099. Vaginal Bleeding in the Nonpregnant Patient

General

Normal Cycle: 4 days of menses, then day 5-14 is follicular phase where ovary matures oocyte – Estrogen is produced. Pituitary gland responds to estrogen by producing FSH and LH – this releases matured oocyte. Residual capsule forms corpus luteum. During luteal phase, corpus luteum produces estrogen/progesterone to make endometrium ready for implantation. Corpus luteum waits for HCG which is produced from embryo. If none is produced, corpus luteum regresses and estrogen/progesterone levels fall. When these levels fall, vasoconstriction occurs and lining sloughs/ischemia. Average menstrual blood is 25-60mL (actual blood; endometrial fluid is usually more like 70mL). Average tampon absorbs 20-30mL. In early menarche, periods can vary for the first 1-2 years, sometimes 5 years.

Menorrhagia: menses >7d, > 60mL, or < 21 days recurrence. Metrorrhagia: irregular vaginal bleeding outside cycle. Though little correlation between pad/tampon usage and actual fluid/blood loss.

Menopause: usually around 51yo. Estrogen production decreases and FSH/LH increases. No mid cycle rise in estrogen for ovulation.

Pelvic exam: Cervix: inspecting for polyps, inflammation, infection, ulcers, possible cancer.

Disorders

Leiomyomas: fibroids – benign tumors of muscle cell origin. 25% in white women, 50% in black women. Decrease with menopause. Usually not acute pain related unless degeneration (rapid growth with loss of blood supply). Tx: NSAIDs, medroxyprogresterone/depomedroxyprogesterone. Hysteroscopy for intracavitary leiomyomas; uterine artery embolization can be considered as well.

Adenomyosis: endometrial tissue grows deep into myometrium. Menorrhagia common – usually due to poor muscle contraction in menstruation. Usually in the 30-40s. Tx: NSAIDs, sometimes surgery.

Endometriosis: can sometimes cause heavy/irregular menses.

Post-menopausal bleeding: endometrial cancer must be considered. Stable patients can be discharged with f/u with OB/GYN for outpatient ultrasound and possible biopsy.

Systemic diseases: consider coagulation disorders including von Willebrand disease (vWD – MCC). Hypothyroidism can cause menorrhagia – check TSH. Consider cirrhosis. Hormone replacement with menopause can cause bleeding – new studies have shown no benefit for CV risk and increased risk for endometrial/breast/colorectal/blood clots.

Dysfunctional uterine bleeding: no organic or systemic disease found for cause of bleeding. Ovulatory bleeding: bleeding occurring during ovulation. Tx: oral contraceptives, NSAIDs, danazol (androgen), progestin; consider endometrial ablation or hysterectomy for extreme cases. Anovolutary: in extremes in age – usually due to no ovum so unopposed estrogen – irregular bleeding. You really shouldn’t call the patient’s diagnosis “Dysfunctional uterine bleeding” since you haven’t fully worked the patient up with US, hormone levels, etc. Just call her “Vaginal bleeding.”

Physical/psychological, illness, malnutrition, rapid weight loss/gain, intense physical regiment can affect hypothalamus and cause amenorrhea or irregular heavy periods.

Treatment

Treatment for hemodynamically stable uterine bleeding:

  1. Oral estrogen (Premarin) 10mg/d (2.5mg QID) or 25mg IV every 2-4hr for 24 hrs. When bleeding resolves, add medroxyprogesterone acetate (Provera) 10mg/d. Continue both for 7-10 days.
  2. OCP: Ethinyl estradiol 25mg and norethindrone 1mg (Loestrin, Microgestin, Junel, Gildess, Femhrt; Ortho Tricyclen 35mg extradiol): This regiment is for severe bleeding: 4 tabs for 7 days or slower taper 4 tabs x 2d, 3 tabs x 2 d, 2 tabs x 2 d, 1 tab x 3d. Antibiotics do not effect OCP efficacy except for TB drugs. Monophasic means same amount of estrogen throughout course of month. Ortho-Novum 1/35 (norethindrone/ethinyl estradiol) – 2 pills/day x 5d, then 1 pill/day until pack gone – 2.5 weeks of hormone. Expect withdrawal bleeding but should be normal period. No OCPS for: prior DVT or stroke, >35yo and SMOKES, cancer, CV disease, active liver disease, pregnancy. Relative risk of 5 for clot. Absolute risk still low but increases with age. healthy 0.05% per year. Highest risk in first 3 months. No evidence for risk for short-course higher dose. Ok to start in ED without US (consider progestin only if worried) and needs f/u in 10 days. Need to give anti-emetics when giving OCPs.
  3. Progesterone: medroxyprogesterone actetate (Provera/DepoProvera): 10mg/d x 10d. Very similar, though some risk with DVT (not 0%).
  4. Tranexamic acid (Lysteda) 0.3-1g PO q8hr x 3d.

Hemodynamic Unstable: look for source to try and localize. If unable and coming from uterus, will need immediate D&C. Uterine packing should be avoided (infection, hides ongoing blood loss). Consider Estrogen 25mg every 4-6 hours for severe bleeding (requiring hospitalization) – usually will stop within 5 hours.

NSAIDs: reduce blood loss in 20-50%. Reduce endometrial prostaglandin levels. Reduce dysmenorrhea. Likely naproxen 500mg BID or ibuprofen 400mg q6h.  Less effective with fibroids.

Ferrous sulfate 325mg TID for moderate bleeding (Hgb 7-10).

Patient already on Implanon/Depoprovera with breakthrough bleeding: responds to short course estrogen. 1.25mg conjugated estrogen daily for 7-14 days.

Hysteroscopy: can be diagnostic (looking for polyps/myoma, biopsy) as well as therapeutic.

Endometrial ablation: uses laser/electrocautery/rollerball elation. Amenorrhea in 50%, decreased flow in 35%. Improvement in symptoms in 80%.

vWD: can be given DDAVP (desmopressin acetate) as intranasal, parenterally, or SC. Patient’s must be type/screened though to check for antibodies which can cause thrombocytopenia if not.

PCOS: Polycystic Ovary Syndrome: hyperandrogegism. Triad: obesity, hirsutism, oligomenorrhea. When menses occur, they are heavy. Usually acne, alopecia, elevated LH with low/normal FSH. Tx usually with low dose OCP.

References/Resources

Tintinalli, Seventh Edition, Chapter 99: Vaginal Bleeding in the Nonpregnant Patient

CrashingPatient.com, Scott Weingart, Women’s Health, Reviewed 6/27/17

Non-Pregnant Vaginal Bleeding, Joelle Borhart, AAEM Scientific Assembly 2012

 

 

 

 

099. Vaginal Bleeding in the Nonpregnant Patient