Vaginal bleeding is one of the most common symptoms of obstetrical and gynecological disorders and can come from any part of the reproductive tract, such as the vagina, cervix, and uterus. The vast majority of bleeding comes from the uterus and is called vaginal bleeding except for normal menstruation. Vaginal bleeding can also be a manifestation of coagulation disorders such as idiopathic thrombocytopenic purpura, leukemia, aplastic anemia, and liver function impairment.
1. The etiology of abnormal vaginal bleeding varies in women of different ages.
(1) When abnormal vaginal bleeding occurs in women of childbearing age who have sex, pregnancy-related diseases such as ectopic pregnancy, miscarriage, gravida, and poor postpartum uterine regeneration or placental residue should be excluded first. The next consideration is abnormal uterine bleeding due to endocrine hormonal changes in women, which is often referred to as “menstrual disorders” or ovulatory bleeding. Finally, inflammation, such as vaginitis, cervicitis, endometritis, and gynecological tumors, such as uterine fibroids, cervical cancer, endometrial cancer, etc.
(2) When abnormal vaginal bleeding occurs in menopausal and postmenopausal women, gynecological tumors, such as cervical cancer, endometrial cancer, fallopian tube cancer, ovarian tumors, uterine sarcoma, vaginal cancer, endometrial polyps and uterine fibroids, should be excluded first. Next, consider inflammation, such as vulvodynia, vaginitis, cervicitis, endometritis, etc., and menopausal menstrual disorders.
(3) In adolescent girls with abnormal vaginal bleeding, uterine bleeding caused by endocrine hormonal changes in women should be excluded first, followed by consideration of etiologies such as hematologic disorders and abnormal liver function.
(4) Vaginal bleeding in girls should first exclude trauma and foreign bodies, and secondly consider the possibility of cervical chylous sarcoma and other lesions.
2. The manifestation of vaginal bleeding varies, and its etiology is identified according to the characteristics of vaginal bleeding, which are mainly periodic regular vaginal bleeding and non-periodic vaginal bleeding.
(1) Vaginal bleeding with a cyclic pattern includes
(1) Increased menstrual flow: characterized by a normal menstrual cycle, but high menstrual flow or long periods, often associated with uterine fibroids, adenomyosis or placement of an intrauterine device;
②Intermenstrual bleeding: occurs in the middle of two menstrual periods, often lasting 3 to 4 days, usually with less bleeding than menstrual flow, occasionally accompanied by pain or discomfort in the lower abdomen. This kind of bleeding is caused by the rupture of follicles between menstrual periods and the temporary decrease of estrogen level, also called ovulatory bleeding;
(3) Pre- or post-menstrual spotting bleeding: small amount of vaginal bleeding before or several days after menstruation, often incomplete. It can be seen as a side effect of luteal insufficiency or irregular shedding of endometrium or placement of intrauterine device. A similar situation can occur with endometriosis.
(2) Vaginal bleeding without a regular cycle includes
(1) Contact bleeding: vaginal bleeding that occurs immediately after sexual intercourse or gynecological vaginal examination, bright red in color and may be more or less in amount, commonly associated with acute cervicitis, early cervical cancer, cervical polyps or submucosal fibroids of the uterus.
②Vaginal bleeding after menopause: Women of childbearing age who have normal sex life with or without lower abdominal pain and nausea should first consider ectopic pregnancy, miscarriage, and gravidity. Adolescent non-sexual women or menopausal women with no other symptoms should first consider menstrual disorders, but gynecological malignancies should be excluded.
③Postmenopausal vaginal bleeding: the amount of bleeding is usually small and may be continuous or repeated. Occasionally, it may be accompanied by lower abdominal pain. Endometrial cancer should be ruled out first. It can also be seen in atrophic vaginitis or endometritis, etc.
④Vaginal bleeding after trauma: It often occurs after a span injury or after a woman’s first sexual hymenal laceration, and the amount of bleeding may be more or less, accompanied by pain in the vulva.
Abnormal vaginal bleeding should be seen early, especially if it exceeds the amount of menstruation or is accompanied by abdominal pain, nausea and vomiting, or a feeling of anal distention.
After consultation, the doctor will ask about the patient’s age, bleeding characteristics, history of sexual intercourse, presence of intrauterine device, past menstrual and childbirth history, etc., and then conduct relevant tests to confirm the diagnosis.
Gynecological examination is performed to understand the source of bleeding, the presence of trauma, vaginal foreign bodies, inflammation, abnormal vaginal and cervical masses, pelvic inflammatory disease, pelvic masses, etc.
A urine pregnancy test can clarify whether the condition is pregnancy-related. In case of maternal bleeding, gynecological examination can find out whether miscarriage is unavoidable, and ultrasound can check whether the intrauterine embryo is alive to determine subsequent treatment measures.
Gynecologic ultrasound, especially transvaginal or rectal intracavitary color ultrasound, can provide a lot of information that can help in diagnosis, such as how thick the endometrium is, whether there are any occupying lesions, whether there are myomas or adenomyosis in the muscular layer, whether the intrauterine device is ectopic, and whether there are abnormal masses in the area of the ovaries and fallopian tubes. If the urine pregnancy test is positive, ectopic pregnancy should be suspected if an abnormal mass is found outside the uterus without an intrauterine gestational sac.
Routine blood and coagulation tests are useful to understand the degree of anemia and to rule out coagulation disorders.
Colposcopy and hysteroscopy can be used to take biopsies of abnormalities in the cervix or uterine cavity to confirm the presence of lesions by pathological examination.
The above tests can help to rule out organic lesions before considering menstrual disorders due to endocrine abnormalities. Measuring and recording the basal body temperature every morning immediately after waking up can help to diagnose the type of menstrual disorder by taking venous blood at different times of the menstrual cycle to detect changes in endocrine hormone levels.
In conclusion, vaginal bleeding should not be taken lightly and there is no need to be overly alarmed. The diagnosis of the disease should be made on an individual basis, with each lesion being identified according to its degree of risk.