Vaginal bleeding

Last updated: May 9, 2024

Summary

Vaginal bleeding that is not attributable to expected menstrual bleeding can be a clinical feature of a number of genitourinary conditions that affect not only the vagina but also the uterus, ovarian tubes, ovaries, and urethra. There are various causes of abnormal vaginal bleeding, and workup is determined by the patient's age and pregnancy status. Pain is an important differentiating feature that can further narrow down the differential diagnosis of abnormal vaginal bleeding.

See also “The menstrual cycle and menstrual cycle abnormalities” and “Antepartum hemorrhage”.

Overview

Overview of causes of vaginal bleeding in different age groups
Age group	Causes
Premenarchal children	Estrogen withdrawal (in neonates) Precocious puberty Trauma Tumors (e.g., sarcoma botryoides) Foreign bodies Vulvovaginitis
Nonpregnant women	Abnormal uterine bleeding Uterine leiomyoma Adenomyosis Endometriosis Endometrial hyperplasia Endometrial polyps Pelvic inflammatory disease Polycystic ovary syndrome Endocrine disorders (e.g., hypothyroidism, hyperprolactinemia) Coagulopathies (e.g., von Willebrand disease) Genitourinary trauma
Pregnant women	Ectopic pregnancy Spontaneous abortion Antepartum hemorrhage Placental abruption Placenta previa Uterine rupture Trauma in pregnancy
Postmenopausal women	Gynecologic malignancies (e.g., cervical or endometrial cancer) Benign proliferative disorders Endometriosis Endometrial hyperplasia Endometrial polyps Uterine leiomyoma Hormone replacement therapy Atrophic vaginitis Endocrine disorders (e.g., hypothyroidism)

Painful vaginal bleeding

Overview of differential diagnoses of painful vaginal bleeding ^[1]
Differential diagnosis		Clinical features			Diagnostic findings
Differential diagnosis		Description of pain	Other clinical features		Diagnostic findings
Ectopic pregnancy		Lower unilateral abdominal pain and guarding	Amenorrhea		Ultrasound: may show echogenic mass in the tube or cervix Positive pregnancy test
Spontaneous abortion		Cramping abdominal-pelvic pain	Vaginal bleeding Fever, purulent vaginal discharge, ↑ HR, ↓ BP in septic abortion		Ultrasound: disappearance of previously detected embryonic cardiac activity ↓ ß-hCG Open cervical os in incomplete abortion
Benign neoplasms	Adenomyosis	Chronic pelvic pain	Menorrhagia Dysmenorrhea Infertility	Uniformly enlarged uterus	Ultrasound: may show asymmetric myometrial wall thickening and myometrial cysts
Benign neoplasms	Uterine leiomyoma	Back or pelvic pain/discomfort	Menorrhagia Dysmenorrhea Infertility	Irregularly enlarged uterus	Ultrasound: may show hypoechoic, heterogeneous tumors
Ovarian cyst rupture		Sudden onset of unilateral abdominal pain	Onset usually during physical activity (exercise, sexual intercourse)		Ultrasound: may show pelvic free fluid and/or adnexal mass
Infection/inflammation	Pelvic inflammatory disease	Lower bilateral abdominal pain	Fever Menorrhagia Metrorrhagia Dyspareunia Purulent cervical discharge		Ultrasound: may show free fluid, abscesses, pyosalpinx/hydrosalpinx Cervical and urethral swab: positive PCR and cultures for Neisseria gonorrhoeae and/or Chlamydia trachomatis
Infection/inflammation	Cervicitis	Lower abdominal pain Pelvic pain	Intermenstrual bleeding Vaginal discharge Dyspareunia Usually no fever		Cervical swab: positive PCR and cultures for N. gonorrhea and/or C. trachomatis
Endometriosis		Chronic pelvic pain that worsens before the onset of menses	Dysmenorrhea Premenstrual or postmenstrual bleeding Dyspareunia Infertility		Ultrasound: may show ovarian cysts and/or nodules in the bladder or rectovaginal septum Laparoscopy: endometriotic implants and adhesions
Trauma (e.g., foreign body, sexual abuse)		Pelvic pain	Bruising Hematoma (possible accompanying injuries)		Depends on the type and mechanism of trauma

Painless vaginal bleeding

Overview of differential diagnoses of painless vaginal bleeding ^[1]
Differential diagnosis		Clinical features	Diagnostic findings
Polycystic ovary syndrome		Amenorrhea, oligomenorrhea, breakthrough bleeding, hypermenorrhea Hirsutism Obesity Acne vulgaris Infertility	Ultrasound: enlarged ovaries with numerous anechoic cysts
Endometrial hyperplasia		Constant bleeding Intermenstrual bleeding	Ultrasound: endometrial thickening Histology: proliferation of organized glandular tissue
Endometrial polyp		Irregular menstrual bleeding, spotting Menorrhagia	Ultrasound: echogenic mass arising from endometrium Hysteroscopy: exophytic mass
Malignant neoplasms	Cervical cancer	Menometrorrhagia Postcoital spotting Abnormal vaginal discharge	Ultrasound: hypoechoic mass involving the cervix
Malignant neoplasms	Endometrial cancer	Metrorrhagia Menometrorrhagia	Ultrasound: endometrial thickening Histology: disorganized glandular tissue with cellular atypia
Adverse effects (resulting from, e.g., anticoagulants, oral contraceptives, intrauterine devices)		Anticoagulants: easy bruising, bleeding diathesis	Depends on the cause (e.g., displacement of an intrauterine device)
Anembryonic pregnancy ^[2]		Can be asymptomatic Vaginal bleeding, loss of pregnancy symptoms, and falling β-hCG levels	Transvaginal ultrasound No visible embryo in a gestational sac measuring ≥ 25 mm OR No visible embryo during a follow-up endovaginal ultrasound ≥ 11 days after confirming the presence of a gestational sac with a yolk sac OR No visible embryo during a follow-up endovaginal ultrasound ≥ 2 weeks after confirming the presence of a gestational sac without an embryo or a yolk sac

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