Abnormal Vaginal Bleeding

Abnormal vaginal bleeding (AVB) is defined as "any change in menstrual-period frequency or duration, or amount of flow, as well as bleeding between cycles" (1). AVB is also referred to as abnormal uterine bleeding. Women are often quite distressed and worried by the appearance of AVB and it is one of the most common reasons they consult a doctor. There are a number of causes for AVB, some of which are life threatening. Achieving a correct diagnosis, therefore, can be challenging. This article will focus on the causes and treatments of AVB in women who have reached puberty.

Causes

Commonly, AVB in pre/perimenopausal women is pregnancy-related bleeding. It can be an indication of miscarriage or ectopic pregnancy. If these complications occur before a woman is aware she is pregnant she will not identify the AVB as being pregnancy-related. Therefore, it is important that the possibility of pregnancy is discussed in an initial consultation.

AVB is also a common side effect of the oral contraceptive Pill, particularly in the first three months of use. Bleeding can occur if the hormone level is not high enough to keep the lining of the uterus (endometrium) stable or if a woman misses some of the pills, or the absorption is affected by drug interactions or vomiting/diarrhoea. This type of bleeding is referred to as 'break through bleeding'. If the break through bleeding continues (and is not caused by missed pills) a higher dose Pill can be prescribed. AVB can be a side effect of injectable contraceptives (eg. Depo-Provera) and implants (eg. Implanon).

Endocrine abnormalities can also be a cause of AVB. Women with hypothyroidism may experience heavy and/or long periods or, when more severe, a lack of periods (amenorrhea). Hyperthyroid women may find their periods become irregular, scanty, shorter or that they stop altogether. Similarly, Type 1 diabetes and polycystic ovary syndrome (PCOS) are other conditions that can contribute to changes in the normal menstrual cycle.

Medications like anticoagulants, some antidepressants, antipsychotics, corticosteroids and hormonal medications can also cause AVB. Non-prescription medications can play a role with some herbal supplements associated with AVB. For example, ginseng and soy supplements can result in elevated levels of oestrogen, resulting in AVB. Similarly, gingko can also lead to AVB.

AVB can occur as a result of coagulation disorders (eg. von Willebrand disease), genital tract infections (eg., sexually transmitted infection), ovarian cysts, polyps, fibroids, cancers of the genital tract, liver disease, hypertension and trauma to the genital area. Other factors which can impact on a woman's menstrual cycle include weight loss, eating disorders, stress, increased exercise and premature ovarian failure.

Diagnosis

As there are numerous causes for AVB it is vital that a thorough history taking is conducted. The doctor should start by asking the woman about her normal menstrual cycle and then what the abnormal uterine bleeding is like (When did it start? Is there any pattern to it? What is the colour of the blood? Are there any other accompanying symptoms like pain or cramping? Is it accompanied by any bladder/bowel symptoms? Is it associated with sexual penetration?). The doctor will also enquire about childbearing history, pregnancy termination, contraceptive use, sexual activity, existence of other health conditions and general well being (diet, stress levels, exercise, weight). Whether the woman is taking any medications, including complementary medicines should also be discussed. Other symptoms characteristic to particular conditions might also be noted at this time (eg. hirsutism, obesity - PCOS, palpitations - hyperthyroidism, jaundice - liver disease).

What diagnostic tests are performed will depend on the woman's symptoms, the length of time the symptoms have been present for, whether she is premenopausal, perimenopausal or postmenopausal and her risk factors for endometrial cancer. Risk factors for endometrial cancer include obesity, diabetes, no children, family history, tamoxifen therapy and, most importantly, age.

The doctor may carry out a pelvic examination. It allows them to visualise the cervix and palpitate the abdomen to check for uterus size and mobility and the presence of ovarian tumours and/or other growths. If the woman is at risk of sexually transmitted infections a cervical swab might be taken. A Pap smear may also be taken at this time. Blood tests may be ordered to help determine if a woman is ovulating and to check for other conditions like PCOS, insulin resistance, anemia, and thyroid and blood disorders.

Other diagnostic tests include transvaginal ultrasonography, saline infusion sonohysterography, endometrial biopsy and dilation and curettage (D & C) with/without hysteroscope.

References

1. Albers J A et al. Abnormal uterine bleeding Am Fam Physician 2004; 69:8:1915-26

Further help and information from Women's Health Queensland Wide

Health Information Line:
Our free statewide line is staffed by women's health nurses and midwives. They provide women with up to date information, support and referral to health practitioners and services. Women can contact the Health Information Line by phone or email via the 'Ask a Health Question' page on the website. All phone calls and emails are confidential.
(07) 3839 9988 or 1800 017 676 (toll free outside Brisbane)

Library:
Our free lending library offers a select range of books on major women's health topics. Topic-based booklists are availableon our website, or can be posted out; books can be requested by phone or email and are posted to borrowers. Contact on administration : (07) 3839 9962

Website:
All our factsheets and booklets are available on our website. The website also features articles on women's health from our newsletter, student factsheets, upcoming events, library services and 'Ask a Health Question' page. A list of reputable links is also available where women can search for further information on health topics.
www.womhealth.org.au

This article was originally written by Kirsten Braun and reviewed by the Editorial Committee for Health Journey, Vol II 2005. The article was abbreviated on October 28 2010.

Please note that this article is an archive. While every effort was made to ensure the information was accurate at the time of publication, the article has not been updated since this time. 

Last Modified: June 1, 2005