Gynecology [VAG BLEEDING 1: INTRO]

Introduction and Age Differential 11 51

Vaginal bleeding should occur in reproductive aged females and
should be at regular intervals - 21-35 days between cycles. Premenstrual Reproductive Postmenopausal
Menarche occurs around age 11 and has some trouble getting
started (normal). Menopause is around 51 and has some trouble
Foreign Body (MC) Pregnancy (MC) Atrophy (MC)
turning off (normal). When bleeding is heavy (menorrhagia),
Sexual Abuse Anatomy Endometrial Ca
irregular (metrorrhagia), or occurs in either premenarchal or
Precocious Puberty DUB HRT
postmenopausal females there may be a problem.
Sarcoma Botyroides
Bleeding exists along an age spectrum, with the most common Speculum Exam UPT Endometrial
causes of bleeding differing in each age group. Sampling

In premenarchal girls who are bleeding suspect foreign bodies

(most common) and sexual abuse. These girls needs a speculum
exam, often under anesthesia. Premenarchal Girls Vaginal Bleeding: covered in Puberty

In a post menopausal woman bleeding is cancer until proven

otherwise, ruled out with endometrial sampling. It’s usually
NOT cancer - simple atrophy is the most common. Hormone Postmenopausal women: covered in Endometrial cancer
replacement therapy can also induce bleeding.

For the reproductive aged female with meno, metro, or

menometrorrhagia it is far more complicated; we will follow the
neumonic “PAD”: Pregnancy, Anatomy, Dysfunctional Uterine Pregnancy: Covered in Vaginal Bleeding Pregnancy
Bleeding. Start by ruling out pregnancy with a UPT. Anatomy: Covered in Vaginal Bleeding Anatomy
DUB/AUB: Covered in Vaginal Bleeding Anatomy
Acute Uterine Bleeding
Women bleed. Some women can bleed a lot. They soak tampons,
and this may lead to an anemia. Anemia of chronic blood loss
(effectively iron deficiency anemia) can be treated with iron
supplementation and then finding out what is causing the heavy
bleeding. That’s what the vaginal bleed lectures are about.

But if a woman comes in with heavy, life-threatening bleeding,

the treatment course is quite different. The treatment parallels a
GI bleed.

The primary goal is stability: 2 large bore IVs, intravenous fluid

bolus, type and cross, transfuse as needed. To turn off uterine
bleeding, IV estrogen is administered.

If IV estrogen cannot obtain control of the bleeding, surgical

intervention is required, and escalates in severity.

Intracavitary balloon tamponade applies pressure and is

temporizing. D&C doesn’t impact subsequent menses, and might
take care of the problem acutely. Uterine artery embolization
(or ligation) is used when a vascular pathology is suspected (like
AVM or fibroids), and Hysterectomy is definitive, but the most
aggressive.

Women should be discharged on iron and some sort of

suppressive therapy (like OCPs) if she kept her uterus.

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