As with most hemorrhages from body orifices, vaginal bleeding is best approached by the anatomic method. Thus, the important structures of the female genital tract are cross-indexed with etiologic categories as in Table 59. In all bleeding symptoms, one must include blood vessels and the blood as part of the anatomic breakdown. Histologic breakdown is of little importance anywhere except in the uterus, and in making certain that one does not forget the many types of ovarian tumors (e.g., fibromas, polycystic ovaries, corpus luteum, follicular cysts, and arrhenoblastoma). In the uterus, histology reminds one of endometriosis, adenomyosis, and fibroids.
Physiology should bring to mind the most common cause of uterine bleeding—dysfunctional bleeding. Thus, when the normal sequence of follicle-stimulating hormone (FSH) stimulating estrogen production and luteinizing hormone (LH) stimulating progesterone production from the corpus luteum is interrupted, by whatever cause, the resulting poorly formed endometrium will bleed at an inappropriate time (metrorrhagia) or excessively during the appropriate time (menorrhagia). Aside from the many neoplasms, cysts, and inflammatory conditions of the ovary (listed in Table 59), one must consider other endocrine disorders such as adrenal neoplasms, hyper- and hypothyroidism, hypopituitarism, and acromegaly.
Although the differential diagnosis is developed adequately in Table 59, a description of the most important causes is provided here. The most important vaginal conditions are a ruptured hymen, atrophic vaginitis, and carcinoma. Cervical carcinoma is the most important cause of bleeding of the cervix. Fibroids may be a more common cause of uterine bleeding than endometrial carcinoma, but both are superseded by pregnancy and dysfunctional uterine bleeding. Proceeding to the fallopian tubes, one must not forget ectopic pregnancy and pelvic inflammatory disease (PID) as causes of vaginal bleeding. Ovarian cysts and tumors are common causes of dysfunctional bleeding, but the serous cystadenoma and carcinomas present that way only infrequently.
Approach to the Diagnosis
The differential diagnosis of vaginal bleeding depends on the clinical picture. The most common cause of unexpected bleeding in all women is dysfunctional uterine bleeding due to imbalance of estrogen and progesterone during the menstrual cycle. Nevertheless, vaginal bleeding in a postmenopausal woman must be considered a malignancy until proven otherwise. An endometrial biopsy should be done. Vaginal bleeding in the prepubertal female should prompt an investigation for child abuse or incest as well as neoplasm. There is also the possibility of vaginal carcinoma due to diethylstilbestrol ingestion by the mother.
A careful vaginal examination with the patient fully relaxed is most important. A rectovaginal examination must be performed to palpate masses in the cul-de-sac. If an adequate vaginal examination is impossible (as in the case of obesity), then proceed with ultrasonography. Any vaginal discharge must be cultured for gonococci and Chlamydia organisms to rule out PID. A biopsy is done of any suspicious lesion of the vagina or cervix, and a Pap smear is performed. If the diagnosis is uncertain at this point, a gynecology consult is in order. A dilation and curettage (D&C) or endometrial biopsy must be done if uterine carcinoma is suspected. In women of childbearing age, a routine pregnancy test should be done, but if an ectopic pregnancy is suspected a serum radioimmunoassay (RIA) for the beta-human chorionic gonadotropin (β-hCG) subunit pregnancy test will be more definitive. Ultrasonography will often determine if a pelvic mass is an ectopic pregnancy. Ultrasonography will also be helpful in diagnosing ovarian cysts and tumors, but a computed tomography (CT) scan of the pelvis can be more definitive.
Dysfunctional uterine bleeding is most often physiologic. However, a granulosa cell tumor of the ovary can be the cause. Ultrasonography or a CT scan may be able to reveal such a tumor, but culdoscopy or laparoscopy may be required. If the dysfunctional bleeding is thought to be due to hypothyroidism or hyperthyroidism, a thyroid profile may be done. If it is believed to be due to a pituitary adenoma, a magnetic resonance imaging (MRI) of the brain and serum LH and FSH assays should be done. Anemia and systemic disease must be ruled out also (see tests listed below).
If pathologic causes of dysfunctional uterine bleeding are excluded, normal cyclic bleeding may be reestablished by a course of cyclic estrogen and progesterone or progesterone alone (a “medical D & C”). If this is unsuccessful, a surgical D&C is required.
Other Useful Tests
Complete blood count (CBC) (anemia)
Sedimentation rate (PID)
Venereal disease research laboratory (VDRL) test (chancre, gumma)
Tuberculin test (pelvic tuberculosis)
Coagulation profile (see page 423)
Antinuclear antibody (ANA) analysis (collagen disease)
Coombs test (lupus)
Serum estradiol and progesterone levels (ovarian cyst or tumor)
Urinary gonadotropins (choriocarcinoma)
Cancer antigen 125 (CA125) test (metastatic endometrial carcinoma)
Serum iron and ferritin (iron deficiency anemia)