Abnormal Vaginal Bleeding

Abnormal Vaginal Bleeding

Objectives Describe normal menses
Describe various causes of vaginal bleeding Educate patients about abnormal vaginal bleeding Triage and perform assessment of patients presenting with vaginal bleeding By the end of this lecture, participants will be able to: Describe normal menses. Describe various causes of vaginal bleeding. Educate patients about abnormal vaginal bleeding. Triage and perform assessment of patients presenting with vaginal bleeding.

Poll Question What is the average blood loss during a typical menstrual cycle? 20 cc 40 cc 60 cc 80 cc Before we begin, I’d like to ask a poll question. What do you think is the average blood loss during the menstrual cycle? 20 cc 40 cc 60 cc 80 cc Let’s move on to our first case study, and we’ll come back to the answer in just a moment.

What should be the first question(s)
Case Study 1 42-year-old Veteran “Heavy” vaginal bleeding for 3 days Some cramping Married, 2 children What should be the first question(s) on your mind? Case Study #1 Case #1 A 42-year-old veteran, presents complaining of vaginal bleeding that has been “heavy” for the past 3 days associated with some cramping. She is married with two children. ***What should be the first question(s) in your mind?

Initial Assessment Hemodynamic stability Pregnancy
Abdominal/pelvic pain Menstruation patterns Other symptoms Blood loss LMP, contraception, menopause, hysterectomy Early pregnancy bleeding may be life-threatening Many women unaware of pregnancy Always consider her to be pregnant and rule that out first Urine test detects pregnancy 2 wks after conception Serum test detects about 1 wk after conception All clinics caring for women should have point-of-care (on-site) urine pregnancy tests; urine results faster, newer tests highly accurate Check for hypotension, tachycardia, orthostasis, fever, ill appearance. By always reviewing these key items we can get important information for our assessment. What are the first, most important things to assess? Hemodynamic stability and pregnancy! 1. Check for hemodynamic stability- hypotension, tachycardia, orthostasis Also look for things like fever, ill appearance 2. Evaluate for pregnancy (LMP, contraception, menopause, hysterectomy) Bleeding in early pregnancy may be life-threatening Many women are unaware of pregnancy Always consider a woman to be pregnant and rule that out first Urine test detects pregnancy 2 weeks after conception Serum test can detect about 1 week after conception All clinics caring for women should have point-of-care (can be done in the office) urine pregnancy tests – urine pregnancy results are faster and newer tests are highly accurate We will discuss the remaining assessment points in more detail later. These points include further assessment of: Abdominal/pelvic pain Menstruation pattern Other symptoms Estimated blood loss Remaining assessment points discussed later.

Hemodynamically Stable?
IF your patient is not hemodynamically stable, your assessment stops there. An urgent evaluation is a must at this point in your assessment, and appropriate action must be taken (i.e., the patient needs to be transferred as appropriate…ED) NO  urgent evaluation

Pregnant? POSITIVE PREGNANCY TEST  Urgent evaluation
The second question you ask…almost at the same time…is the patient pregnant? A patient who is bleeding this heavily and has a positive pregnancy test needs urgent evaluation, and again, appropriate action must be taken to transfer the patient for appropriate care. We will discuss pregnancy later in this presentation.

Poll Answer What is the average blood loss during a typical menstrual cycle? 20 cc 40 cc 60 cc 80 cc Now let’s pause for a moment and take a look at the answer to the poll question. As you recall the question was the average blood loss during the normal menstrual cycle. The options were: 20 cc 40 cc 60 cc 80 cc The answer is 40 cc. So, let’s explore normal menses, including average blood loss. Now we’ll explore normal menses, including average blood loss.

Normal Menses Cycle every 24 - 35 days
Increased cervical mucus secretions at mid-cycle Premenstrual symptoms (cramps, breast tenderness, bloating, appetite/mood changes) Normal Menses Cycle every days Duration days Average blood loss 40 ml (2 tbs) per cycle Pad count not reliable to quantify blood loss Symptoms associated with menstrual cycle Before we can address this patient, let’s look at what is “normal” in relation to menses. Cycle every days Duration days Blood loss Average blood loss is 40 ml (2 tbs) per cycle Heavy blood loss is >80 ml per cycle Pad count is not reliable to quantify blood loss; compare to her normal cycle Symptoms associated with menstrual cycle: Increased cervical mucus secretions at mid-cycle Premenstrual symptoms (cramps, breast tenderness, fluid retention, appetite or mood changes) Heavy blood loss is >80 ml per cycle

Menstrual Cycle First part of cycle:
Estrogen dominant  endometrium builds Ovulation occurs 14 days before onset of the next period After ovulation, corpus luteum is formed and creates progesterone. Second part of cycle: Progesterone dominant  endometrium is stabilized First part of the menstrual cycle: Estrogen dominant  building up endometrium Note that ovulation occurs 14 days before the onset of the next period. After ovulation, corpus luteum is formed and creates progesterone. Second part of menstrual cycle: Progesterone dominant  stabilizes the endometrium

Correlation Between Cycle Duration and Bleeding
Intervals between cycles Endometrial proliferation Duration of bleeding Shorter intervals between cycles  endometrium has less time to proliferate  shorter duration of bleeding Longer intervals between cycles  endometrium proliferates  longer periods of bleeding Intervals between cycles and bleeding duration commonly correlate: With shorter intervals between cycles, the endometrium has less time to proliferate. Thus, there is a shorter duration of bleeding. Longer intervals between cycles allow the endometrium to proliferate. Thus, there are longer periods of bleeding.

Back to the case of our 42 yo veteran with onset “heavy” vaginal bleeding and cramping Why does heavy bleeding occur? NON-PREGNANT CAUSES: present as… Regular, cyclic (ovulatory bleeding) Irregular, not cyclic (anovulatory bleeding) PREGNANCY COMPLICATIONS (discussed later) Back to the case of our 42 yo veteran with onset “heavy” vaginal bleeding and cramping. Why could this patient be having heavy bleeding? The list is long… There are two basic categories: Non-pregnant causes and pregnancy complications A. NON-PREGNANT CAUSES – bleeding presents as: Regular, cyclic (ovulatory bleeding) Irregular, not cyclic (anovulatory bleeding) B. PREGNANCY COMPLICATIONS (will talk about these complications later) FOR REFERENCE: Causes of heavy vaginal bleeding… Coagulopathies Neoplasm Structural Lesions Other von Willebrand's disease Thrombocytopenia (due to idiopathic thrombocytopenic purpura, hypersplenism, chronic renal failure) Acute leukemia Anticoagulants Advanced liver disease Endometrial adenocarcinoma Uterine sarcoma Leiomyomata uteri (fibroids) Adenomyosis Polyps Endometritis Hypothyroidism Intrauterine device Hyperestrogenism Endometriosis

What Causes Ovulatory Bleeding?
Can be heavy, prolonged bleeding at regular intervals or intermenstrual bleeding Possible causes: Coagulopathy Neoplasm/malignancy Structural lesions (fibroids, polyps) Other (inflammation, infection like STI or endometritis) Regular, cyclic (ovulatory) bleeding can be heavy, prolonged bleeding at regular intervals or intermenstrual bleeding (between cycles) Possible causes include: Coagulopathy Neoplasm/Malignancy Structural lesions (fibroids, polyps) Other (inflammation, infection like STI or endometritis…especially post-procedure or post-partum)

Uterine Lesions Structural lesions can cause regular, heavy bleeding
Fibroids or other lesions that are in or near the lining, in particular, can cause heavy bleeding Fibroids usually cause regular, heavy bleeding but can also cause intermenstrual bleeding Other lesions, such as polyps, or even inflammation and infection can also cause heavy bleeding Endometritis (infection in the uterine lining, is particularly prevalent during post-partum or post-procedure periods Uterine Lesions Uterine fibroids are one example of structural lesions that can cause regular, heavy bleeding. Fibroids and other lesions that are in or near the lining, in particular, can cause heavy bleeding. Typically, fibroids cause regular, heavy bleeding, but they can also cause bleeding between periods. Other lesions in the uterus such as polyps, or even inflammation and infection can also cause heavy bleeding. Endometritis, which is an infection in the lining of the uterus, is particularly prevalent during post-partum or post-procedure periods.

What Causes Anovulation and Anovulatory Bleeding?
Primary hypothalamic-pituitary dysfunction Pituitary tumors and pituitary syndromes Stress, eating disorders, intense exercise Other endocrine problems Polycystic ovary syndrome Hyper- or hypothyroidism Medications Hormonal contraceptives Many other causes What causes Anovulation/Anovulatory Bleeding? Anything that disturbs the pituitary-hypothalamus-ovarian axis that most of us learned about in school can disrupt the delicate balance and cause ovulation to NOT occur 1. Primary hypothalamic-pituitary dysfunction Pituitary tumors and pituitary syndromes Stress, eating disorders, intense exercise 2. Other Endocrine Problems Polycystic ovary syndrome Hyper-or hypothyroidism 3. Medications Hormonal contraceptives 4. Many other causes… NEXT FOR REFERENCE: Causes of Anovulation Primary hypothalamic-pituitary dysfunction: Other disorders Medications Kallman's syndrome Idiopathic hypogonadotropic hypogonadism Tumors, trauma, or radiation of the hypothalamic or pituitary area Sheehan's syndrome Empty sella syndrome Pituitary adenoma or other pituitary tumors Lymphocytic hypophysitis (autoimmune diseases) Lactational amenorrhea Stress Eating disorders Intense exercise Immaturity at onset of menarche or perimenopausal decline Polycystic ovary syndrome Hyperthyroidism/hypothyroidism Hormone-producing tumors (adrenal, ovarian) Chronic liver or renal disease Cushing's disease Congenital adrenal hyperplasia Premature ovarian failure, which may be autoimmune, genetic, surgical idiopathic, or related to drugs or radiation Turner syndrome Androgen insensitivity syndrome Oral contraceptives Progestins Antidepressant/antipsychotic drugs Corticosteroids Chemotherapeutic agents

Anovulation Menstrual Cycle
In normal menstrual cycle, endometrial lining builds up with estrogen and stabilizes with progesterone If ovulation doesn’t occur, progesterone isn’t produced Thus, endometrium continues to build, isn’t stabilized, and begins to slough off A woman might experience irregular bleeding which can be heavy or light Anovulation Remember that, in our graph of the normal menstrual cycle, the endometrial lining builds up with estrogen. Stabilization of the lining occurs with progesterone. When ovulation doesn’t occur, progesterone isn’t produced and the endometrium continues to build and isn't stabilized and can begin to slough off. Thus, a woman might experience irregular bleeding which can be heavy or light. Menstrual Cycle

Back to the case… 42-year-old veteran What more should you ask?
Hemodynamic Stability Pregnancy Let’s return to our 42 yo veteran with “heavy” vaginal bleeding. Remember emphasis on hemodynamic stability and pregnancy. We have already discussed these first two points. What more should you ask?

Initial Assessment Hemodynamic stability Pregnancy
Abdominal/pelvic pain Menstruation patterns Other symptoms Blood loss Ask about abdominal or pelvic pain: Related to menstrual cramps that have worsened with increased flow? Something serious like an ectopic pregnancy (with a positive pregnancy test)? Query pain duration, constant or cyclical, location (midline or lateral), sudden onset or gradual Ask about menstruation patterns What is normal for her? History of irregular/heavy menses? Abdominal/pelvic pain: Could be just be related to ‘menstrual cramps’ that have gotten worse with increased flow or Could mean something serious like an ectopic pregnancy (in patients with a positive pregnancy test) Query duration, constant or cyclical, location (midline or lateral), sudden onset or gradual Ask about menstruation patterns What is normal for this patient? History of irregular/heavy menses? Ask about other symptoms: Related to anemia: shortness of breath, light-headedness, syncope, fatigue Or infection: fever, chills Estimate blood loss Ask about other symptoms: Related to anemia: shortness of breath, light-headedness, syncope, fatigue Related to infection: fever, chills

Estimating Blood Loss Try to obtain objective evidence
For triage, try to quantify bleeding by number of pads the woman is using, or ask her to compare it with her normal menses. Typical definition of profuse bleeding: soaks large sanitary pad or tampon every hour or two, for two or more hours Prolonged uterine bleeding = bleeding for >7 days For diagnosis, pad/tampon counts are unreliable. Studies show 50% of women complaining of heavy bleeding have normal blood loss. Estimates of blood loss taken by history are not reliable, though you may get a sense of changes in pattern. CBC and ferritin can help figure out if she has ongoing, significant blood loss, but these may be normal in a patient with acute blood loss only. Try to obtain objective evidence of blood loss For triage, try to quantify bleeding by number of pads the woman is using, or ask her to compare it with her normal menses Typical definition of profuse bleeding: soaks large sanitary pad or tampon every hour or two, for two or more hours Prolonged uterine bleeding = bleeding for >7 days For diagnosis, pad and tampon counts are unreliable. Studies show 50% of women with complaints of heavy bleeding have normal blood loss. For the most part, estimates of blood loss taken by history are not reliable, though you may be able to get a sense of changes in pattern. CBC and ferritin can certainly help figure out if patients have ongoing, significant blood loss, but remember that even these may be normal in a patient with acute blood loss only.

Our 42 yo veteran with onset “heavy” vaginal bleeding…
Sexually active with husband No contraception Regular periods, 3 months of heavy bleeding Normal vital signs, appears well but worried Negative pregnancy test; CBC, ferritin, TSH ordered Let’s review more information about our 42 yo veteran with onset “heavy” vaginal bleeding: Sexually active with her husband; no contraception Periods regular and just started getting heavy past 3 months Appears well, but worried Normal vital signs Urine pregnancy test – negative CBC, ferritin, TSH were ordered (per protocol) It was decided that the patient was to be seen by the provider. It was decided that she should be seen by the provider

Exam Room Set-Up Specifics about room set-up and assisting during the exam is covered in another session, but in general, necessary equipment includes: Table with foot rests, privacy curtain, lockable door Gown and cover sheet Gloves for provider and assistant Surgical lubricant Speculum appropriate for patient: Graves (small, med, large) or Pederson Light source Supplies for Pap and GC/chlamydia tests Procto swabs (also known as fox swabs) Monsels /silver nitrate sticks if recent gynecological procedure Pad / panty liner / tissues for post-procedure Female chaperone is required; assistant may be used in this role Privacy As a nurse, you may be responsible for setting up the room and/or assisting with the exam Specifics about setting up the room and assisting during the exam is covered in another session, but in general, equipment needed includes: Table with foot rests, privacy curtain, lockable door Gown and cover sheet Gloves for provider and assistant Surgical lubricant Speculum appropriate for patient: Graves (small, med, large) or Pederson Light source Supplies for Pap and GC/chlamydia tests Procto swabs (also known as fox swabs) Monsels /silver nitrate sticks if recent gynecological procedure Pad / panty liner / tissues for patient post-procedure Note that: A female chaperone is required regardless of provider gender; assistant may be used in this role Privacy

Further Evaluation Specific Treatment – Medications Pelvic Ultrasound
NSAIDS (e.g., ibuprofen, narpoxen) Hormonal contraceptives (e.g., OCPs, Depo) Pelvic Ultrasound Endometrial Biopsy Following the examination, the provider may recommend: Specific treatment: medications * NSAIDs (such as ibuprofen, naproxen) * Hormonal contraceptives (such as oral contraceptive pills or Depo-Provera) Additional evaluation might be necessary. * Pelvic Ultrasound (TVUS) * Endometrial Biopsy Let’s look a little bit closer at the pelvic US and the endometrial biopsy since nurses are often asked to explain at least the basics of these procedures. Nurses are often asked to explain at least the basics of pelvic US and endometrial biopsy procedures…

Pelvic Ultrasound Transabdominal What is it?
Test to look at organs and structures in the pelvis. How is it done? An instrument called a “transducer” sends out sound waves that bounce off body structures like an echo to create a picture. A clear gel, placed between the transducer and pelvis, allows smooth movement of the transducer over skin and eliminates air between the skin and transducer to improve sound conduction. A typical US exam takes minutes. Risks? No radiation exposure. Usually painless, but may cause some mild discomfort as the transducer is guided over a full bladder. Image used with permission from Krames StayWell Pelvic Ultrasound Transabdominal Patient education: What is it? Test to look at woman’s organs and structures within the pelvis. How is it done? An instrument called a “transducer” sends out sound waves that bounce off body structures like an echo to create a picture. A clear conducting gel is placed between the transducer and the pelvis. The gel allows smooth movement of the transducer over the skin and eliminates air between the skin and the transducer for the best sound conduction. A typical ultrasound exam takes minutes. Risks? There is no radiation exposure. Ultrasound is usually a painless procedure, but there may be some mild discomfort as the transducer is guided over the full bladder. Photo used with permission from Krames StayWell.

Pelvic Ultrasound Transvaginal What is it?
Test to look at reproductive organs. How is it done? Probe is inserted into vagina. It is covered with a condom and surgical lubricant. Probe sends out sound waves that bounce off body structures to create a picture. What are you looking for? Abnormal findings, such as fibroids. Thickness of the endometrial stripe. Risks? No radiation exposure. Generally painless, but pressure from probe could be uncomfortable. Patients with vaginal atrophy/ dryness might be uncomfortable. Pelvic Ultrasound Transvaginal Patient education: What is it? Test to look at a woman’s reproductive organs. How is it done? A probe sends out sound waves that reflect off the body structures, creating a picture. The probe is inserted into the vagina. It is covered with a condom and a surgical lubricant. What are you looking for? Abnormal findings, such as fibroids Thickness of the endometrial stripe Risks? Generally painless, but remind the patient that pressure from the probe could be uncomfortable. Also patients with vaginal atrophy/dryness might be uncomfortable. There is no radiation exposure. Photo used with permission from Krames StayWell. Photo source: Krames Image used with permission from Krames StayWell

Endometrial Biopsy What is an endometrial biopsy? Tissue is taken from uterine lining (endometrium) and checked in pathology for abnormal or malignant cells. How is it done? Office-based, no sedation, typically pre-medicate with an NSAID Patient will be lying down with feet in foot rests. Provider will insert speculum to visualize the cervix. Cervix is cleaned with antiseptic and then grasped with a tenaculum to stabilize the uterus. Cervical dilator may be used to open cervical canal if there is stenosis. Small, hollow, plastic tube is gently passed into uterine cavity. Gentle suction removes sampling of the lining. Patient might be taken to OR for HSC, D&C with anesthesia. However, office procedures are safe, and a decrease in morbidity and mortality from D&C has been noted since office-based endometrial biopsies were introduced. When is it recommended? For abnormal bleeding…heavy or prolonged…generally women >40 What are you looking for? Cause of abnormal bleeding Checking for endometrial cancer (very accurate for diagnosing endometrial cancer) What are potential complications? Are rare; generally a very safe procedure Infection, bleeding, cramping Perforation of the uterus Patient Education: What is an endometrial biopsy? A procedure in which tissue is taken from the lining of the uterus (endometrium) and checked in pathology for any abnormal or malignant cells. How is it done? Office-based, no sedation, typically pre-medicate with NSAID Patient will be lying down with feet in foot rests. Provider will insert speculum to visualize the cervix. Cervix is cleaned with antiseptic and then grasped with a tenaculum to stabilize the uterus. Cervical dilator may be needed to open the cervical canal if there is stenosis. Then small, hollow plastic tube is gently passed into the uterine cavity. Gentle suction removes a sampling of the lining. Patient might be taken to the OR for HSC, D&C with anesthesia. However, office procedures are safe, and a decrease in morbidity and mortality from D&C has been noted since office-based endometrial biopsies were introduced. When is it recommended? Abnormal bleeding…heavy or prolonged…generally women >40 What are you looking for? Cause of abnormal bleeding, checking for endometrial cancer Very accurate in the diagnosis of endometrial cancer What are potential complications? Are rare; generally a very safe procedure Infection, bleeding, cramping, perforation of the uterus

Endometrial Biopsy Image used with permission from Krames StayWell
Photo used with permission from Krames StayWell. Image used with permission from Krames StayWell

Back to our 42 yo veteran with “heavy” vaginal bleeding……
Normal endometrial biopsy Ultrasound showed 2 small fibroids Bleeding was controlled by low-dose oral contraceptive OK…so let’s return to our 42 yo veteran with “heavy” vaginal bleeding. We have determined that she is not pregnant…and was to be seen by the provider. We now have obtained the following information: Normal endometrial biopsy US showed 2 small fibroids Bleeding was controlled on low-dose oral contraceptive Whether or not the fibroids are causing the heavy bleeding is not certain – it could be just changes in the patient’s cycle as she approaches the perimenopausal years. Whether or not fibroids are causing the heavy bleeding is not certain – it could be just changes in her cycle as she approaches the perimenopausal years.

Poll Question Vaginal bleeding in a woman with a new positive pregnancy test may be due to: Threatened abortion Incomplete spontaneous abortion Ectopic pregnancy Vaginal laceration/abrasion All of the above Before we move on to our second case study, let’s take a minute for another poll question. Vaginal bleeding in a woman with a new positive pregnancy test may be due to: Threatened abortion Incomplete spontaneous abortion Ectopic pregnancy Vaginal laceration/abrasion All of the above Let’s read the next case study and come back for the answer in just a moment.

What are ALWAYS your two primary triage concerns?
Case Study 2 33-year-old Veteran Normal cycles, but over past 4-6 weeks has had spotting on most days and some heavier bleeding for a few days Sexually active with a single male partner What are ALWAYS your two primary triage concerns? Case #2 A 33-year-old Veteran presents with a complaint of vaginal bleeding that is very irregular. She’s had normal cycles, but over the past 4-6 weeks has had spotting on most days and some heavier bleeding for a few days. She is sexually active with a single male partner.

Initial Assessment Hemodynamic stability
Is she hemodynamically stable? Is she pregnant? After establishing status of her hemodynamic stability and pregnancy, you can move on to a more detailed pain assessment, assessment of her menstrual patterns, other symptoms, and estimated blood loss. Note that this evaluation follows the same steps as the evaluation for the previous patient. Initial Assessment Hemodynamic stability Pregnancy Abdominal/pelvic pain Menstruation patterns Other symptoms Blood loss Remember: What are ALWAYS your two primary triage concerns? Is she hemodynamically stable? Is she pregnant? After establishing hemodynamic stability and pregnancy, you can move on to a more detailed pain assessment, assessment of her menstrual patterns, other symptoms, and estimated blood loss. Note that this evaluation follows the same steps as the evaluation for the previous patient.

Case Study 2 Continued…. No acute distress Normal vital signs No pain
Positive urine pregnancy test Case #2 Continued… She appears in no acute distress, her vital signs are normal, she has no pain Her urine pregnancy test is positive

What Diagnoses Do You Need to Have in Mind?
1st trimester (Spotting may be normal, but some abnormalities need to be kept in mind) 2nd & 3rd trimester (Bleeding is NEVER normal; causes might include abruptio placenta or placenta previa) Unrelated to pregnancy (Vaginal lesions or lacerations, cervical polyps, or ectropion may still occur –why the exam is important) 1st trimester Spotting may be normal. There are abnormalities to keep in mind, and we will discuss some of these in a minute. 2nd & 3rd trimesters Bleeding is NEVER normal Causes of bleeding might include: abruptio placenta, placenta previa We are not going to focus on 2nd or 3rd trimester bleeding, because, at the VA in particular, it is far more likely that you will see early pregnancy bleeding and even see patients who are bleeding who don’t know they are pregnant. So we will look a little more closely at the first trimester. Don’t forget that even though a patient is pregnant, she may have bleeding that is not related to pregnancy. Things like…. Vaginal lesions, lacerations Cervical polyps, ectropion ….may still occur – this is why the exam is important

Causes of First Trimester Bleeding
Ectopic pregnancy outside of uterus (97% of time in fallopian tube) Miscarriage (impending, inevitable, incomplete, or complete AB) Physiologic or implantation bleeding (small amount of spotting/bleeding approx days after fertilization; diagnosis of exclusion; no intervention) Non-pregnancy causes (discussed already) Any first trimester bleeding is considered an ectopic until proven otherwise Ectopic pregnancy occurs outside the uterus, 97% of the time in the fallopian tube Miscarriage (Impending AB, inevitable AB, complete SAB, incomplete AB) Physiologic bleeding: This is a diagnosis of exclusion. It is characterized by a small amount of spotting or bleeding approximately 10 to 14 days after fertilization (at the time of the missed menstrual period), and is presumed to be related to implantation of the fertilized egg in the decidua (lining of the uterus), although this hypothesis has been questioned. No intervention is indicated. Non-pregnancy causes – discussed already

Poll Answer Vaginal bleeding in a woman with a new positive pregnancy test may be due to: Threatened abortion Incomplete spontaneous abortion Ectopic pregnancy Vaginal laceration/abrasion All of the above Let’s return to our poll question… Vaginal bleeding in a woman with a new positive pregnancy test may be due to: Threatened abortion Incomplete spontaneous abortion Ectopic pregnancy Vaginal laceration/abrasion All of the above The correct answer is all of the above.

Back to the case of our 33 yo Veteran with irregular vaginal bleeding… Next steps for evaluation
Pelvic exam Serum pregnancy test (levels of HCG will be checked against weeks of gestation + US) Ultrasound Referral for OB care (if woman does not have an ectopic, chances of adverse outcomes are low, but still must be followed closely by OB) Evaluation for this case study will include… Pelvic exam Serum (quantitative) pregnancy test – levels of HCG will be checked against weeks of gestation and ultrasound Ultrasound Referral for OB care If this patient does not have an ectopic pregnancy, chances are low that there will be an adverse outcome, but this patient needs to be followed closely by an OB

Poll Question Does recurrent bleeding or spotting between periods require further evaluation? Yes No Before we go onto our next case, let’s take a minute for another poll question… Does recurrent bleeding/ spotting between periods require further evaluation? Yes No We’ll move on and come back with the answer in just a moment.

What are possible causes?
Case Study 3 24-year-old Veteran Spotting between her periods which come like clockwork every 28 days. No missed cycles. No pain, cramping, vaginal discharge. No sexual activity for over 6 months What are possible causes? In our third case study, a 24-year-old female Veteran presents with abnormal bleeding. For the past several months, she has had spotting between her usual periods which are coming like clockwork every 28 days. She has no pain, cramping, or vaginal discharge. She has never missed a menstrual cycle. She has not been sexually active for over 6 months.

Causes of Intermenstrual Bleeding
Hormonal Contraception (most common) IUD Infection Cervical Polyps or Ectropion Endometrial polyps Cancer Postcoital Bleeding Physiologic (spotting at time of ovulation due to decline in estrogen) This patient has ‘intermenstrual bleeding’ – regular periods, but bleeding in between. The possible causes are numerous… Most commonly due to OCP use Pelvic or vaginal infection Cervical or endometrial polyps Cancer Postcoital bleeding suggests cervicitis, cervical polyps or cancer, or ectropion Spotting at the time of ovulation can occur secondary to a brief decline in estrogen at that point in the cycle Many of these may be evident on physical exam, so a complete H&P by the provider is the next step. Many of these may be evident on exam, so a complete H&P is the next step.

Poll Answer Does recurrent bleeding or spotting between periods require further evaluation? Yes No Now let’s pause for a moment and take a look at the poll answer. Our question was: Does recurrent bleeding/ spotting between periods require further evaluation? Yes No Answer: Yes As we have just reviewed, physiologic bleeding is a diagnosis of exclusion. Therefore, a pelvic exam with cervical cancer screening is the MINIMUM evaluation this patient will need. It is most likely that she will need additional evaluation beyond that. As we have just reviewed, physiologic bleeding is a diagnosis of exclusion. Therefore, a pelvic exam with cervical cancer screening is the MINIMUM evaluation this patient will need. Likely that she will need additional evaluation beyond that.

What questions should you ask?
Case Study 4 65-year-old Veteran Light vaginal bleeding, occurring on two days in past 3 weeks Menopause 12 years ago Sexually active with long-term female partner What questions should you ask? In our fourth case study, a 65-year-old woman calls the clinic complaining of vaginal bleeding. Bleeding is described as light Bleeding has occurred 2 days, twice in the past 3 weeks She is no longer having menses since she went through menopause over 12 years ago She remains sexually active with her long-term female partner

Emphasis is a bit different when assessing postmenopausal women… with vaginal bleeding
Pregnancy Less concern about pregnancy as women get older HOWEVER, if patient is still menstruating, there is a chance she could be pregnant… we have seen pregnancy in women who are in their early 50’s Hemodynamic stability Difficult to assess hemodynamic stability over the phone HOWEVER, this patient reported small amounts of bleeding. If indeed there is little bleeding, hemodynamic instability is less of a concern.

Assessment: POSTMENOPAUSAL WOMEN
Trauma (Any precipitating factors? Atrophy?) Bleeding pattern (When did it start? Temporal pattern, duration, postcoital, quantity?) Associated symptoms (Pain, fever, changes in bladder/bowel function?) Medications/supplements (Hormones, anticoagulants, soy-containing herbal or dietary supplements?) Family history (Breast, colon, endometrial cancer?) The emphasis is a bit different when assessing postmenopausal women with vaginal bleeding: Trauma: Any precipitating factors? Atrophy? Bleeding: When did the bleeding start? What is the nature of the bleeding (temporal pattern, duration, postcoital, quantity)? Associated symptoms: Are there any associated symptoms such as pain, fever, or changes in bladder or bowel function? Medications/supplements: What is the medical hx and are any medications being taken (e.g., hormones, anticoagulants)? Are any soy-containing herbal or dietary supplements being taken? Family history: Is there a family history of breast, colon, and endometrial cancer?

Postmenopausal Bleeding Possible Causes
Atrophy Cancer Polyps/Fibroids/Adenomyosis Medications (HRT, herbal or dietary supplements) Infections Other (diseases in adjacent organs, post-radiation) Postmenopausal Bleeding Possible Causes What do you need to have in mind as far as causes of Postmenopausal Bleeding? Atrophy Cancer Polyps/Fibroids/Adenomyosis Medications – postmenopausal hormone replacement therapy, herbal and dietary supplements Infections Other – diseases in adjacent organs, post-radiation

Primary goal of evaluating postmenopausal bleeding is to exclude malignancy
History Physical exam, pelvic exam, Pap Ultrasound and/or endometrial biopsy* Different approach may be used for patients on hormone replacement therapy The primary goal of evaluating patients with postmenopausal bleeding is to exclude malignancy History Physical, including pelvic exam and cervical cancer screening Ultrasound and/or endometrial biopsy *A different approach may be used for patients on hormone replacement

Key Points for Vaginal Bleeding
Multiple causes of abnormal bleeding; evaluation depends on bleeding pattern, patient age, other factors Two main issues for women of childbearing age: • Hemodynamic stability • Pregnancy Main issue for postmenopausal women is to rule out malignancy Key points for abnormal vaginal bleeding: There are many possible causes and evaluation depends on the bleeding pattern, patient age, and other factors. There are two main issues for women of childbearing age who have abnormal bleeding: hemodynamic stability and pregnancy The main point for postmenopausal women who have abnormal bleeding is to rule out malignancy

Abnormal Vaginal Bleeding

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