Approach to vaginal bleeding in the emergency department
- Robert Dart, MD
Robert Dart, MD
- Associate Professor of Emergency Medicine
- Boston University School of Medicine
- 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 — Adult and Pediatric Emergency Medicine
- 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 review will discuss the basic physiology of menstruation and provide a basic 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 elsewhere. (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 average age of menarche is approximately 12.5 years. 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".)
In the follicular phase of the menstrual cycle, 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. Once estrogen levels reach a threshold level for about 36 hours, a surge in LH occurs, which triggers ovulation and the beginning of the luteal phase of the menstrual cycle. 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, progesterone levels fall, and menstruation occurs.
The endometrium is composed of three layers: basal, spongy, and compact. The basal layer contains stem cells for regeneration but also provides a cleavage plane between the basal and spongy layers when menstruation occurs. The endometrium undergoes characteristic changes in structure and thickness during the course of each menstrual cycle.
- Chimbira TH, Anderson AB, Turnbull Ac. Relation between measured menstrual blood loss and patient's subjective assessment of loss, duration of bleeding, number of sanitary towels used, uterine weight and endometrial surface area. Br J Obstet Gynaecol 1980; 87:603.
- Warner PE, Critchley HO, Lumsden MA, et al. Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. Am J Obstet Gynecol 2004; 190:1216.
- Lane DE. Polycystic ovary syndrome and its differential diagnosis. Obstet Gynecol Surv 2006; 61:125.
- Clark TJ, Voit D, Gupta JK, et al. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. JAMA 2002; 288:1610.
- Fishman A, Paldi E. Vaginal bleeding in premenarchal girls: a review. Obstet Gynecol Surv 1991; 46:457.
- Kalinski MA, Guss DA. Hemorrhagic shock from a ruptured ectopic pregnancy in a patient with a negative urine pregnancy test result. Ann Emerg Med 2002; 40:102.
- Barnhart K, Mennuti MT, Benjamin I, et al. Prompt diagnosis of ectopic pregnancy in an emergency department setting. Obstet Gynecol 1994; 84:1010.
- Taipale P, Hiilesmaa V, Ylöstalo P. Transvaginal ultrasonography at 18-23 weeks in predicting placenta previa at delivery. Ultrasound Obstet Gynecol 1998; 12:422.
- Nielsen S, Hahlin M. Expectant management of first-trimester spontaneous abortion. Lancet 1995; 345:84.
- Lipscomb GH, McCord ML, Stovall TG, et al. Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies. N Engl J Med 1999; 341:1974.
- Dart RG, Mitterando J, Dart LM. Rate of change of serial beta-human chorionic gonadotropin values as a predictor of ectopic pregnancy in patients with indeterminate transvaginal ultrasound findings. Ann Emerg Med 1999; 34:703.
- Hickey M, Higham JM, Fraser I. Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane Database Syst Rev 2012; :CD001895.
- PHYSICAL EXAMINATION
- ANCILLARY STUDIES
- Pregnancy tests
- Pelvic ultrasound
- Additional tests
- DIFFERENTIAL DIAGNOSIS
- DIAGNOSTIC APPROACH AND DISPOSITION
- Basic questions
- Determine hemodynamic status
- Determine pregnancy status
- Determine differential diagnosis based on age
- - Premenarchal patient
- - Premenopausal patient
- - Peri and postmenopausal patient
- SUMMARY AND RECOMMENDATIONS