Abnormal Vaginal Bleeding
During the reproductive years, bleeding from the vagina may be abnormal when menstrual periods are too heavy or too light, last too long, occur too frequently, or are irregular. Any vaginal bleeding that occurs before puberty or after menopause is abnormal. Bleeding from the vagina may originate in the vagina or other reproductive organs, particularly the uterus.
Many disorders, including inflammation, infection, and cancer, can cause bleeding from the vagina. Injuries, including that due to sexual abuse, can also cause bleeding. The cause may be hormonal changes, resulting in a type of bleeding called dysfunctional uterine bleeding. Some causes are more common among certain age groups.
In children, vaginal bleeding is rare and should be evaluated by a doctor. The most common cause is injury to the vulva or vagina (sometimes due to insertion of an object, such as a toy). Vaginal bleeding may also result from prolapse of the urethra (in which the urethra bulges outside of the body) or tumors of the reproductive tract. Tumors of the ovaries usually cause bleeding only if they produce hormones. Bleeding may also be caused by vaginal adenosis (overgrowth of glandular tissue in the vagina). Having vaginal adenosis increases the risk of developing clear cell adenocarcinoma (a cancer of the cervix and vagina) later in life.
Bleeding in children may also result from puberty that starts very early (precocious puberty (see Section 23, Chapter 271)). This cause can be easily recognized because pubic hair and breasts also develop.
In women of reproductive age, abnormal bleeding may be caused by birth control methods, such as oral contraceptives (a combination of a progestin and estrogen or a progestin alone) or an intrauterine device (IUD). Abnormal bleeding may also be caused by complications of pregnancy, such as an ectopic pregnancy, or by infections of the uterus, usually after delivery of a baby or an abortion.
Other causes of bleeding include blood disorders involving abnormal clotting (such as leukemia or a low platelet count), a hydatidiform mole, endometriosis, and noncancerous growths (such as adenomyosis, fibroids, cysts, and polyps). Cancer may cause bleeding in women of reproductive age, but not commonly. Bleeding from the vulva is usually due to injury. Thyroid disorders can cause menstrual periods to be irregular, to be heavy and occur more frequently, or to occur less frequently (as well as to stop).
In postmenopausal women, bleeding from the vagina may be due to thinning of the lining of the vagina (atrophic vaginitis), thinning or thickening (hyperplasia) of the lining of the uterus, or polyps in the uterus. Cancer, such as cancer of the cervix, vagina, or lining of the uterus (endometrial cancer) can also cause bleeding.
Diagnosis and Treatment
The cause of abnormal bleeding may be suggested by symptoms and the results of a physical examination (including a pelvic examination). But additional procedures may be needed. If doctors suspect vaginal adenosis, a biopsy of the vagina is performed. Usually, women who have abnormal bleeding from the vagina, particularly after menopause, are evaluated to determine whether they have cancer of the vagina, cervix, or lining of the uterus (see Section 22, Chapter 252). Procedures may include a Papanicolaou (Pap) test, a biopsy of the cervix, and dilation and curettage (D and C). Ultrasonography using an ultrasound device inserted through the vagina into the uterus (transvaginal ultrasonography) can determine whether the uterine lining is thickened. A biopsy of cells obtained during dilation and curettage can determine if the thickening is due to cancer.
Treatment varies, depending on the cause. Usually, a girl who has vaginal adenosis does not need to be treated unless cancer is detected. However, she is reexamined at regular intervals for signs of cancer. Uterine polyps, fibroids, and cancers may be surgically removed.
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