# Vaginal bleeding

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{{Infobox medical condition (new)
| name            = Vaginal bleeding
| field           = [Gynecology](/source/Gynecology)
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| caption         = [Sonohysterography](/source/Sonohysterography) performed because of postmenopausal bleeding. In serial images, polyps would be less mobile than the freely moving debris seen within the uterine cavity in the image.
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'''Vaginal bleeding''' is any expulsion of [blood](/source/blood) from the [vagina](/source/vagina). This bleeding may originate from the [uterus](/source/uterus), vaginal wall, or [cervix](/source/cervix).<ref>{{Cite news|url=https://medlineplus.gov/vaginalbleeding.html|title=Vaginal Bleeding {{!}} Uterine Fibroids {{!}} MedlinePlus|access-date=2018-11-07}}</ref> Generally, it is either part of a normal [menstrual cycle](/source/menstrual_cycle) or is caused by hormonal or other problems of the reproductive system, such as [abnormal uterine bleeding](/source/abnormal_uterine_bleeding).

Regular monthly vaginal bleeding during the reproductive years, [menstruation](/source/menstruation), is a normal physiologic process. During the reproductive years, bleeding that is excessively heavy ([menorrhagia](/source/Heavy_menstrual_bleeding) or heavy [menstrual bleeding](/source/menstrual_bleeding)), occurs between monthly menstrual periods ([intermenstrual bleeding](/source/intermenstrual_bleeding)), occurs more frequently than every 21 days ([abnormal uterine bleeding](/source/abnormal_uterine_bleeding)), occurs too infrequently ([oligomenorrhea](/source/oligomenorrhea)), or occurs after vaginal intercourse ([postcoital bleeding](/source/postcoital_bleeding)) should be evaluated.<ref name=":2">{{Cite web|title=Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women|url=https://www.acog.org/en/clinical/clinical-guidance/committee-opinion/articles/2013/04/management-of-acute-abnormal-uterine-bleeding-in-nonpregnant-reproductive-aged-women|access-date=2021-09-13|website=www.acog.org|language=en}}</ref><ref>{{Cite web|title=Abnormal Uterine Bleeding|url=https://www.acog.org/en/womens-health/faqs/abnormal-uterine-bleeding|access-date=2021-09-13|website=www.acog.org|language=en}}</ref>

The causes of abnormal vaginal bleeding vary by age,<ref name="Berek">{{Cite book|title=Berek & Novak's gynecology|editor-last1=Berek|editor-first1=Jonathan S.|editor-last2=Berek|editor-first2=Deborah L.|isbn=9781496380333|edition=  16th|location=Philadelphia|publisher=[Wolters Kluwer](/source/Wolters_Kluwer)|date=2019|oclc=1064622014}}</ref> and such bleeding can be a sign of specific medical conditions ranging from [hormone imbalances](/source/Hormone_imbalance) or [anovulation](/source/anovulation) to malignancy ([cervical cancer](/source/cervical_cancer), [vaginal cancer](/source/vaginal_cancer) or [uterine cancer](/source/uterine_cancer)).<ref name=":2" />  In young children, or elderly adults with cognitive impairment, the source of bleeding may not be obvious, and may be from the urinary tract ([hematuria](/source/hematuria)) or the rectum rather than the vagina, although most adult women can identify the site of bleeding.<ref name=":0">{{Cite journal|last=Munro|first=Malcolm G|date=2014|title=Investigation of Women with Postmenopausal Uterine Bleeding: Clinical Practice Recommendations|journal=The Permanente Journal|volume=18|issue=1|pages=55–70|doi=10.7812/TPP/13-072|issn=1552-5767|pmc=3951032|pmid=24377427}}</ref> When vaginal bleeding occurs in prepubertal [children](/source/children) or in [postmenopausal](/source/postmenopausal) women, it always needs medical attention.<ref name=":12">{{Cite journal|last1=Howell|first1=Jennifer O.|last2=Flowers|first2=Deborah|date=2016|title=Prepubertal Vaginal Bleeding: Etiology, Diagnostic Approach, and Management|journal=Obstetrical & Gynecological Survey|language=en|volume=71|issue=4|pages=231–242|doi=10.1097/OGX.0000000000000290|pmid=27065069|s2cid=10895909|issn=0029-7828}}</ref><ref name=":22">{{Cite journal|last1=Dwiggins|first1=Maggie|last2=Gomez-Lobo|first2=Veronica|date=2017|title=Current review of prepubertal vaginal bleeding|journal=Current Opinion in Obstetrics and Gynecology|language=en|volume=29|issue=5|pages=322–327|doi=10.1097/GCO.0000000000000398|pmid=28858895|s2cid=21732956|issn=1040-872X}}</ref><ref name=":0" />

Vaginal bleeding [during pregnancy](/source/Obstetrical_bleeding) can be normal, especially in [early pregnancy](/source/Early_pregnancy_bleeding).<ref name=":1">{{Cite web |title=Bleeding During Pregnancy |url=https://www.acog.org/en/womens-health/faqs/bleeding-during-pregnancy |access-date=2021-09-13 |website=www.acog.org |language=en}}</ref> However, bleeding may also indicate a pregnancy complication that needs to be medically addressed.<ref name=":1" /> During pregnancy bleeding is usually, but not always, related to the pregnancy itself.

The treatment of vaginal bleeding is dependent on the specific cause, which can often be determined through a thorough history, physical, and medical testing.<ref name="Munro 3–13">{{Cite journal |last1=Munro |first1=Malcolm G. |last2=Critchley |first2=Hilary O.D. |last3=Broder |first3=Michael S. |last4=Fraser |first4=Ian S. |last5=for the FIGO Working Group on Menstrual Disorders |date=April 2011 |title=FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age |url=https://obgyn.onlinelibrary.wiley.com/doi/10.1016/j.ijgo.2010.11.011 |journal=International Journal of Gynecology & Obstetrics |language=en |volume=113 |issue=1 |pages=3–13 |doi=10.1016/j.ijgo.2010.11.011 |pmid=21345435 |issn=0020-7292|url-access=subscription }}</ref>

== Etiology ==
The parameters for normal menstruation have been defined as a result of an international process designed to simplify terminologies and definitions for abnormalities of menstrual bleeding.<ref>{{Cite journal|last1=Fraser|first1=Ian S.|last2=Critchley|first2=H. O. D.|last3=Munro|first3=M. G.|last4=Broder|first4=M.|date=2007|title=Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding?|journal=Human Reproduction (Oxford, England)|volume=22|issue=3|pages=635–643|doi=10.1093/humrep/del478|issn=0268-1161|pmid=17204526|doi-access=free}}</ref><ref>{{Cite journal|last1=Fraser|first1=Ian S.|last2=Critchley|first2=Hilary O. D.|last3=Munro|first3=Malcolm G.|last4=Broder|first4=Michael|last5=Writing Group for this Menstrual Agreement Process|date=2007|title=A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding|journal=Fertility and Sterility|volume=87|issue=3|pages=466–476|doi=10.1016/j.fertnstert.2007.01.023|issn=1556-5653|pmid=17362717|doi-access=free}}</ref>  The causes of abnormal vaginal bleeding vary by age.<ref name="Berek"/>

=== Prepubertal ===
Bleeding in children is of concern if it occurs before the expected time of [menarche](/source/menarche) and in the absence of appropriate pubertal development. Bleeding before the onset of pubertal development deserves evaluation. It could result from local causes or from hormonal factors.<ref name=":12"/><ref name=":22"/> In children, it may be challenging to determine the source of bleeding, and "vaginal" bleeding may actually arise from the bladder or urethra, or from the rectum.<ref>{{Cite journal|last1=Aprile|first1=Anna|last2=Ranzato|first2=Cristina|last3=Rizzotto|first3=Melissa Rosa|last4=Arseni|first4=Alessia|last5=Da Dalt|first5=Liviana|last6=Facchin|first6=Paola|date=2011|title="Vaginal" bleeding in prepubertal age: A rare scaring riddle, a case of the urethral prolapse and review of the literature|journal=Forensic Science International|language=en|volume=210|issue=1–3|pages=e16–e20|doi=10.1016/j.forsciint.2011.04.017|pmid=21592695}}</ref>

Vaginal bleeding in the first week of life after birth is a common observation, and pediatricians typically discuss this with new mothers at the time of hospital discharge.<ref>{{Cite journal|last=Langan|first=R.C.|date=2006|title=Discharge procedures for healthy newborns.|url=https://www.aafp.org/afp/2006/0301/p849.html#afp20060301p849-b19|journal=Am Fam Physician|volume=73|issue=5|pages=849–52|via=PUBMED|pmid=16529093}}</ref><ref>{{Cite web|url=https://www.uptodate.com/contents/newborn-appearance-the-basics?topicRef=5068&source=see_link|title=Patient Education: Newborn Appearance (The Basics)|website=UpToDate|access-date=August 29, 2019}}</ref>  During childhood, one of the most common causes of vaginal bleeding is presence of a [foreign body](/source/foreign_body) in the vagina which may be caused by normal self-exploration or can be indicative of sexual abuse. This is often associated with pelvic pain, foul discharge, or recurrent genitourinary infections.<ref name=":22" /> Other causes include trauma (either accidental or non accidental, i.e. [child sexual abuse](/source/child_sexual_abuse) or [molestation](/source/Sexual_assault)), urethral prolapse, vaginal infection ([vaginitis](/source/vaginitis)), [vulvar ulcers](/source/Genital_ulcer), vulvar skin conditions such as [lichen sclerosus](/source/lichen_sclerosus), and rarely, a tumor (benign or malignant [vaginal tumors](/source/vaginal_tumors), or hormone-producing ovarian tumors). Hormonal causes include central [precocious puberty](/source/precocious_puberty), or peripheral precocious puberty ([McCune–Albright syndrome](/source/McCune%E2%80%93Albright_syndrome)), or primary [hypothyroidism](/source/hypothyroidism).<ref>{{Cite journal|last1=Elmaoğulları|first1=Selin|last2=Aycan|first2=Zehra|date=September 2018|title=Abnormal Uterine Bleeding In Adolescents|journal=Journal of Clinical Research in Pediatric Endocrinology|volume=10|issue=3|pages=191–197|doi=10.4274/jcrpe.0014|issn=1308-5727|pmc=6083466|pmid=29537383}}</ref><ref>{{Cite journal|last1=Dumitrescu|first1=Claudia E|last2=Collins|first2=Michael T|date=2008-05-19|title=McCune-Albright syndrome|journal=Orphanet Journal of Rare Diseases|volume=3|article-number=12|doi=10.1186/1750-1172-3-12|issn=1750-1172|pmc=2459161|pmid=18489744 |doi-access=free }}</ref>

Genitourinary injury is also a common cause, and is often the most common cause of hospitalization or emergency department visits for prepubertal vaginal bleeding, comprising up to 45% of such cases.<ref name=":22" /> The most common genitourinary injury is the straddle injury, which often occurs during a fall, often on a sharp edge, and can cause lacerations between the labial folds.<ref name=":22" />

While vaginal bleeding in children is typically alarming to parents, most causes are benign, although sexual abuse or tumor are particularly important to exclude. An examination under anesthesia (EUA) may be necessary to exclude a vaginal foreign body or tumor, although instruments designed for office [hysteroscopy](/source/hysteroscopy) can sometimes be used in children with [topical anesthesi](/source/Topical_anesthetic)<nowiki/>a for office [vaginoscopy](/source/vaginoscopy), precluding the need for sedation or [general anesthesia](/source/General_anaesthesia) and [operating room](/source/operating_room) time.<ref>{{Cite journal|last=Simms-Cendan|first=Judith|date=2018|title=Examination of the pediatric adolescent patient|journal=Best Practice & Research. Clinical Obstetrics & Gynaecology|volume=48|pages=3–13|doi=10.1016/j.bpobgyn.2017.08.005|issn=1532-1932|pmid=29056510}}</ref>

=== Premenopausal ===

==== Background ====
In [premenopausal women](/source/premenopausal_women), bleeding can be from the uterus, from [vulvar](/source/Vulva) or vaginal lesions, or from the cervix.<ref name=":7">{{Cite book |last1=Berek |first1=Jonathan S. |url=http://archive.org/details/novaksgynecology00bere |title=Novak's gynecology |last2=Adashi |first2=E. Y. |last3=Hillard |first3=Paula Adams |last4=Jones |first4=Howard W. (Howard Wilbur) |date=1996 |publisher=Baltimore : Williams & Wilkins |others=Internet Archive |isbn=978-0-683-00593-6}}</ref> A [gynecologic examination](/source/Gynecological_Examination) can be performed to determine the source of bleeding. Bleeding may also occur as a result of a pregnancy complication, such as a spontaneous abortion ([miscarriage](/source/miscarriage)), [ectopic pregnancy](/source/ectopic_pregnancy), or abnormal growth of the [placenta](/source/placenta), even if the woman is not aware of the pregnancy.<ref name=":7" /> This possibility must be kept in mind with regard to diagnosis and management.

Generally, the causes of abnormal uterine bleeding in premenopausal women who are not pregnant include [fibroids](/source/Uterine_fibroid), [polyps](/source/Endometrial_polyp), hormonal disorders such as [polycystic ovary syndrome](/source/polycystic_ovary_syndrome) (PCOS), [blood clotting disorders](/source/Coagulopathy), and [cancer.](/source/Uterine_cancer) Infections such as [cervicitis](/source/cervicitis) or [pelvic inflammatory disease](/source/pelvic_inflammatory_disease) (PID) can also result in vaginal bleeding. [Postcoital bleeding](/source/Postcoital_bleeding) is bleeding that occurs after sexual intercourse. Lastly, a normal and common side effect of [birth control](/source/birth_control) includes vaginal spotting or bleeding.<ref name=":2" />

==== Clinical guidelines (FIGO classification) ====
A more specific clinical guideline, called the PALM-COEIN system, has been developed by FIGO (International Federation of Gynecology and Obstetrics) to classify the causes of abnormal uterine bleeding.<ref>{{Cite journal |last1=Munro |first1=Malcolm G. |last2=Critchley |first2=Hilary O.D. |last3=Fraser |first3=Ian S. |date=2011 |title=The FIGO classification of causes of abnormal uterine bleeding in the reproductive years |journal=Fertility and Sterility |language=en |volume=95 |issue=7 |pages=2204–2208.e3 |doi=10.1016/j.fertnstert.2011.03.079 |pmid=21496802 |doi-access=free}}</ref> This acronym stands for ''P''olyp, ''A''denomyosis, ''L''eiomyoma, ''M''alignancy and Hyperplasia, ''C''oagulopathy, ''O''vulatory Disorders, ''E''ndometrial Disorders, ''I''atrogenic Causes, and ''N''ot Classified. The FIGO Menstrual Disorders Group, with input from international experts, recommended a simplified description of abnormal bleeding that discarded imprecise terms such as [menorrhagia](/source/menorrhagia), [metrorrhagia](/source/metrorrhagia), [hypermenorrhea](/source/hypermenorrhea), and [dysfunctional uterine bleeding](/source/dysfunctional_uterine_bleeding) (DUB) in favor of plain English descriptions of bleeding that describe the vaginal bleeding in terms of cycle regularity, frequency, duration, and volume.<ref>{{Cite journal |last1=Fraser |first1=Ian S. |last2=Critchley |first2=Hilary O. D. |last3=Munro |first3=Malcolm G. |last4=Broder |first4=Michael |last5=Writing Group for this Menstrual Agreement Process |date=2007 |title=A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding |journal=Fertility and Sterility |volume=87 |issue=3 |pages=466–476 |doi=10.1016/j.fertnstert.2007.01.023 |issn=1556-5653 |pmid=17362717 |doi-access=free}}</ref>

The PALM causes are related to uterine structural, anatomic, and histolopathologic causes that can be assessed with imaging techniques such as ultrasound or biopsy to view the histology of a lesion.<ref name=":42">{{Cite journal|last1=Munro|first1=Malcolm G.|last2=Critchley|first2=Hilary O.D.|last3=Fraser|first3=Ian S.|date=2011|title=The FIGO classification of causes of abnormal uterine bleeding in the reproductive years|journal=Fertility and Sterility|language=en|volume=95|issue=7|pages=2204–2208.e3|doi=10.1016/j.fertnstert.2011.03.079|pmid=21496802|doi-access=free}}</ref> The COEIN causes of abnormal bleeding are not related to structural causes.<ref name=":42" />

'''PALM - Structural causes of uterine bleeding'''

* '''Polyps:''' [Endometrial polyp](/source/Endometrial_polyp)s are benign growths that are typically detected during gynecologic [ultrasonography](/source/Gynecologic_ultrasonography) and confirmed using [saline infusion sonography](/source/saline_infusion_sonography) or [hysteroscopy](/source/hysteroscopy), often in combination with an [endometrial biopsy](/source/endometrial_biopsy) providing [histopathologic](/source/Histopathology) confirmation. Endocervical polyps are visible at the time of a gynecologic examination using a [vaginal speculum](/source/Speculum_(medical)), and can often be removed with a minor office procedure.
* '''Adenomyosis:''' [Adenomyosis](/source/Adenomyosis) is a condition in which endometrial glands are present within the muscle of the uterus (myometrium), and the pathogenesis and mechanism by which it causes abnormal bleeding have been debated.<ref name=":4">{{Cite journal|last=Abbott|first=Jason A.|date=2017|title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)—Pathogenesis, diagnosis, and management|journal=Best Practice & Research Clinical Obstetrics & Gynaecology|language=en|volume=40|pages=68–81|doi=10.1016/j.bpobgyn.2016.09.006|pmid=27810281}}</ref>
* '''Leiomyoma (fibroids):''' [Uterine leiomyoma](/source/Uterine_leiomyoma), commonly termed uterine fibroids, are common, and most fibroids are asymptomatic.<ref name="Berek" /> The presence of leiomyomas may not be the cause of abnormal bleeding, although fibroids that are submucosal in location are the most likely to cause abnormal bleeding.<ref name=":42" /> 
* '''Malignancy (pre-cancer and cancer):''' The Malignancy and Hyperplasia category of the PALM-COEIN system includes malignancies of the genital tract, including cancers of the [vulva](/source/Vulvar_cancer), the [vagina](/source/Vaginal_cancer), the [cervix](/source/Cervical_cancer), and the [uterus](/source/Uterine_cancer). [Endometrial hyperplasia](/source/Endometrial_hyperplasia), included in this PALM category of abnormal bleeding, is more common in women who are obese or who have a history of chronic [anovulation](/source/Anovulation_in_polycystic_ovary_syndrome). When endometrial hyperplasia is associated with atypical cells, it can progress to cancer or occur concurrently with it.<ref name="Berek" /> While endometrial hyperplasia and [endometrial cancer](/source/endometrial_cancer) occur most commonly among [post-menopausal](/source/Post_menopausal) women, most patients with endometrial cancer have abnormal bleeding, and thus the diagnosis must be considered in women during the reproductive years.<ref name="Berek" /><ref name=":42" />

'''COEIN - Non-structural causes of uterine bleeding'''
* '''Coagulopathies (blood clotting disorders):''' [Heavy menstrual bleeding](/source/Heavy_menstrual_bleeding) can be related to [coagulopathies](/source/Coagulopathy).<ref name=":5">{{Cite journal|last1=James|first1=Andra H.|last2=Kouides|first2=Peter A.|last3=Abdul-Kadir|first3=Rezan|last4=Edlund|first4=Mans|last5=Federici|first5=Augusto B.|last6=Halimeh|first6=Susan|last7=Kamphuisen|first7=Pieter W.|last8=Konkle|first8=Barbara A.|last9=Martínez-Perez|first9=Oscar|date=2009|title=Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel|journal=American Journal of Obstetrics and Gynecology|language=en|volume=201|issue=1|pages=12.e1–12.e8|doi=10.1016/j.ajog.2009.04.024|pmid=19481722}}</ref> [Von Willebrand disease](/source/Von_Willebrand_disease) is the most common coagulopathy, and most women with von Willebrand disease have heavy menstrual bleeding.<ref name=":5" />  Of women with heavy menstrual bleeding, up to 20% will have a bleeding disorder.<ref>{{Cite journal|last1=Davies|first1=Joanna|last2=Kadir|first2=Rezan A.|date=2017|title=Heavy menstrual bleeding: An update on management|journal=Thrombosis Research|language=en|volume=151|pages=S70–S77|doi=10.1016/S0049-3848(17)30072-5|pmid=28262240}}</ref> Heavy menstrual bleeding since [menarche](/source/menarche) is a common symptom for women with bleeding disorders, and in retrospective studies, bleeding disorders have been found in up to 62% of adolescents with heavy menstrual bleeding.<ref>{{Cite journal|last1=Zia|first1=Ayesha|last2=Rajpurkar|first2=Madhvi|date=2016|title=Challenges of diagnosing and managing the adolescent with heavy menstrual bleeding|journal=Thrombosis Research|language=en|volume=143|pages=91–100|doi=10.1016/j.thromres.2016.05.001|pmid=27208978}}</ref>  
* '''Ovulatory dysfunction:''' ''O''vulatory dysfunction or [anovulation](/source/anovulation) is a common cause of abnormal bleeding that may lead to irregular and unpredictable bleeding, as well as variations in the amount of flow including heavy bleeding. Endocrine, or hormonal, causes of ovulatory disorders include [polycystic ovary syndrome](/source/polycystic_ovary_syndrome) (PCOS), [thyroid disorders](/source/thyroid_disorders), [hyperprolactinemia](/source/Hyperprolactinaemia), obesity, eating disorders including [anorexia nervosa](/source/anorexia_nervosa) or [bulimia](/source/Bulimia_nervosa),  or to an imbalance between exercise and caloric intake.<ref>{{Cite web|title=Amenorrhea: Absence of Periods|url=https://www.acog.org/en/womens-health/faqs/amenorrhea-absence-of-periods|access-date=2021-09-13|website=www.acog.org|language=en}}</ref>
* '''Endometrial:''' ''E''ndometrial causes of abnormal bleeding include infection of the endometrium, [endometritis](/source/endometritis), which may occur after a [miscarriage](/source/miscarriage) (spontaneous abortion) or a delivery, or may be related to a [sexually-transmitted infection](/source/Sexually_transmitted_infection) of the uterus, fallopian tubes or pelvis generally termed [pelvic inflammatory disease](/source/pelvic_inflammatory_disease) (PID).  Other endometrial causes of abnormal bleeding may relate to the ways that the endometrium heals itself or develops blood vessels.<ref name=":42" /> 
* '''Iatrogenic (caused by medical treatment or procedures):''' The most common [''I''atrogenic](/source/Iatrogenic) cause of abnormal bleeding relates to treatment with hormonal medications such as birth control pills, patches, rings, injections, implants, and intrauterine devices (IUDs).  Hormone therapy for treatment of menopausal symptoms can also cause abnormal bleeding. Unscheduled bleeding that occurs during such hormonal treatment is termed "[breakthrough bleeding](/source/breakthrough_bleeding)" (BTB)  [Breakthrough bleeding](/source/Breakthrough_bleeding) may result from inconsistent use of hormonal treatment, although in the initial months after initiation of a method, it may occur even with perfect use, and may ultimately affect adherence to the medication regimen.<ref>{{Cite journal|last1=Rosenberg|first1=Michael J.|last2=Burnhill|first2=Michael S.|last3=Waugh|first3=Michael S.|last4=Grimes|first4=David A.|last5=Hillard|first5=Paula J.A.|date=1995|title=Compliance and oral contraceptives: A review|journal=Contraception|volume=52|issue=3|pages=137–141|doi=10.1016/0010-7824(95)00161-3|pmid=7587184|issn=0010-7824}}</ref>  The risk of breakthrough bleeding with oral contraceptives is greater if pills are missed.<ref>{{Cite journal|last1=Talwar|first1=P. P.|last2=Dingfelder|first2=J. R.|last3=Ravenholt|first3=R. T.|date=1977-05-26|title=Increased risk of breakthrough bleeding when one oral-contraceptive tablet is missed|journal=The New England Journal of Medicine|volume=296|issue=21|pages=1236–1237|issn=0028-4793|pmid=854070|doi=10.1056/NEJM197705262962122}}</ref>  
* '''Not classified:''' The Not Classified category of the PALM-COEIN system includes conditions that may be rare, or whose contribution to abnormal bleeding has not been well established or understood.<ref name=":42" />

=== Pregnancy ===
Vaginal bleeding occurs during 15–25% of first trimester [pregnancies](/source/Pregnancy).<ref>{{Cite web|url=https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy|title=Bleeding During Pregnancy - ACOG|website=www.acog.org|access-date=2018-11-07}}</ref> Of these, half go on to [miscarry](/source/miscarriage) and half bring the fetus to term.<ref name=Preg09>{{cite journal|last=Snell|first=BJ|title=Assessment and management of bleeding in the first trimester of pregnancy.|journal=Journal of Midwifery & Women's Health|date=Nov–Dec 2009|volume=54|issue=6|pages=483–91|pmid=19879521|doi=10.1016/j.jmwh.2009.08.007}}</ref> There are a number of causes including complications to the [placenta](/source/placenta), such as [placental abruption](/source/placental_abruption) and [placenta previa](/source/Placenta_praevia). Other causes include [miscarriage](/source/miscarriage), [ectopic pregnancy](/source/ectopic_pregnancy), [molar pregnancy](/source/molar_pregnancy), incompetent cervix, [uterine rupture](/source/uterine_rupture), and [preterm labor](/source/Preterm_birth).<ref>{{Cite web|title=Bleeding during pregnancy Causes|url=https://www.mayoclinic.org/symptoms/bleeding-during-pregnancy/basics/definition/sym-20050636|access-date=2020-10-29|website=Mayo Clinic|language=en}}</ref> Bleeding in early pregnancy may be a sign of a [threatened](/source/threatened_miscarriage) or [incomplete](/source/incomplete_miscarriage) miscarriage. In the second or third trimester a placenta previa (a placenta partially or completely overlying the cervix) may bleed quite severely. [Placental abruption](/source/Placental_abruption) is often associated with uterine bleeding as well as uterine pain.<ref>{{Cite web|url=https://medlineplus.gov/ency/patientinstructions/000605.htm|title=Placenta abruptio: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|access-date=2018-11-07}}</ref>

Vaginal bleeding [during pregnancy](/source/Obstetrical_bleeding) can be normal, especially in [early pregnancy](/source/Early_pregnancy_bleeding). Light spotting early on in pregnancy can be a result of the fertilized egg implanting into the uterus. Additionally, during pregnancy, the blood supply to the cervix increases, which can cause the cervix to be more friable and bleed more easily than a non-pregnant woman's cervix. Because of this, some light spotting after intercourse can be normal. However, bleeding may also indicate a pregnancy complication that needs to be medically addressed and any vaginal bleeding during pregnancy should prompt a call to the patient's obstetric provider.<ref>{{Cite journal |date=October 2021 |title=ACOG Committee Opinion No. 804: Physical Activity and Exercise During Pregnancy and the Postpartum Period: Correction |url=https://journals.lww.com/10.1097/AOG.0000000000004558 |journal=Obstetrics & Gynecology |language=en |volume=138 |issue=4 |pages=683 |doi=10.1097/AOG.0000000000004558 |pmid=34623087 |issn=0029-7844|url-access=subscription }}</ref>

=== Perimenopausal ===
While many of the causes of premenopausal bleeding still apply to perimenopausal women, there is an additional cause of abnormal uterine bleeding in this category of women, which is the hormonal changes. Around age 40, women's hormones begin to change and this can cause variation in menstrual patterns. This can last for years, with menstrual periods lasting various lengths and coming at various intervals. [Menopause](/source/Menopause) is considered complete after a woman has gone 12 months without a menstrual period.<ref>{{Citation |last1=Parihar |first1=Mandakini |title=Perimenopausal Bleeding |date=2015 |work=Clinical Practice Guidelines on Menopause |pages=35 |url=http://dx.doi.org/10.5005/jp/books/12591_10 |access-date=2024-02-16 |publisher=Jaypee Brothers Medical Publishers (P) Ltd. |last2=Vij |first2=Anu|doi=10.5005/jp/books/12591_10 |isbn=978-93-5152-127-3 |url-access=subscription }}</ref>

=== Postmenopausal ===
Endometrial atrophy, uterine fibroids, and [endometrial cancer](/source/endometrial_cancer) are common causes of postmenopausal vaginal bleeding. About 10% of cases are due to endometrial cancer.<ref name="pmid30083701">{{cite journal | vauthors = Clarke MA, Long BJ, Del Mar Morillo A, Arbyn M, Bakkum-Gamez JN, Wentzensen N | title = Association of Endometrial Cancer Risk With Postmenopausal Bleeding in Women: A Systematic Review and Meta-analysis | journal = JAMA Intern Med | volume = 178 | issue = 9 | pages = 1210–1222 | date = September 2018 | pmid = 30083701|pmc = 6142981| doi = 10.1001/jamainternmed.2018.2820 }}</ref> Uterine fibroids are benign tumors made of muscle cells and other tissues located in and around the wall of the [uterus](/source/uterus).<ref>{{Cite news|url=https://medlineplus.gov/uterinefibroids.html|title=Uterine Fibroids {{!}} Fibroids {{!}} MedlinePlus|access-date=2018-10-23}}</ref> Women with fibroids do not always have symptoms, but some experience vaginal bleeding between periods, pain during sex, and lower back pain.<ref>{{Cite web|url=https://www.nichd.nih.gov/health/topics/uterine/conditioninfo/symptoms|title=What are the symptoms of uterine fibroids?|website=NICHD.NIH.gov|access-date=2018-10-23}}</ref> <!--This article has a delayed release (embargo) and will be available in PMC on August 6, 2019-->

== Diagnostic evaluation ==
The cause of the bleeding can often be discerned on the basis of the bleeding history, physical examination, and other medical tests as appropriate. The physical examination for evaluating vaginal bleeding typically includes visualization of the cervix with a [speculum](/source/speculum_(medical)), a [bimanual exam](/source/bimanual_exam), and a [rectovaginal exam](/source/rectovaginal_exam). These are focused on finding the source of the bleeding and looking for any abnormalities that could cause bleeding. In addition, the abdomen is examined and palpated to ascertain if the bleeding is abdominal in origin. Typically a [pregnancy test](/source/pregnancy_test) is performed as well.<ref name=Tintinalli>{{cite book |last1 = Morrison |first1 = LJ |last2 = Spence |first2 = JM |title = Vaginal Bleeding in the Nonpregnant Patient |work = Tintinalli's Emergency Medicine: A Comprehensive Study Guide |location = New York City |publisher = McGraw-Hill |year = 2011}}</ref> If bleeding was excessive or prolonged, a CBC may be useful to check for [anemia](/source/anemia). Abnormal endometrium may have to be investigated by a [hysteroscopy](/source/hysteroscopy) with a [biopsy](/source/biopsy) or a [dilation and curettage](/source/dilation_and_curettage).

In 2011, the [International Federation of Gynaecology and Obstetrics](/source/International_Federation_of_Gynaecology_and_Obstetrics) (FIGO) recognized two systems designed to aid research, education, and clinical care of women with abnormal uterine bleeding (AUB) in the reproductive years.<ref name="Munro 3–13"/>{{Main|FIGO classification of uterine bleeding}}
In postmenopausal vaginal bleeding, the primary goal of any diagnostic evaluations is to exclude endometrial hyperplasia and malignancy. [Transvaginal ultrasonography](/source/Vaginal_ultrasonography) and endometrial sampling are common methods for an initial evaluation. Guidelines from the [American College of Obstetricians and Gynecologists (ACOG)](/source/American_College_of_Obstetricians_and_Gynecologists) recommend [transvaginal ultrasonography](/source/transvaginal_ultrasonography) as an appropriate first-line procedure to identify which patients are at higher risk of [endometrial cancer](/source/endometrial_cancer).<ref name=":02">{{Cite journal|date=May 2018|title=ACOG Committee Opinion No. 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding|journal=Obstetrics & Gynecology|language=en-US|volume=131|issue=5|pages=e124–e129|doi=10.1097/AOG.0000000000002631|pmid=29683909|issn=0029-7844|doi-access=free}}</ref> Endometrial sampling is indicated if having the following findings and/or symptoms:<ref name=":02" />

* Endometrial thickness greater than 4&nbsp;mm
* Diffuse or focal increased echogenicity (heterogeneity)
* Failure to visualize the endometrium
* Persistent or recurrent bleeding regardless of endometrial thickness

Endometrial sampling can be obtained either by an [endometrial biopsy](/source/endometrial_biopsy) using an endometrium sampling device such as a pipelle or by [dilation and curettage](/source/dilation_and_curettage) (D&C) with or without a [hysteroscopy](/source/hysteroscopy).<ref>{{Cite web|title=Tests for Endometrial Cancer|url=https://www.cancer.org/cancer/endometrial-cancer/detection-diagnosis-staging/how-diagnosed.html|access-date=2021-09-13|website=www.cancer.org|language=en}}</ref>thumb|FIGO System 1. The system for definition and nomenclature of normal and abnormal uterine bleeding (AUB) in the reproductive years.

== Complications ==
Severe acute bleeding, such as caused by ectopic pregnancy and post-partum [hemorrhage](/source/hemorrhage), leads to [hypovolemia](/source/hypovolemia) (the depletion of blood from the circulation), progressing to [shock](/source/shock_(circulatory)).<ref>{{Cite journal|last1=Newsome|first1=Janice|last2=Martin|first2=Jonathan G.|last3=Bercu|first3=Zachary|last4=Shah|first4=Jay|last5=Shekhani|first5=Haris|last6=Peters|first6=Gail|date=December 2017|title=Postpartum Hemorrhage|journal=Techniques in Vascular and Interventional Radiology|volume=20|issue=4|pages=266–273|doi=10.1053/j.tvir.2017.10.007|issn=1557-9808|pmid=29224660}}</ref> This is a [medical emergency](/source/medical_emergency) and requires hospital attendance and [intravenous fluids](/source/Intravenous_therapy), usually followed by [blood transfusion](/source/blood_transfusion). Once the circulating volume has been restored, investigations are performed to identify the source of bleeding and address it.<ref name=Tintinalli/> Uncontrolled life-threatening bleeding may require [uterine artery embolization](/source/uterine_artery_embolization) (occlusion of the blood vessels supplying the uterus), [laparotomy](/source/laparotomy) (surgical opening of the abdomen), occasionally leading to [hysterectomy](/source/hysterectomy) (removal of the uterus) as a last resort.<ref name=":4" />

A possible complication from protracted vaginal blood loss is [iron deficiency anemia](/source/iron_deficiency_anemia), which can develop insidiously.<ref name=":6">{{Cite journal|last1=Mansour|first1=Diana|last2=Hofmann|first2=Axel|last3=Gemzell-Danielsson|first3=Kristina|date=January 2021|title=A Review of Clinical Guidelines on the Management of Iron Deficiency and Iron-Deficiency Anemia in Women with Heavy Menstrual Bleeding|journal=Advances in Therapy|volume=38|issue=1|pages=201–225|doi=10.1007/s12325-020-01564-y|issn=1865-8652|pmc=7695235|pmid=33247314}}</ref> Eliminating the cause will resolve the [anemia](/source/anemia), although some women require [iron](/source/iron) supplements or [blood transfusion](/source/blood_transfusion)s to improve the anemia.<ref name=":6" />

== Treatment ==
While many forms of vaginal bleeding are normal and do not require treatment, other forms will require medical attention. Hormonal management is usually the first option used to treat acute abnormal uterine bleeding. These hormonal medications include [birth control pills](/source/Oral_contraceptive_pill), [medroxyprogesterone acetate](/source/Depot_medroxyprogesterone) (brand name [Depo-Provera](/source/Depo-Provera)), and [conjugated equine estrogen](/source/conjugated_equine_estrogen).<ref name=":2" /><ref name=":3">{{Cite journal|last1=Sweet|first1=Mary Gayle|last2=Schmidt-Dalton|first2=Tarin A.|last3=Weiss|first3=Patrice M.|last4=Madsen|first4=Keith P.|date=2012-01-01|title=Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women|url=https://www.aafp.org/afp/2012/0101/p35.html|journal=American Family Physician|volume=85|issue=1|pages=35–43|pmid=22230306|issn=0002-838X}}</ref> Long-term treatments include [hormonal IUD](/source/Intrauterine_device) insertion, birth control pills, progestin pills or progestin shots ([Depo-Provera](/source/Medroxyprogesterone_acetate)), and [NSAIDs](/source/NSAIDs) such as [ibuprofen](/source/ibuprofen)<ref name=":2" /><ref name=":3" /> Certain medications may not be safe for certain women. Women with blood clotting disorders may also need to see a hematologist.<ref name=":2" />

Surgical treatments may also be considered if the bleeding is severe or if there are reasons patients cannot take the hormonal medications listed above.<ref name=":2" /> These options include [dilation & curettage](/source/Dilation_and_curettage), [endometrial ablation](/source/endometrial_ablation), and [hysterectomy](/source/hysterectomy) (removal of the uterus). Hysterectomy will result in infertility, so surgical decisions will include women's preferences regarding future fertility when possible.<ref name=":2" />

==See also==
*[Istihadha](/source/Istihadha)
*[Abnormal uterine bleeding](/source/Abnormal_uterine_bleeding)
*[Implantation bleeding](/source/Implantation_bleeding)

==References==
{{reflist}}

{{Medical resources
|   ICD11       = {{ICD11|GA20}}, {{ICD11|GA21}}, {{ICD11|GA30.1}}
|   ICD10       = {{ICD10|N92}}, {{ICD10|N93}}
|   ICD9        =
|   MedlinePlus = 007496
}}
{{Diseases of the pelvis and genitals}}

Category:Noninflammatory disorders of female genital tract

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Adapted from the Wikipedia article [Vaginal bleeding](https://en.wikipedia.org/wiki/Vaginal_bleeding) by Wikipedia contributors ([contributor history](https://en.wikipedia.org/wiki/Vaginal_bleeding?action=history)). Available under [Creative Commons Attribution-ShareAlike 4.0 International](https://creativecommons.org/licenses/by-sa/4.0/). Changes may have been made.