Remote Primary Health Care Manuals

Abnormal vaginal bleeding in non-pregnant women

  • Bleeding from
    • Uterus endometrium or uterine lining that is not a normal period
    • Cervix or vagina — always abnormal
  • Includes
    • Bleeding between periods
    • Bleeding after sex
    • Spotting any time in menstrual cycle
    • Heavier bleeding at period or bleeding for more days than normal
    • Bleeding after menopause
    • Cycles longer than 35 days or shorter than 21 days — usually abnormal
  • Normal periods usually have regular pattern and blood loss
  • No periods for 3–6 months abnormal
  • Bleeding from vulva, urinary tract, bowel, perineum can be mistaken for vaginal bleeding
Red Flags — Urgent Medical Consult
  • Bleeding between periods, after sex or after menopause 
  • Shock or torrential bleeding — see Vaginal bleeding
  • Heavy bleeding lasting 7 days or more
  • Heavy bright red bleeding with large clots — see Vaginal bleeding
  • Hb less than 100g/L
  • Fever or abdominal tenderness/rebound
  • Pain not controlled with paracetamol
  • Genital tract injury
  • If given birth less than 6 weeks ago or recent termination of pregnancy — see Secondary postpartum haemorrhage

Causes of abnormal vaginal bleeding (non-pregnant)

  • Uterus
    • Hormone problems causing irregular ovulation and irregular periods
    • Young women soon after menarche (starting periods)
    • Older women approaching menopause
    • Endocrine disorders (eg PCOS)
    • Medicines — MRT, hormonal contraception
    • Infections — STIs, PID, endometritis after childbirth, or surgery on uterus (eg termination of pregnancy, D&C)
    • Inflammation (eg foreign body, intrauterine device IUD)
    • Structural abnormalities (eg fibroids, endometrial polyps, adenomyosis)
    • Medical problems (eg blood clotting problems)
    • Endometrial cancer — more common in over 40 years, obesity and PCOS risk factors
  • Cervix — inflammation, STI, polyps, cancer
  • Vagina — inflammation, tumours, trauma
  • Genital tract injury

Assessing abnormal bleeding

Do first

If life-threatening bleeding — urgent medical consult, see Heavy vaginal bleeding straight away

  • Check for signs of shock
    • Increased RR
    • Pulse weak and fast (more than 100bpm) or difficult to feel
    • Central capillary refill longer than 2 seconds
    • Pale, cool, moist skin
    • Restless, confused, drowsy, occasionally unconscious
    • Low BP for age or relative to person's previously recorded values
  • Do urine pregnancy test if
    • Woman of child-bearing age
    • Any doubt that older woman is postmenopausal
    • If test positive — see Bleeding in pregnancy

Ask

  • Pattern of bleeding — heavy bleeding, bleeding between periods, irregular bleeding, bleeding after sex
  • Medical history or check file notes
    • Cervical screening history
    • Last mammogram and breast check
    • Obstetric history
    • Serious medical problems — cancer, diabetes, thyroid problems, blood clotting problems, liver disease
    • Previous period problems, bleeding after surgery or dental extractions, postpartum haemorrhage, nose bleeds, bruising
    • Contraception — especially oral contraceptive pill, Depo-Provera, contraceptive/ENG-implant, intrauterine device IUD
    • Previous contraceptive use — could contraceptive implant or IUD have been left in
    • Other medicines — especially blood thinners and MRT
  • Menarche (age periods started)
  • Last period — how long ago, was it normal (eg right time, usual amount of bleeding)
  • Usual menstrual cycle — time between periods, length of bleeding, how much blood (number of pads or tampons, soaking through clothes or bedding, passing clots)
  • Changes in usual pattern of bleeding (eg spotting, between periods, after sex)
  • Pain with bleeding — where, when, how severe
  • If pain or heavy bleeding — ask about genital injury (eg sexual assault)
  • Last unprotected sex
  • Anaemia symptoms — tiredness, weakness, breathlessness
  • Urine symptoms — especially blood in urine
  • Bowel problems — constipation, diarrhoea, change in habit, blood in faeces

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 

Do

  • POC Tests — Hb
  • U/A — pregnancy test, urine MC&S
  • Head-to-toe exam — with attention to
    • Arms — check for contraceptive implant
    • Abdomen — feel for tenderness, rebound, guarding
    • Perineum — carefully check for bleeding site
  • If woman has ever had sex — speculum examination if trained
    • Inspect vagina and cervix for bleeding site
    • Do cervical screening if due — even if bleeding
    • If bleeding after sex, in-between normal periods or woman postmenopausal — collect cervical sample for HPV+LBC co-test
    • Swabs for STI check – woman, young person
    • Check for IUD strings
    • Bimanual examination, if skilled
  • If speculum examination not appropriate — collect low vaginal swabs for STI check
  • If heavy bleeding and history of bleeding problems — take blood for FBC, liver function test, thyroid function test, clotting studies (INR/APTT)
  • If irregular periods — take blood for PCOS
  • If not sure woman postmenopausal — take blood for FSH and LH, oestradiol
  • Medical consult if
    • Bleeding from site other than uterus
    • Bleeding after menopause
  • Talk with doctor about need for pelvic ultrasound
    • Transvaginal preferred — gives clearer picture

Follow-up

  • If abnormal uterine bleeding — ask woman to keep a bleeding chart (record of bleeding episodes)
    • Medical consult with results for diagnosis and management plan
  • Woman with persistent bleeding after sex, bleeding in between periods or bleeding after menopause could have cervical cancer
    • Refer to gynaecologist and for colposcopy even if HPV+LBC co-test negative
    • Woman with only 1 episode of bleeding after sex doesn't need to see gynaecologist especially if cervix looks normal and HPV+LBC co-test negative
  • All postmenopausal bleeding after amenorrhoea (12 months of no periods in woman of menopausal age) needs to be investigated
    • Bleeding from genital tract (uterus, cervix, vagina) in postmenopausal woman must be investigated to exclude endometrial or cervical cancer
  • Women over 40 with abnormal bleeding have increased risk of endometrial and cervical cancer and will need
    • HPV+LBC co-test
    • Referral to a gynaecologist
    • Pelvic ultrasound (if cervix normal)
    • Hysteroscopy​ (operation to look inside uterus) and D&C (scrape inside wall of uterus) OR endometrial biopsy — small piece of tissue from inside uterus taken to check for cancer