Table of Contents

 

1. Abstract
2. Case Presentation
3. Introduction
4. Critical Appraisal Of The Literature
5. Etiology And Pathophysiology
   1. The PALM-COEIN Classification System
6. Differential Diagnosis
   1. Girls Aged 12 To 18 Years
   2. Women Aged 19 To 39 Years
   3. Women Aged 40 Years And Older
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Pregnancy Test
   2. Complete Blood Count
   3. Coagulation Studies
   4. Other Studies
   5. Imaging Studies
10. Treatment
    1. The Unstable Patient
    2. The Stable Patient
       1. Oral Contraceptive Pills
       2. Oral Progestin
       3. Nonsteroidal Anti-Inflammatory Drugs
       4. Antifibrinolytic Agents
       5. Iron
       6. Transfusion Of Packed Red Blood Cells
       7. Danazol
    3. Surgical Treatments
    4. Treatment Summary
11. Special Circumstances
    1. Prepubescent Children
       1. Causes Of Prepubertal Bleeding
          • Vaginitis
          • Foreign Bodies
          • Sexual Abuse
          • Tumors
          • Trauma
12. Controversies And Cutting Edge
13. Disposition
14. Summary
15. Risk Management Pitfalls For Vaginal Bleeding In Nonpregnant Patientssuch
16. Time- And Cost-Effective Strategies
17. Case Conclusion
18. Clinical Pathway For Vaginal Bleeding In Nonpregnant Patients
19. Tables and Figures
    1. Table 1. Differential Diagnosis Of Abnormal Uterine Bleeding In Nonpregnant Females
    2. Table 2. Pharmacologic Treatment Regimens For Acute Abnormal Uterine Bleeding
    3. Table 3. Potential Pathogens And Nonpathogenic Bacteria Isolated From Cultures In Prepubertal Girls
    4. Figure 1. Normal Menstrual Cycle
    5. Figure 2. PALM-COEIN Classification System
    6. Figure 3. The Bakri SOS Tamponade Balloon
    7. Figure 4. Proper Placement Of Uterine Tamponade Balloon
    8. Figure 5. Child In Knee-Chest Position
    9. Figure 6. Child In Frog-Leg Position
    10. Figure 7. American Academy Of Pediatrics Guidelines For The Evaluation Of Sexual Abuse In Children
20. References

Abstract

Abnormal uterine bleeding is the most common reason women seek gynecologic care, and many of these women present to an emergency department for evaluation. It is essential that emergency clinicians have a thorough understanding of the underlying physiology of the menstrual cycle to appropriately manage a nonpregnant woman with abnormal bleeding. Evidence to guide the management of nonpregnant patients with abnormal bleeding is limited, and recommendations are based mostly on expert opinion. This issue reviews common causes of abnormal bleeding, including anovulatory, ovulatory, and structural causes in both stable and unstable patients. The approach to abnormal bleeding in the prepubertal girl is also discussed. Emergency clinicians are encouraged to initiate treatment to temporize an acute bleeding episode until timely follow-up with a gynecologist can be obtained.

Key words: abnormal uterine bleeding, nonpregnant vaginal bleeding, heavy menstrual bleeding, prepubertal bleeding

Case Presentation

It’s the middle of a busy night shift in the ED, and a 23-year-old woman with vaginal bleeding has been waiting several hours to be seen. Her vital signs are normal. She has no past medical history and takes no medications. She states that she has been bleeding continuously for the past 2 weeks. Her menstrual periods have always been irregular, but she has never bled for this long. She describes the bleeding as heavy, sometimes with clots, and she is frequently changing her sanitary pad. A pregnancy test was ordered from triage and is negative. The patient is desperate for you to stop the bleeding, and you wonder if there is anything you can offer her besides a box of tampons and a gynecology referral….

As you walk out the room, the radio goes off and a panicked paramedic reports that they are en route with a 42-year-old woman who is having profuse vaginal bleeding and appears very ill. She is pale, tachycardic, and hypotensive. She has a history of fibroids. She has been bleeding heavily for 3 days, and the bleeding has acutely increased in the past few hours. The on-call gynecologist is delivering a baby at the hospital across town, and you will have to stabilize this patient and manage her on your own for a few hours….

Introduction

Abnormal uterine bleeding is the most common reason women seek gynecologic care,¹ and many of these women present to an emergency department (ED) for evaluation. Abnormal vaginal bleeding can be very distressing for a woman. At a minimum, it is an inconvenience that disrupts her daily life; in severe cases, bleeding can result in life-threatening hemorrhage requiring emergency intervention. Abnormal bleeding may also herald a serious underlying pathology such as cancer. Many women presenting to the ED for evaluation of vaginal bleeding fear that they are in the serious category, and the provider must be sensitive to her concerns. The role of the emergency clinician is to rule out life-threatening complications associated with abnormal uterine bleeding and to obtain emergent, urgent, or routine gynecologic consultation as needed. Emergency clinicians are often hesitant to initiate therapies to temporize a stable patient’s bleeding, instead deferring this to a gynecologist on an outpatient basis. The goal of this issue of Emergency Medicine Practice is to provide an evidence-based approach to the nonpregnant woman presenting with vaginal bleeding.

Critical Appraisal Of The Literature

A literature search was performed using PubMed, including the search terms menorrhagia, abnormal uterine bleeding, nonpregnant vaginal bleeding, dysfunctional uterine bleeding, and heavy menstrual bleeding.

The resulting 6000 abstracts were reviewed for applicability, and results were limited to the English language and to articles published in the last 20 years. Emphasis was placed on trials conducted in the ED or in the acute clinical setting. Additional references were identified by reviewing bibliographies of relevant articles. The Cochrane Database of Systematic Reviews was searched using the term heavy menstrual bleeding, yielding 41 results, 14 of which were applicable to this review. The National Guideline Clearinghouse (www.guideline.gov) was queried using the search term heavy menstrual bleeding. A total of 24 guidelines were found, 2 of which were applicable to this review.^2,3 Both of the guidelines were produced by the American College of Obstetricians and Gynecologists (ACOG). ACOG also recently released a Committee Opinion on the management of abnormal uterine bleeding, which is included in this review.⁴ There are currently no American College of Emergency Physicians (ACEP) clinical policies that apply to vaginal bleeding in the nonpregnant patient.

It is inherently difficult to form an evidencebased approach to guide the treatment of the nonpregnant patient with vaginal bleeding because high-quality evidence is currently lacking. Unfortunately, there are no large prospective randomized controlled trials, and we must rely on expert opinion, observational studies, and case reports for guidance. Of the few small randomized controlled trials that are available, there is great variability of outcomes across the studies, making comparisons of different interventions difficult.

Risk Management Pitfalls For Vaginal Bleeding In Nonpregnant Patientssuch

1. “The patient denied being sexually active, so I didn’t think I needed to do a pregnancy test.” All patients of reproductive age with vaginal bleeding must have a pregnancy test. Many patients participate in activities that they do not consider “sexual activity” but that may result in pregnancy. Vaginal bleeding in pregnancy can be life-threatening, as in the case of ectopic pregnancy, and cannot be missed.
2. “The patient was from a nursing home, and the caregiver had noted blood in the patient’s underwear when changing her. I performed a vaginal examination and didn’t see any bleeding, so I discharged her back to the nursing home.” Patients and caregivers often assume that blood seen in underwear or on a diaper is pelvic in origin, but this is not always the case. If no blood is found on pelvic examination, a rectal examination and hemoccult test of stool is indicated as well as urinalysis for hematuria.
3. “The patient said that oral contraceptive pills had helped stop a bleeding episode in the past, so I started her on an oral contraceptive pill taper even though she was 40 years old and smoked.” Use of estrogen-containing oral contraceptive pills increase the risk of developing thromboembolism, and they are contraindicated in women aged > 35 years who smoke.
4. “The 51-year-old patient had been having intermittent vaginal bleeding for the past few months. I told her it was likely the beginning of menopause and that she shouldn’t be concerned.” Anovulatory cycles are physiologic as a woman approaches menopause; however, perimenopausal and postmenopausal women with abnormal bleeding should be considered to have a malignancy until proven otherwise, and they should be referred to see a gynecologist as soon as possible.
5. “A mother brought her 5-month-old daughter in for vaginal bleeding. I found a foreign body which was the likely cause, so I discharged the patient after removing it.” Sexual abuse must always be considered when evaluating a young girl with vaginal bleeding. A 5-month-old child would be unable to insert a foreign body into her vagina on her own. In such cases, Child Protective Services should be contacted, and the patient should be admitted if a safe environment cannot be guaranteed.
6. “The child had a vulvar hematoma from a straddle injury. She said she didn’t have to urinate while in the ED, so I discharged her.” Patients with vulvar hematomas should demonstrate the ability to void while in the ED prior to discharge. If the patient is unable to urinate, a urinary catheter should be placed, and the patient may require admission.
7. “The vaginal laceration was deep and complex, but I thought I could repair it in the ED and avoid transferring the patient.” Deep or complex genital lacerations require evaluation by a gynecologist or surgeon, and they are usually repaired in an operating room where appropriate lighting and anesthesia can help visualize all injured structures. Incorrectly closed genital wounds place the woman at risk for continued pain, sexual dysfunction, and urinary or bowel incontinence.
8. “The patient said that the bleeding wasn’t heavy, so I didn’t think I needed to do a pelvic examination.” A pelvic examination is required for all patients complaining of vaginal bleeding. The provider must confirm that the bleeding is pelvic in origin and assess for trauma, masses, and signs of infection.
9. “The patient was taking warfarin, but she said her international normalized ratio (INR) had been checked recently and it was therapeutic, so I didn’t think I had to repeat it.” Any patient presenting with abnormal vaginal bleeding who is anticoagulated should have coagulation studies performed in the ED. Drugs such as warfarin interact with many different medicines and foods, and a patient’s INR can easily become supratherapeutic.
10. “Even though the patient was hypotensive and tachycardic when she checked in, she felt so much better after a few liters of intravenous fluid that I discharged her.” Any patient with bleeding requiring significant fluid resuscitation or blood products should be admitted for observation and gynecology consultation.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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3. No authors listed. ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115(1):206-218. (Practice guideline)
4. * American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 557: management of acute abnormal uterine bleeding in nonpregnant reproductiveaged women. Obstet Gynecol. 2013;121(4):891-896. (Practice guidelines)
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