Vaginal bleeding

Last updated: January 4, 2022

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Vaginal bleeding that is not attributable to expected menstrual bleeding can be a clinical feature of a number of genitourinary conditions that affect not only the vagina but also the uterus, ovarian tubes, ovaries, and urethra. There are various causes of abnormal vaginal bleeding, and workup is determined by the patient's age and pregnancy status. Pain is an important differentiating feature that can further narrow down the differential diagnosis of abnormal vaginal bleeding.

For more information about physiological menstrual bleeding and abnormal uterine bleeding, see “The menstrual cycle and menstrual cycle abnormalities”. For more information on vaginal bleeding in pregnancy, see “Differential diagnosis of antepartum bleeding”.

Overview of causes of vaginal bleeding in different age groups
Age group Causes
Premenarchal children
Nonpregnant women
Pregnant women
Postmenopausal women
Overview of differential diagnoses of painful vaginal bleeding [1]
Differential diagnosis Clinical features Diagnostic findings
Description of pain Other clinical features
Ectopic pregnancy
  • Lower unilateral abdominal pain and guarding
Spontaneous abortion
  • Cramping abdominal-pelvic pain
Benign neoplasms Adenomyosis
  • Chronic pelvic pain
  • Ultrasound: may show asymmetric myometrial wall thickening and myometrial cysts
Uterine leiomyoma
  • Back or pelvic pain/discomfort
Ovarian cyst rupture
  • Sudden onset of unilateral abdominal pain
  • Onset usually during physical activity (exercise, sexual intercourse)
  • Ultrasound: may show pelvic free fluid and/or adnexal mass
Infection/inflammation Pelvic inflammatory disease
  • Lower bilateral abdominal pain
Cervicitis

Endometriosis

  • Chronic pelvic pain that worsens before the onset of menses
Trauma
(e.g., foreign body, sexual abuse)
  • Depends on the type and mechanism of trauma
Overview of differential diagnoses of painless vaginal bleeding [1]
Differential diagnosis Clinical features Diagnostic findings

Polycystic ovary syndrome

Endometrial hyperplasia

  • Constant bleeding
  • Intermenstrual bleeding

Endometrial polyp

Malignant neoplasms Cervical cancer
Endometrial cancer
Adverse effects
(resulting from, e.g., anticoagulants, oral contraceptives, intrauterine devices)

Anembryonic pregnancy [2]

  • Can be asymptomatic
  • Vaginal bleeding, loss of pregnancy symptoms, and falling β-hCG levels
  • Transvaginal ultrasound
    • No visible embryo in a gestational sac measuring ≥ 25 mm
      OR
    • No visible embryo during a follow-up endovaginal ultrasound ≥ 11 days after confirming the presence of a gestational sac with a yolk sac
      OR
    • No visible embryo during a follow-up endovaginal ultrasound ≥ 2 weeks after confirming the presence of a gestational sac without an embryo or a yolk sac
  1. Albers JR, Sharon KH, Wesley RM. Abnormal uterine bleeding. Am Fam Physician. 2004; 69 (8): p.1915-1926.
  2. Chaudhry K, Tafti D, Siccardi MA. Anembryonic Pregnancy (Blighted Ovum). Statpearls. 2020 .

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