Chapter 36: Vaginal Bleeding Evaluation

Vaginal Bleeding Evaluation elucidates the critical role of the hypothalamic-pituitary-ovarian (HPO) axis in regulating the menstrual cycle and explains how systemic imbalances or immature axis function—common in adolescents and perimenopausal patients—can lead to anovulatory cycles and dysfunctional uterine bleeding. The diagnostic reasoning process is structured by age and reproductive status, prioritizing the exclusion of life-threatening emergencies such as hemodynamic instability and ruptured ectopic pregnancy. For patients of reproductive age, the text details various pregnancy complications, including spontaneous abortion (threatened, inevitable, incomplete, complete, and missed), placenta previa, and placenta abruptio, utilizing diagnostic tools like serial quantitative human chorionic gonadotropin (hCG) testing and transvaginal ultrasound. The chapter thoroughly examines organic and structural causes of abnormal bleeding, including uterine leiomyomas (fibroids), which often present as firm, irregular masses, and adenomyosis, characterized by a boggy, tender, and globally enlarged uterus. It also addresses malignant risks, specifically emphasizing the need to investigate postmenopausal bleeding via endometrial biopsy to rule out endometrial hyperplasia and cancer, particularly in the context of risk factors like obesity and unopposed estrogen therapy. Systemic etiologies are explored in depth, covering endocrine disorders such as Polycystic Ovary Syndrome (PCOS), thyroid dysfunction (hypothyroidism and hyperthyroidism), and hyperprolactinemia, as well as coagulation disorders like von Willebrand disease and leukemia that may present as heavy menstrual bleeding. Infectious causes, including Pelvic Inflammatory Disease (PID), endometritis, and cervicitis, are discussed alongside physical exam findings like cervical motion tenderness and discharge. The text further outlines the assessment of pediatric vaginal bleeding, considering causes such as foreign bodies, trauma, and urethral prolapse, while reviewing the impact of medications including contraceptives, anticoagulants, and tamoxifen.