Vaginal bleeding

# Overview
Vaginal bleeding refers to bleeding in females that are either a physiologic response during the non-conceptional menstrual cycle or caused by hormonal or organic problems of the reproductive system. Vaginal bleeding may occur at any age, but always needs investigation when encountered in female children or postmenopausal women. Vaginal bleeding during pregnancy may indicate a possible pregnancy complication that needs to be medically addressed.

# Anatomy
Blood loss per vaginam (Latin: from the vagina) typically arises from the lining of the uterus (endometrium), but may arise from uterine or cervical lesions, the vagina, and rarely from the Fallopian tube. During pregnancy it is usually but not always related to the pregnancy itself. Rarely, the blood may actually arise from the urinary tract (hematuria), although the vast majority of women can identify the difference. It can also be a sign of vaginal cancer.

# Causes

## Life Threatening Causes
- Abdominal cancer
- Adenocarcinoma
- Bleeding tendency
- Blood clotting disorders
- Cervical cancer
- Choriocarcinoma
- Dysfunctional uterine bleeding
- Endometrial cancer
- Endometrial infection
- Fallopian tube cancer
- Fibromyoma
- Genital tract tumors
- Glassy cell carcinoma of the cervix
- Myoma
- Neuroendocrine carcinoma of the cervix
- Pelvic cancer
- Peritoneum cancer
- Primary fallopian tube cancer
- Primary malignant melanoma of the cervix
- Rectal bleeding
- Trophoblastic cancer
- Uterine cancer
- Vaginal cancer
- Vulval squamous cell carcinoma

## Common Causes
- Abortion
- Abruptio placentae
- Adenomyosis
- Amniocentesis
- Anovulation
- Ante-partum hemorrhage
- Asherman syndrome
- Cervical ectropion
- Cervical polyps
- Cervical smear
- Cervicitis
- Cervix cancer
- Cervix disorder
- Cervix infection
- Choriocarcinoma
- Chorionic villus sampling
- Contraceptive implants
- Decreased menses
- Dysfunctional uterine bleeding
- Ectopic pregnancy
- Endometrial cancer
- Endometrial hyperplasia
- Endometrial infection
- Endometrial stromal sarcoma
- Endometriosis
- Endometritis
- Endometrium atrophy
- Estrogen withdrawal
- Fallopian tube cancer
- Fibroids
- Fibromyoma
- Foreign body
- Genital tract tumors
- Glassy cell carcinoma of the cervix
- Hydatidiform mole
- Iucd
- Malignant mixed mullerian tumor
- Menopause
- Menstruation
- Miscarriage
- Mittelschmerz
- Oral contraception
- Ovarian cancer
- Ovarian cyst
- Ovary infection
- Pelvic inflammatory disease
- Perimenopause
- Placenta previa
- Placenta vein rupture
- Placental abruption
- Placental hypertrophy
- Polycystic ovary syndrome
- Precocious puberty
- Pregnancy complications
- Pregnancy
- Premature menarche
- Primary dysmenorrhoea
- Primary fallopian tube cancer
- Primary malignant melanoma of the cervix
- Progestagens
- Puerperal fever
- Sarcoma botryoides
- Secondary fallopian tube cancer
- Spontaneous abortion
- Thinning vaginal lining
- Threatened miscarriage
- Tubal ligation syndrome
- Urethral caruncle
- Urethral prolapse
- Uterine atony
- Uterine cancer
- Uterine disorder
- Uterine fibroids
- Uterine growths
- Uterine infection
- Uterine polyps
- Uterine sarcoma
- Vaginal cancer
- Vaginal foreign body
- Vaginal infection
- Vaginal injury
- Vaginitis
- Vitamin a embryopathy
- Vulva disorder
- Vulva injury
- Vulval squamous cell carcinoma
- Vulvovaginitis

## Causes by Organ System

## Causes in Alphabetical Order
- Abdominal cancer
- Abortion
- Abruptio placentae
- Actinomycosis
- Adenocarcinoma
- Adenomyosis
- Amniocentesis
- Amphetamine abuse
- Anemia
- Anovulation
- Ante-partum hemorrhage
- Asherman syndrome
- Autoimmune thrombocytopenia
- Autoimmune thyroid diseases
- Bladder bleeding
- Bladder infection
- Bleeding tendency
- Blood clotting disorders
- Bxo
- Cervical cancer
- Cervical dysplasia
- Cervical ectropion
- Cervical polyps
- Cervical smear
- Cervicitis
- Cervix cancer
- Cervix disorder
- Cervix infection
- Chlamydia
- Choriocarcinoma
- Chorionic villus sampling
- Clomiphene
- Clotting disorder
- Condyloma acuminate
- Contraceptive implants
- Decreased menses
- Dicoumarol
- Dienogest
- Dilatation and curettage
- Dysfunctional uterine bleeding
- Ectopic pregnancy
- Endometrial cancer
- Endometrial hyperplasia
- Endometrial infection
- Endometrial stromal sarcoma
- Endometriosis
- Endometritis
- Endometrium atrophy
- Estradiol valerate
- Estrogen withdrawal
- Exogenous hormonal preparations
- Fallopian tube cancer
- Fibroids
- Fibromyoma
- Foreign body
- Ganirelix
- Genital tract tumors
- Glassy cell carcinoma of the cervix
- Gonorrhea
- Granuloma inguinale
- Graves disease
- Hereditary hemorrhagic telangiectasia
- Hormonal contraception
- Hormonal disorder
- Hormonal imbalance
- Hydatidiform mole
- Hyperoestrogenic states
- Hyperthyroidism
- Hypothyroidism
- Iucd
- Lichen sclerosis
- Low estrogen levels
- Malignant mixed mullerian tumor
- Medroxyprogesterone acetate
- Menopause
- Menstruation
- Mifepristone
- Miscarriage
- Misoprostol
- Mittelschmerz
- Molestation
- Myoma
- Neuroendocrine carcinoma of the cervix
- Oral contraception
- Ovarian cancer
- Ovarian cyst
- Ovary infection
- Pelvic cancer
- Pelvic inflammatory disease
- Perimenopause
- Peritoneum cancer
- Peritoneum disorders
- Phenprocoumon
- Placenta previa
- Placenta vein rupture
- Placental abruption
- Placental hypertrophy
- Polycystic ovary syndrome
- Precocious puberty
- Pregnancy
- Pregnancy complications
- Premature menarche
- Primary cortisol resistance
- Primary dysmenorrhoea
- Primary fallopian tube cancer
- Primary malignant melanoma of the cervix
- Progestagens
- Puerperal fever
- Rectal bleeding
- Sarcoma botryoides
- Secondary fallopian tube cancer
- Sexual intercourse
- Sexually transmitted diseases
- Smoking
- Spironolactone
- Spontaneous abortion
- Tamoxifen
- Tampon
- Thinning vaginal lining
- Threatened miscarriage
- Thrombocytopenia
- Thrombocytopenic purpura
- Thyroid disorders
- Tiagabine
- Trauma
- Trimethadione
- Trophoblastic cancer
- Tubal ligation syndrome
- Tumors
- Ulipristal
- Urethral caruncle
- Urethral prolapse
- Uterine atony
- Uterine cancer
- Uterine disorder
- Uterine fibroids
- Uterine growths
- Uterine infection
- Uterine polyps
- Uterine sarcoma
- Vaginal cancer
- Vaginal foreign body
- Vaginal infection
- Vaginal injury
- Vaginitis
- Vitamin a embryopathy
- Von willebrand disease
- Vulva disorder
- Vulva injury
- Vulval squamous cell carcinoma
- Vulvovaginitis
- Warfarin
- Y chromosome pericentric inversion

# Investigation
The diagnosis can often be made on the basis of the bleeding history, physical examination, and  other medical tests as appropriate. Typically a pregnancy test and additional hormonal tests, a Pap smear, a transvaginal ultrasound are needed. If bleeding was excessive or prolonged, a CBC may be useful to check for anemia. Abnormal endometrium may have to be investigated by a hysteroscopy with a biopsy or a dilation and curettage.

# Differential Diagnosis
In alphabetical order.  
- Abortion
- Adherent placental residue
- Adnexitis
- Adrenal disease
- Atonic secondary bleeding
- Carcinoma
- Cervical Cancer
- Cervical ectopia
- Cervical erosion
- Cervical neoplasms
- Cervical polyp
- Cervicitis
- Chorionepithelioma
- Colpitis Senilis
- Corpus luteum deficiency syndrome
- Ectopic Pregnancy
- Endometrial polyps
- Endometriosis
- Endometritis
- Estrogen-progestogen therapy
- Estrogen breakthrough bleeding
- Fibrinogen deficiency
- Follicle persistence
- Granulosa cell tumor
- Hydatidiform mole
- Hypothalamic or pituitary lesion
- Inadequate corpus luteum
- Injuries
- Intrauterine device (IUD)
- Lacerated placenta
- Midcycle ovulatory bleeding
- Myoma
- Neoplasms
- Placenta Previa
- Postcoital hemorrhage
- Premature placental abruption
- Prolapsed uterus
- Rupture hemorrhage
- Ruptured uterus
- Stress/psychogenic factors
- Thyroid disease
- Trauma
- Uterine adenomytosis
- Uterine leiomyomas
- Vaginal Cancer
- Vaginal infections
- Vaginal varices
- Varicosis of the vagina
- Velamentous insertion
- Vulvar Cancer

# Treatment
The treatment will be directed at the cause. Hormonal bleeding problems during the reproductive years, if bothersome to the woman, are frequently managed by use of combined oral contraceptive pills.

### Contraindicated medications
Vaginal Bleeding is considered an absolute contraindication to the use of the following medications:
- Hydroxyprogesterone caproate, Dinoprostone

# Complications
A possible complication from protracted vaginal blood loss is iron deficiency anemia, which can develop insidiously. Eliminating the cause will resolve the anemia, although some women require iron supplements or blood transfusions to improve the anemia.