Any woman complaining of abnormal vaginal bleeding should be examined.

Occasionally, you will find a laceration of the vagina, a bleeding lesion, or bleeding from the surface of the cervix due to cervicitis. More commonly, you will find bleeding from the uterus coming out through the cervical os.

Excluding pregnancy, there are really only three reasons for abnormal uterine bleeding:

• Mechanical Problems
• Hormonal Problems
• Malignancy

The limited number of possibilities makes your caring for these patients very simple.

If the bleeding is heavy, obtain a blood count and assess the rate of blood loss to determine how much margin of safety you have. Someone with a good blood count (hematocrit) and minimal rate of blood loss (less than a heavy period), can tolerate this rate of loss for many days to weeks before the bleeding itself becomes a threat. Determine whether the bleeding is significant enough to begin iron replacement therapy.

Pregnancy Problems

A variety of pregnancy problems can cause vaginal bleeding. These include:

• Abortion (threatened, incomplete, complete, missed, or inevitable)
• Ectopic Pregnancy
• Placental Abruption
• Placenta Previa

If the bleeding patient has a positive pregnancy test, a careful search should be made for each of these problems. However, if the pregnancy test is negative, pregnancy-related bleeding problems are effectively ruled out.

Mechanical Problems

Such problems as uterine fibroids or polyps are examples of mechanical problems inside the uterus.

A simple ultrasound scan, if available, can reveal the presence of fibroids and their location. Those fibroids that are impinging on the endometrial cavity are the most likely to be responsible for abnormal bleeding.

Endometrial polyps can be identified with a fluid-enhanced ultrasound (sonohysterography), a simple office procedure. They can also be identified during hysteroscopy.

Since mechanical problems have mechanical solutions, these patients will need surgery of some sort (Polypectomy, D&C, Hysteroscopy, Hysterectomy, Myomectomy, etc.) to resolve their problem.

If surgery is not available, most patients with these mechanical problems will do better if they take oral contraceptive pills. So long as the pill is strong enough to suppress ovarian function, menstrual flows will be shorter and lighter. If complete suppression of bleeding is desired, BCPs can be taken continuously. After one or two months, menses would be expected to stop.

Another form of mechanical problem is an IUD causing abnormal bleeding. These should always be removed.

Hormonal Problems

Hormonal causes for abnormal bleeding include anovulation leading to an unstable uterine lining, breakthrough bleeding associated with birth control pills, and spotting at midcycle associated with ovulation. Some of these cases will be related to an underlying medical abnormality, such as polycystic ovary syndrome, hyper or hypothyroidism, adrenal hyperplasia, and pituitary adenoma. Rarely, this may be due to a hormone secreting neoplasm of the ovary.

The optimal solution to all of these problems is to find and treat those underlying medical abnormalities that exist, and/or take control of the patient hormonally and insist (through the use of BCPs) that she have normal, regular periods.

• Thyroid disease can be ruled out clinically or through laboratory testing (TSH)
• Adrenal hyperplasia can be ruled out clinically or through laboratory testing (DHEAS, 17 hydroxyprogesterone, ACTH stimulation test)
• Prolactin-secreting pituitary adenoma can be ruled out clinically or through laboratory testing (serum prolactin)
• Hormone-secreting ovarian neoplasms can be ruled out clinically or through laboratory testing (ultrasound, estradiol, testosterone)

If the abnormal bleeding is light and the patient’s blood count good, starting low-dose BCPs at the next convenient time will usually result in effective control within a month or two.

If the bleeding is quite heavy or her blood low, then it is best to have the patient lie still while you treat her with birth control pills. This should work well, unless she has been having prolonged, intractable uterine bleeding. In the latter case, the endometrial lining will have been denuded and probably will not respond well to the progestin dominant BCPs.

For those with intractable anovulatory bleeding, plain estrogen in doses of 2.5 up to 25 mg a day can be effective in promoting endometrial proliferation, stopping the bleeding. After the bleeding is initially controlled with estrogen, progesterone is added to stabilize the endometrium, leading up to a hormonal withdrawal flow a week or two later. Two drawbacks to this approach are the nausea that frequently accompanies such large doses of estrogen, and the theoretical risk of thromboembolism among women exposed to large amounts of estrogen while on bed rest.

Giving iron supplements is a good idea (FeSO4 325 mg TID PO or its’ equivalent) for anyone who is bleeding heavily.

Malignancy

Abnormal bleeding can also be a symptom of malignancy, from the vagina, cervix or uterus.

Cancer of the vagina is extraordinarily rare and will present with a palpable, visible, bleeding lesion on the vaginal wall. Cancer of the cervix is more common but a normal Pap smear and normal exam will effectively rule that out. Should you find a bleeding lesion in either the vagina or on the cervix, these should be biopsied.

Factors that increase the risk for endometrial carcinoma include:

• Increased estrogen exposure (exogenous or endogenous)
• Diabetes
• Overweight (through increased conversion of androstenedione to estrone by body fat cells)
• Chronic, untreated anovulation (many years)

Cancer of the uterus (endometrial carcinoma) occurs most often in the older population (post-menopausal) and is virtually unknown in patients under age 35. For those women with abnormal bleeding over age 40, an endometrial biopsy is a wise precaution during the evaluation and treatment of abnormal bleeding.