EM@3AM: Vaginal Bleeding

Answer: For a pre-menopausal non-pregnant female with vaginal bleeding, the next steps may include a CBC and type & screen, STI testing, and/or a transvaginal ultrasound.

Epidemiology:

• Vaginal bleeding is a common concern seen in the emergency department.
• An estimated 5% of emergency department visits are for vaginal bleeding, with 1% of those caused by a life-threatening emergency.¹
• Almost one-third of all women will experience abnormal vaginal bleeding in their lifetime, and many will present to our emergency departments.²
• Vaginal bleeding can have a significant impact on our patients’ quality of life.^3,4

History:

• Quantity:
  • It is often difficult for patients to quantify this⁵
  • How long has the bleeding has been going on for?
  • How does it compare to a normal period?
• Timing:
  • Do they have heavy menstrual bleeding (can suggest a structural cause)?⁶
  • Or are they bleeding in between periods (which may suggest ovulatory dysfunction)?⁷
  • Last menstrual period?
• Associated pain
• Other bleeding history:
  • Personal or family history of easy bruising, epistaxis, gum bleeding to suggest an underlying coagulopathy?
• Symptomatic anemia:
  • Lightheadedness, syncope, chest pain, palpitations, or shortness of breath?
  • Have they needed a blood transfusion before?
• Sexual history:
  • Are they sexually active?
  • If so, have they been screened for STIs recently?
• Medications:
  • Blood thinners?
  • Hormonal contraception or recent plan B?
• Pregnancy:
  • Is there any chance they could be pregnant?
• Trauma:
  • Any inciting factors that preceded the bleeding such as sexual intercourse and/or manipulation?

Exam:

Equipment:

• A speculum
• Lubricant
• Scopettes
• Swabs to collect samples
• Extra pads for the patient once the exam is complete
• A bedpan if the patient’s bed does not have stirrups

Tips on troubleshooting the speculum exam:

• Communication:
  • Ask if they have had difficulty with speculum exams before.
  • Talk through each step as you perform it. ⁸
  • Use neutral language:⁹
    • “Let your knees fall to the side”
    • “Take some deep breaths”
    • Avoid colloquial phrases (“relax” or “open your legs”).
  • Obtain informed consent from your patient
  • Have a chaperone in the room to assist you. ¹⁰
• Lubricant: Apply a generous amount to the speculum to reduce discomfort.
• Positioning:¹¹
  • If using a bed with stirrups that allow for dorsal lithotomy:
    • Have the patient bring their buttocks to the edge of bed
    • “Like you’re about to fall off”
    • Then place each leg in a stirrup.
  • If only regular hospital beds are available:
    • A slanted bed pan can be placed under the patient’s bottom to mimic dorsal lithotomy.
    • Patient can bring their buttocks to the edge of the bedpan
    • Then have them drop their knees to the side.
• Visualize the introitus:
  • Use the index and middle finger of the non-dominant hand to spread the labia until the vaginal introitus is clearly visualized.
  • Hold this hand above at 11 and 1 o’clock to provide a clear view
  • Insert the speculum with your dominant hand.
• Posterior pressure:
  • The anterior wall of the vagina (which sits against the urethra) is much more sensitive than the posterior wall (which sits against the rectum). ¹²
  • Rest the speculum against the posterior wall to avoid anterior pressure.
• Follow the course of vagina and look for where tissue changes:
  • Pink rugated tissue of the vagina will start to change
  • Visualize the smooth rounded edges of the cervix.
• You may not be deep enough:
  • Sometimes we open the bills of the speculum prematurely.
  • If the tissue doesn’t appear to change, then close the bills and advance the speculum further.
• Adjust angle:
  • If your speculum and hand are flush against the perineum and no cervix is visualized, the speculum is likely underneath or on top of the cervix.
  • Close the bills, retract slightly, adjust the angle either up or down, advance, and open again.
• Visualizing structures:
  • Use a scopette to absorb blood if bleeding obscures your view
  • Note how much blood is in the vaginal vault and if it is dark (old blood) or bright (fresh blood).
  • Look for any masses or bleeding at the cervical os.
  • Examine the external genitalia and vaginal walls for evidence of trauma or lacerations
• Removal:
  • When the exam is complete, retract the speculum so that the cervix is no longer between the bills then close the bills.
  • Place your index and middle finger on the bills to ensure they remain closed as you remove the speculum.
  • The speculum has a tendency to open as it is removed from the vaginal vault and will hit the anterior wall of the vagina which can cause extreme discomfort to the patient.¹²

Differential:

Many emergency medicine resources cite the PALM COEIN mnemonic.⁶ However, the PALM COEIN system was developed by OB/GYNs to promote a standardized approach but does not translate well to our practice in the emergency department.

Instead, I’d like to propose an alternate framework geared towards the emergency medicine physician: the POSIT framework.

• The most important question for us is If a patient is pregnant and has vaginal bleeding we may consider the following items:
  • < 20 weeks:
    • Without a confirmed intrauterine pregnancy: an ectopic pregnancy until proven otherwise¹³
    • Threatened abortion
    • Spontaneous abortion (miscarriage)
    • Retained products of conception
  • > 20 weeks:
    • Placenta previa
    • Placental abruption
    • Uterine rupture

• If our patient’s pregnancy test is negative, the other causes we can consider are as follows:
• Ovulatory dysfunction: This typically presents as intermenstrual bleeding, or bleeding between periods.
  • Estrogen is the brick that builds up the endometrial wall and progesterone is the mortar that holds it together. ⁷
  • When these hormones are out of balance due to ovulatory dysfunction, the endometrial lining will shed unpredictably.
  • Causes of anovulation include⁷:
    • Physiologic:
      • Pre-menstrual
      • Peri-menopause
    • Hyperandrogenic:
      • Polycystic ovary syndrome
    • Central:
      • Hyperthyroidism
      • Hypothyroidism
      • Anorexia
      • Too much exercise (can suppress gonadotropin releasing hormone)
    • Iatrogenic:
      • Emergency contraception, birth control pills, and hormone-releasing IUDs and implants exert their contraceptive effect by disrupting the ovulatory cycle.

• Structural⁴:
  • All structural causes can initially be evaluated with a transvaginal ultrasound:
    • Polyps
    • Adenomyosis
    • Leiomyoma (fibroids)
    • Malignancy
      • Postmenopausal vaginal bleeding is malignancy until proven otherwise¹⁴, so follow up is especially important for these patients.

• Infection: Bleeding is not the typical presentation¹⁵, but sexually transmitted infections are quite common.
  • Evaluate patient’s risk for STIs on history
  • Perform a speculum exam to evaluate for signs like cervical motion tenderness, a friable cervix, or purulent discharge.

• Trauma: Any lacerations or trauma to the external genitalia or vagina can result in bleeding.
  • If there is evidence of trauma, consider sexual assault and evaluate patient appropriately.¹⁶
  • Consider consulting social work to ensure these patients have a safe discharge.

Evaluation:

As noted above, the workup for non-pregnant vaginal bleeding includes:

• Urine pregnancy
• Speculum exam
• CBC + type & screen
• Transvaginal ultrasound
• STI screening

Treatment:

• Treating the underlying cause of vaginal bleeding
• For patients who want symptomatic treatment to regulate the bleeding, we can offer medical management⁴. Medroxyprogesterone will stabilize the uterine lining until a patient can follow up with OB/GYN.
  • A reasonable starting dose is 10mg TID x 7 days and then 10mg daily until the patient sees their OB/GYN.
  • Contraindications to medroxyprogesterone include known or suspected cancer, history of DVT/PE/ischemic stroke/MI, or known liver disease.
  • Counsel patients that they may experience some withdrawal or breakthrough bleeding if they miss doses
• Combined oral contraceptives can also provide relief
  • Exercise caution when prescribing an estrogen to patients with a history of smoking, hypercoagulability, or who are over the age of 35 as it can increase the risk for malignancy.
• NSAIDs can reduce bleeding by interrupting the prostaglandin pathway.¹⁷

Disposition:

• If vital signs and labs are normal, discharge home and arrange for OB/GYN follow up.

Pearls:

• Have a focused, EM-based approach for stable, non-pregnant vaginal bleeding by considering POSIT: pregnancy, ovulatory dysfunction, structural causes, infection, and trauma.
• Adequate visualization on speculum examination is aided by proper setup (equipment, patient positioning), and taking a patient-centered approach.
• Assess the underlying cause of the vaginal bleeding when possible in the emergency department and provide symptomatic treatment for patients who want it.

References: 

1. Abbas T, Husain A. Emergency department management of abnormal uterine bleeding in the nonpregnant patient. Emerg Med Pract. 2021;23(8):1-20.
2. Liu Z, Doan QV, Blumenthal P, Dubois RW. A Systematic Review Evaluating Health-Related Quality of Life, Work Impairment, and Health-Care Costs and Utilization in Abnormal Uterine Bleeding. Value in Health. 2007;10(3):183-194. doi:10.1111/j.1524-4733.2007.00168.x
3. Kabra R, Fisher M. Abnormal uterine bleeding in adolescents. Current Problems in Pediatric and Adolescent Health Care. 2022;52(5):101185. doi:10.1016/j.cppeds.2022.101185
4. Matteson KA, Rahn DD, Wheeler TL, et al. Nonsurgical Management of Heavy Menstrual Bleeding: A Systematic Review. Obstetrics & Gynecology. 2013;121(3):632-643. doi:10.1097/AOG.0b013e3182839e0e
5. Warner PE, Critchley HOD, Lumsden MA, Campbell-Brown M, Douglas A, Murray GD. Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. American Journal of Obstetrics and Gynecology. 2004;190(5):1216-1223. doi:10.1016/j.ajog.2003.11.015
6. Munro MG, Critchley HOD, Broder MS, Fraser IS, for the FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynecology & Obstetrics. 2011;113(1):3-13. doi:10.1016/j.ijgo.2010.11.011
7. Steinhauer J. Too much, too little, too late: Abnormal uterine bleeding. Presented at: July 2015; University of California San Francisco School of Medicine, San Francisco, CA.
8. O’Laughlin DJ, Strelow B, Fellows N, et al. Addressing Anxiety and Fear during the Female Pelvic Examination. J Prim Care Community Health. 2021;12:215013272199219. doi:10.1177/2150132721992195
9. Owens L, Terrell S, Low LK, et al. Universal precautions: the case for consistently trauma-informed reproductive healthcare. American Journal of Obstetrics and Gynecology. 2022;226(5):671-677. doi:10.1016/j.ajog.2021.08.012
10. Fiddes P, Scott A, Fletcher J, Glasier A. Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers. Contraception. 2003;67(4):313-317. doi:10.1016/S0010-7824(02)00540-1
11. Williams AA, Williams M. A Guide to Performing Pelvic Speculum Exams: A Patient-Centered Approach to Reducing Iatrogenic Effects. Teaching and Learning in Medicine. 2013;25(4):383-391. doi:10.1080/10401334.2013.827969
12. Lin M. Trick of the Trade: No Pelvic Bed, No Problem. Academic Life in Emergency Medicine. Published March 23, 2016. https://www.aliem.com/trick-of-trade-no-pelvic-bed-no-problem/
13. Simon E. EM@3AM – Ectopic Pregnancy. emDocs. Published August 19, 2017. http://www.emdocs.net/em3am-ectopic-pregnancy/
14. Bengtsen MB, Veres K, Nørgaard M. First-time postmenopausal bleeding as a clinical marker of long-term cancer risk: A Danish Nationwide Cohort Study. Br J Cancer. 2020;122(3):445-451. doi:10.1038/s41416-019-0668-2
15. Yaşa C, Güngör Uğurlucan F. Approach to Abnormal Uterine Bleeding in Adolescents. Jcrpe. 2020;12(1):1-6. doi:10.4274/jcrpe.galenos.2019.2019.S0200
16. Simon E. Managing Sexual Assault in the Emergency Department. emDocs. Published November 28, 2016. https://www.emdocs.net/managing-sexual-assault-emergency-department/
17. Bofill Rodriguez M, Lethaby A, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Gynaecology and Fertility Group, ed. Cochrane Database of Systematic Reviews. 2019;2019(9). doi:10.1002/14651858.CD000400.pub4