Approach to the adult with vaginal bleeding in the emergency department
- Joelle C Borhart, MD
Joelle C Borhart, MD
- Assistant Professor of Emergency Medicine
- Georgetown University
- Section Editor
- Robert S Hockberger, MD, FACEP
Robert S Hockberger, MD, FACEP
- Section Editor — Adult Signs and Symptoms
- Emeritus Professor of Medicine
- David Geffen School of Medicine at UCLA
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
The management of patients presenting to the emergency department (ED) with vaginal bleeding depends upon a number of factors including patient age, pregnancy status, chronicity and severity of bleeding, comorbidities, and medications. An understanding of the menstrual cycle and an organized approach to patient evaluation enable the ED clinician to form an appropriate differential diagnosis and treatment plan.
This topic will review the basic physiology of menstruation and provide an approach to the adult patient who presents to the ED with vaginal bleeding. Detailed discussions of pediatric patients with vaginal bleeding and of specific causes of genital tract bleeding are found separately. (See "Ectopic pregnancy: Clinical manifestations and diagnosis" and "Spontaneous abortion: Risk factors, etiology, clinical manifestations, and diagnostic evaluation" and "Placental abruption: Clinical features and diagnosis" and "Differential diagnosis of genital tract bleeding in women" and "Evaluation and management of female lower genital tract trauma" and "Approach to abnormal uterine bleeding in nonpregnant reproductive-age women".)
The regularity of the menstrual cycle and ovulation are dependent on a complex hormonal feedback mechanism involving the hypothalamus, the pituitary, and the ovary (figure 1). A basic summary of menstruation follows. A more detailed description of menstruation is found elsewhere. (See "Physiology of the normal menstrual cycle" and "Normal puberty".)
The first half of the menstrual cycle is known as the follicular phase. During the follicular phase, gonadotropin-releasing hormone (GnRH) is secreted by the hypothalamus, which then stimulates the pituitary to release both luteinizing hormone (LH) and follicle stimulating hormone (FSH). In the ovary, under the influence of these two hormones, two things occur: A dominant follicle matures, and increasing levels of estrogen are secreted. Estrogen stimulates the endometrial glands and stroma to grow and proliferate, causing the endometrium to thicken.
Once estrogen levels reach a threshold level for about 36 hours, a surge in LH occurs, which triggers ovulation and the beginning of the second half of the menstrual cycle known as the luteal phase. Under the influence of LH, the ruptured dominant follicle rapidly evolves into the corpus luteum, which secretes increased amounts of progesterone. If pregnancy does not occur, the corpus luteum involutes 14 days after ovulation, and progesterone levels fall. The drop in progesterone during the latter part of the luteal phase triggers release of prostaglandins, which cause vasospasm of the arteries feeding the endometrium. This leads to a sloughing of the outer layers of the endometrium (ie, menstruation).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- BASIC PHYSIOLOGY
- PHYSICAL EXAMINATION
- ANCILLARY STUDIES
- Pregnancy tests and pelvic ultrasound
- Fetal heart rate
- Additional tests
- DIFFERENTIAL DIAGNOSIS
- Life-threatening causes
- - Pregnancy ≤20 weeks gestation
- - Pregnancy >20 weeks gestation
- - Other genital tract causes
- Non-life-threatening causes
- DIAGNOSTIC APPROACH, INITIAL MANAGEMENT, AND DISPOSITION
- Basic questions to guide management
- Determine hemodynamic status
- - Initial management of unstable patient
- - Stable patient
- Determine pregnancy status
- - Early pregnancy (before 20 weeks)
- - Late pregnancy (after 20 weeks)
- Determine differential diagnosis based on age
- - Premenarchal patient
- - Premenopausal patient
- - Peri and postmenopausal patient
- SUMMARY AND RECOMMENDATIONS