Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Approach to the adult with vaginal bleeding in the emergency department

Joelle C Borhart, MD
Section Editor
Robert S Hockberger, MD, FACEP
Deputy Editor
Jonathan Grayzel, MD, FAAEM


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:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Sep 19, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. 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.
  2. Lane DE. Polycystic ovary syndrome and its differential diagnosis. Obstet Gynecol Surv 2006; 61:125.
  3. 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.
  4. Fishman A, Paldi E. Vaginal bleeding in premenarchal girls: a review. Obstet Gynecol Surv 1991; 46:457.
  5. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Early Pregnancy:, Hahn SA, Promes SB, Brown MD. Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med 2017; 69:241.
  6. Taipale P, Hiilesmaa V, Ylöstalo P. Transvaginal ultrasonography at 18-23 weeks in predicting placenta previa at delivery. Ultrasound Obstet Gynecol 1998; 12:422.
  7. Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association. Circulation 2015; 132:1747.
  8. Butwick AJ, Goodnough LT. Transfusion and coagulation management in major obstetric hemorrhage. Curr Opin Anaesthesiol 2015; 28:275.
  9. https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/HEMPosterMassiveTransfusionProtocol.pdf?dmc=1&ts=20170831T1650182109 (Accessed on September 05, 2017).
  10. Nielsen S, Hahlin M. Expectant management of first-trimester spontaneous abortion. Lancet 1995; 345:84.
  11. 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.
  12. 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.
  13. Hickey M, Higham JM, Fraser I. Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane Database Syst Rev 2012; :CD001895.