One of the most common obstetric/gynaecological presentations in a hospital/GP setting is vaginal bleeding. When women present with per vaginal (PV) bleeding it is usually because the bleeding is unexpected, irregular, heavy or painful. Other common presentations alongside PV bleeding are pelvic pain, missed periods and vaginal discharge.

Women presenting with PV bleeding can present to their GPs, to A&E, gynaecology outpatient clinics, maternity triage and antenatal clinic visits. As a junior, you could be placed in any of these areas, so it is useful to know about vaginal bleeding.

Don’t forget, you always have the option to ask a senior or specialist clinician for advice on PV bleeding.

Initial review of a patient presenting with PV bleeding

• One of the most important and urgent questions to ask when reviewing a patient presenting with PV bleeding is:

Is the patient haemodynamically stable?

• If the patient is NOT haemodynamically stable, will they require resuscitation and possibly a major haemorrhage call put out?

You can ascertain this by doing a quick A to E assessment and within this looking at their blood pressure and pulse. If you are NOT happy at this stage, grab your team and start resuscitating the patient.

• Once you are happy that the patient is stable you can now begin to take a history.
• The first question you must ask is: Is this patient pregnant? This will inform your decision making about what to ask and do next.

History

As with all medicine, taking a thorough history is fundamental to arriving at the correct diagnosis. See Gynaecology Assessment & Common Disorders for more information.

Is this bleeding expected?

• Ask the patient when their last menstrual period (LMP) was to calculate if this could be expected bleeding? Try to establish their normal bleeding pattern e.g. how many days in-between each period and how long do they bleed for.
• When did the bleeding start? How many days have they been bleeding for?
• Is there any bleeding in between periods (intermenstrual bleeding), is there any bleeding after sexual intercourse (post coital bleeding), are they having bleeding after menopause (post-menopausal bleeding)?
• Have they missed any periods?

Heaviness

• How heavy is the bleeding?
• What colour is the bleeding – fresh red or dark brown?
• You can ask how many full pads they are changing in a day, whether they are using double protection (tampons and pads or 2 pads), if they are flooding (leaking through their underwear) and if they are passing large clots?
• If this is a presentation for menorrhagia: is this bleeding affecting their life? Do they take time off work or limit their daily activities?

Pain

• Do they have cyclical pain?
• Does the pain occur when they are on their period?
• Where is the pain and what helps with their pain?

Bleeding in pregnancy

• One of the most concerning presentations for women who are pregnant is PV bleeding.
• How many weeks pregnant are they?
• If they are pregnant, what is their Rhesus status?
• Has a pregnancy been confirmed with hCG and an ultrasound?
• Is the pregnancy in the correct place? ALWAYS consider if this could be an ectopic pregnancy.

Gynaecological history

• When did they start their periods (menarche)?
• Have they been investigated for abnormal bleeding before?
• Have they had any gynaecological surgery in the past?
• Are their smears up to date and normal?
• Any previous sexually transmitted infections and were they treated?

Obstetric history

• Is there any chance they could be pregnant now?
• Have they ever been pregnant in the past?
• Have they ever had a termination of pregnancy or miscarriage and how were these managed?
• Have they ever had an ante-partum or post-partum hemorrhage in any previous pregnancies?

Past medical history

• Thyroid disorders
• Coagulopathy,
• Pituitary issues
• Breast issues
• Anaemia.
• Any signs or symptoms of malignancy (weight loss, loss of appetite, night sweats).

Drug history

• Are they on any contraception/HRT?
• Are they taking any anticoagulants?

Social

• Smoking history
• How many units of alcohol they drink
• Occupation
• Living situation
• Exercise

Family history

• Do they have a family history of cancer?
• Do they have a family history of bleeding disorders?

Other things to consider and clarify with your patient

• Is this is definitely per-vaginal (PV) bleeding?
• It can often be difficult to distinguish whether it is definitely PV bleeding in certain patients, it will be important to clarify whether this could also be per-rectal (PR) bleeding (GI causes) or bleeding from the urinary tract (e.g. renal/ureteric stones).

Examination

• Abdominal examination – look for tenderness, peritonism & masses.
  • Consider PR examination if no cause of PV bleeding is found.
• Speculum
  • If bleeding: identify whether this is external, vaginal, cervical or uterine & the extent of blood. Inspect the cervical os – if she is pregnant; is it open?
• Bimanual examination – masses, adnexal tenderness, cervical excitation.

See Gynaecological Examination for more information.

Investigations

• Urine pregnancy test (hCG) or serum hCG to exclude pregnancy or to help with ectopic management.
• Swabs for STIs.
• Check for recent cervical screening results.
• Blood tests (FBC, Clotting, TFT, LFTs)
  • If unstable, with symptomatic anaemia, then you will need group & save and crossmatch.
  • If pregnant then you will always need a group and save.
• Transvaginal ultrasound as the first line of radiological investigations.

Differential diagnoses

• When seeing patients, it’s important to start thinking about the likely causes of PV bleeding in the patient’s age group? Is this patient pre- or post-menopausal?
• If post-menopausal, then vaginal bleeding is uterine cancer until proven otherwise.

Causes of post-menopausal bleeding

All cases of post-menopausal bleeding need to be discussed with the gynaecology team; usually via referral through rapid access clinic and TVUS to assess endometrial thickness.

Causes of pre-menopausal bleeding

If pre-menopausal, the mnemonic PALM-COEIN can often help with causes:

Conditions to consider when faced with pregnant patients

Pregnancy <12 weeks

• Ectopic pregnancy – anyone of child-bearing age (pre-menopausal) with abdominal pain and PV bleeding, you must rule out ectopic pregnancy.
• Early miscarriage.
• Retained products of conception – PV bleeding, fever, uterine tenderness or pelvic pain.

Pregnancy 12 to 20 weeks

• Could indicate a second trimester miscarriage.
• Always remember to check rhesus status and give Anti D if Rhesus negative.

Pregnancy more than 20 weeks

• Placental abruption – abdominal pain with dark vaginal bleeding, uterine contractions, uterine tenderness.
• Placenta previa – painless bright red vaginal bleeding. May have uterine contractions as well.
• Uterine rupture – previous C-section, sudden worsening of abdominal pain andhaemodynamic instability.

As a foundation doctor, you will NOT be the one expected to diagnose the condition, but merely keep the patient safe, manage their anaemia if they have lost a lot of blood, and refer to the relevant pathways. Relevant investigations are a bonus!

References

• UpToDate – Approach to the adult with vaginal bleeding in the emergency department
• The Physician Assistant Student’s Guide to the Clinical Year: OB/GYN
• Heavy periods – NHS (www.nhs.uk)
• Diagnosis | Menorrhagia | CKS | NICE
• Miscarriage | Health topics A to Z | CKS | NICE

Written by: Dr Ying Jin, FY1, General Surgery
Reviewed by Dr Alisa Jivraj GPST1 and Dr Aditi Naik O&G ST5
Edited by: Mudassar Khan (Y3 Medical Student)