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Abnormal vaginal bleeding

Abnormal vaginal bleeding is also known as menorrhagia. One in every twenty women (30-49 years of age) will visit the emergency room at some point in life due to abnormal vaginal bleeding.

Most females will get their menarche (first menstruation) between ten and thirteen years of age. At the beginning, menstruations will be irregular and there will generally be no ovulation. It will take a few years for the female body to prepare itself for ovulation and regular monthly menstruations.

The menstrual cycle is highly influenced by hormones. The most important hormones are estrogen, progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH).

Every menstrual cycle has four main stages: follicular, ovulation, secretory and menses. During the follicular stage, a high level of estrogen prepares the womb for the future implantation of an embryo. High estrogen levels will cause increased release of LH and FSH, which will facilitate the release of an egg cell – the ovulation stage. After ovulation, estrogen and progesterone will be produced and released with one major role, to keep the womb prepared for implantation. If the implantation doesn’t occur, then the last stage of the menstrual cycle will begin – menses. During menses, most females will lose 25-60 mL of blood.

Types Of bleeding

There are three main types of abnormal vaginal bleeding in non-pregnant woman: ovulatory, anovulatory and nonuterine bleeding.

  • Ovulatory abnormal bleeding

In the case of ovulatory bleeding, the patient will have regular menstruations but there will be abnormal bleeding, usually in the middle of the menstrual cycle (around the time of ovulation).

The most common cause of this type of abnormal bleeding is low estrogen levels. It can also occur in cases of infection, polyp, lacerations, or cancer.

  • Anovulatory abnormal bleeding

In this case, most patients will complain of irregular menstruations with painless and minimal bleeding. It is not a very common cause of bleeding. The most common causes are disorders of the hypothalamus-pituitary gland-ovary axis, which cause changes in hormone levels. It can also be caused by hormone intake, diseases of liver or kidneys, and polycystic ovary syndrome.

This type of bleeding may cause severe blood loss which can even lead to the need for a blood transfusion. Investigations are required in case that the bleeding doesn’t stop after nine days. It is very important to exclude coagulation problems.

Physical examination is usually normal and ultrasound and endometrial biopsy are required to establish the correct diagnosis. In most cases, contraceptive pills or estrogen provide good results in treatment.

  • Nonuterine abnormal bleeding

In the case of abnormal bleeding, it is very important to exclude nonuterine causes of bleeding. The most common causes of abnormal bleeding are problems with coagulation but it can also be caused by problems with the vagina, cervix, urinary tract or gastrointestinal tract. A detailed history and thorough physical examination are required to exclude nonuterine causes of bleeding.

Examination Of Patients With Abnormal Bleeding

It is very important to get a thorough history regarding the bleeding and sexual activities. The physical examination should include vital signs (blood pressure, pulse rate, temperature, respiration rate), abdominal examination, gynecologic examination, cultures, ultrasound, and laboratory tests which should include hormone levels.

Laboratory tests should include a pregnancy test, complete blood count, coagulation studies, thyroid stimulating hormone (TSH) level, prolactin level, LH, FSH, estrogen, progesterone.


Estrogen is the most commonly used to stop abnormal bleeding. Another option is contraceptive pills with a combination of estrogen and progesterone. Nonsteroid anti-inflammatory drugs (NSAIDs) can be used to stop the bleeding. Clomiphene citrate, Medroxyprogesterone acetate, danazol, Gonadotropin-release hormone agonists, and tranexamic acid are other options.

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