may bleed quite severely.

Postmenopausal women:

• Atrophy of the endometrium may cause bleeding
• Endometrial cancer often presents with blood loss in postmenopausal women

Investigation

The diagnosis can often be made on the basis of the bleeding pattern and other medical details, and (after a Pap smear) many premenopausal women are initially tried for a short period of time on the contraceptive pill. Vaginal ultrasound may identify any lesions or tumors in the uterus or ovaries. In postmenopausal women, a thickened endometrium on vaginal ultrasound is an indication to perform dilation and curettage to identify malignancy.

Complications

The main 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.