VAGINAL BLEEDING
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.
VAGINAL BLEEDING
|
| V | I | N | D |
|
| Vascular | Inflammatory | Neoplasm | Degenerative or |
|
| | | | Deficiency |
|
|
Introitus |
Varicosities |
Syphilitic ulcer Wart |
Granulomatous polyp |
|
Vagina |
| Vaginitis |
Carcinoma Extension of rectal carcinoma |
Atrophic vaginitis |
|
Cervix |
|
Chronic cervicitis Herpes |
Carcinoma Polyp |
|
Uterus |
|
Endometritis |
Endometriosis Carcinoma
Polyps Fibroids
Pregnancy |
Menopause Scurvy
Vitamin K deficiency |
|
Fallopian Tubes |
|
Pelvic inflammatory disease |
Ectopic pregnancy |
|
Ovaries |
|
Oophoritis Tuberculosis | Carcinoma and adenoma Corpus luteum
cyst |
|
Blood Vessels and Blood |
|
|
Leukemia |
Anemia Aplastic anemia |
| |
| |
|
Others |
|
|
Hydatidiform mole |
|
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 superceded 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.
Vaginal bleeding in the prepubertal female should prompt an investigation
for child abuse or incest as well as neoplasm.
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. 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 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.
HEMATURIA
|
| I
| C
| A
| T
| E |
|
| Intoxication
| Congenital
| Allergic or Autoimmune
| Trauma
| Endocrine |
|
| | Malformation |
| | Disorders |
|
|
|
| |
Intercourse Trauma to hymen |
|
| | | |
Foreign body |
| |
| |
|
|
|
Placenta previa |
|
Laceration |
| |
|
| Birth control pills Estrogens and other
hormones |
Anteversion of uterus Retroversion or flexion
of uterus | Idiopathic thrombocytopenic purpura |
Foreign body Abortion, induced |
Menopause Dysfunctional bleeding
Abruptio placenta |
| |
| |
|
| |
|
|
|
| | |
Hypopituitarism Hypothyroidism
Stein–Leventhal ovaries |
|
|
Toxic suppression of platelets Heparin Warfarin |
|
Lupus erythematosus |
Surgery |
|
|
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
- 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)
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Bleeding after sex
Read excerpts from these other book chapters related to Bleeding after sex:
Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
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