Abnormal Vaginal Bleeding

What is abnormal vaginal bleeding?

Abnormal vaginal bleeding (AVB) refers to bleeding which deviates from the normal menstrual pattern (in terms of the amount, duration or interval).
Abnormal menstrual patterns and bleeding are common in young adolescents and women within the ages of 45-50 years.
No cause may be found on investigation in these age groups as it is mostly due to immaturity or ageing of the ovaries and its pituitary controls.
Bleeding may be mild or severe and life threatening. In other age groups, the causes are multiple and may be associated with the identifiable disorders.
Postmenopausal bleeding is said to occur when a woman who has stopped having menstruation for 6-12 or more months begins to bleed per vagina.
Occasionally bleeding from the rectum and urethra may be confused with genital tract bleeding. Treatment is directed at the cause found.

Causes of abnormal vaginal bleeding

Causes in Pre-pubertal girls 

The causes of abnormal vaginal bleeding in prepubertal girls include the following:

  1. Urethral mucosal prolapse
  2. Coital lacerations due to rape and defilement
  3. Trauma

Causes in Young Adolescents 

The causes of AVB in young adolescents include the following:

  1. Dysfunctional uterine bleeding
  2. Complications of pregnancy
  3. Coital lacerations due to rape and defilement
  4. Accidental traumatic lesions of vulva and vagina

Causes in Women of Child Bearing Age 

The causes of abnormal vaginal bleeding in women of childbearing age include the following:

  1. Complications of pregnancy, including ectopic pregnancy, abortion and choriocarcinoma
  2. Coital lacerations
  3. Use of hormonal methods of contraception or intrauterine contraceptive device (IUCD)
  4. Cervical cancer
  5. Fibroids
  6. Dysfunctional bleeding

Causes in Peri-menopausal Women 

The causes of AVB in peri-menopausal women include the following:

  1. Dysfunctional uterine bleeding
  2. All other causes listed for women of childbearing age also apply

Causes in Post-menopausal Women 

The causes of AVB in post menopausal women include the following:

  1. Pelvic cancers such as cervical cancer, endometrial cancer, vulva cancer and ovarian tumours
  2. Withdrawal from oestrogen therapy
  3. Atrophic vaginitis
  4. Endometritis
  5. Coital tears
  6. Urethral caruncle

Symptoms of abnormal vaginal bleeding

The symptoms of abnormal vaginal bleeding include the following:

  1. Vaginal bleeding which deviates from normal menstrual pattern
  2. May be associated lower abdominal pain or dysmenorrhoea Symptoms of anaemia (dizziness, palpitations, easy fatigue etc.)

Signs of abnormal vaginal bleeding

The following are the signs of AVB

  1. Signs of anaemia (if heavy bleeding)
  2. Other signs related to cause

Investigations

  • FBC
  • Sickling test
  • Blood clotting screen e.g. Prothrombin time, INR
  • Pelvic ultrasound scan (to rule out pelvic lesions)
  • Urinalysis
  • Diagnostic Dilatation and Curettage (DD & C) for women of child bearing age and postmenopausal women

Treatment for abnormal vaginal bleeding

Treatment objectives

The following are the treatment objectives of abnormal vaginal bleeding:

  1. To resuscitate patient where necessary
  2. To find the cause of bleeding
  3. To treat and stop the bleeding

Non-pharmacological treatment

Abnormal vaginal bleeding can be treated without the use of drugs. The following are ways it can be treated non-pharmacologically:

  1. Vaginal coital tear – suturing in theatre
  2. Inevitable or incomplete abortion – uterine evacuation
  3. Surgery (myomectomy, hysterectomy, oophorectomy etc.)
  4. Radiation therapy for cancers

Pharmacological treatment

A. Dysfunctional uterine bleeding-mild bleeding

1st Line Treatment
Evidence Rating: [B]
Norethisterone acetate, oral,

  • 5 mg 8 hourly for 10-12 days (to stop bleeding)

Then

  • 5 mg 12 hourly (days 19 to 26 of cycle to prevent bleeding)

2nd Line Treatment
Evidence Rating: [B]
Mefenamic Acid, oral,

  • 500 mg 8 hourly on days 1 to 5 of cycle

(Especially if associated with dysmenorrhoea)

B. Life threatening bleeding

1st Line Treatment
Evidence Rating: [A]
IV fluids and blood transfusion as required
And
Evidence Rating: [A]
Tranexamic Acid, oral or IV,

  • 1 g 6-8 hourly for 4-7 days

2nd Line Treatment
Evidence Rating: [B]
Mefenamic Acid, slow IV injection,

  • 500 mg 8 hourly (days 1 to 5 of cycle)

C. For recurrent or protracted abnormal bleeding

1st Line Treatment
Evidence Rating [A]
Low dose oral contraceptive pill daily for 3-6 cycles or longer
Ethinylestradiol + levonorgestrel

Or

Ethinylestradiol + norethisterone
2nd Line Treatment
Evidence Rating: [C]
Conjugated oestrogen, oral,

  • 1.25-2.5 mg daily for 10-12 days

And

Evidence Rating: [A]
Norethisterone, oral,

  • 5-10 mg 8 hourly for 21 days (days 5-25)

Or

Evidence Rating: [B]
Medroxyprogesterone acetate, oral,

  • 5-10 mg daily for 5-10 days (days 19 to 26 of cycle)

Referral Criteria

Refer all women with heavy menstrual bleeding and/or abnormal vaginal bleeding not responding to therapy to a gynaecologist for comprehensive assessment and management.