Some Causes of Vaginal Bleeding in Nonpregnant Women
Cause | Common Features* | Diagnostic Approach |
|---|---|---|
During the childbearing years | ||
Hormonal imbalance (ovulatory dysfunction) | Usually irregular menstrual periods Sometimes bleeding that lasts longer or is heavier than typical menstrual periods | Tests to rule out other possible causes, including blood tests and usually transvaginal ultrasound (the ultrasound device is inserted in the vagina) |
Fibroids (masses in the muscle layer of the uterus) | Often no symptoms With large fibroids, sometimes pain, pressure, or a feeling of heaviness in the pelvic area | Transvaginal ultrasound Sometimes sonohysterography (ultrasound after fluid is injected into the uterus) MRI, if ultrasound results are inconclusive |
A slow heart rate Weight gain Intolerance of cold Dry and coarse skin Coarse facial features and dullness of facial expression Sluggishness | Blood tests to measure thyroid hormone levels | |
Gestational trophoblastic disease (growth of abnormal tissue in the placenta related to a pregnancy) | Severe nausea and vomiting An abdomen that becomes larger much faster than it does in a normal pregnancy | A pregnancy test Transvaginal ultrasound |
Irregular or no menstrual periods Excess body hair (hirsutism) and/or acne Sometimes obesity Sometimes darkened and thickened skin in the underarm, on the nape of the neck, and in skinfolds | Blood tests to measure levels of hormones, such as dehydroepiandrosterone sulfate (DHEAS) and testosterone Transvaginal ultrasound | |
Polyps of the cervix or uterus | Sometimes no symptoms Bleeding that occurs between menstrual periods or after sexual intercourse | Sometimes transvaginal ultrasound, sonohysterography, or hysteroscopy (insertion of a viewing tube through the vagina to view inside the uterus) Sometimes evaluation under a microscope of the polyp to check for cancer (after a procedure to remove the polyp) |
Complications due to an unrecognized pregnancy
| Sharp or crampy pelvic pain or low back pain Sometimes passage of tissue through the vagina (usually occurs in a miscarriage) If an ectopic pregnancy ruptures, constant severe pelvic pain and sometimes light-headedness, fainting, or dangerously low blood pressure (shock) | A pregnancy test Transvaginal ultrasound Sometimes for a suspected ectopic pregnancy, laparoscopy (insertion of a thin viewing tube into the abdomen) or laparotomy (a large incision into the abdomen enabling doctors to directly view organs) |
Spotting or bleeding between periods (breakthrough bleeding) usually during the first months that oral or other hormonal contraceptives are used | Often no other symptoms | Sometimes transvaginal ultrasound to rule out other causes |
After menopause | ||
Thinning of the lining of the vagina† | Vaginal dryness Pain during sexual intercourse | Examination under a microscope and analysis of a sample of vaginal discharge |
Thickening of the lining of the uterus (endometrial hyperplasia) or cancer of the lining of the uterus (endometrium) | Often no other symptoms Sometimes new onset of vaginal bleeding | Sometimes transvaginal ultrasound, sonohysterography, or hysteroscopy Biopsy of tissue taken from the lining of the uterus |
Often no other symptoms until the cancer is advanced Sometimes vaginal bleeding (often after vaginal sex) or a brown or bloody vaginal discharge Pelvic pain that develops gradually Sometimes weight loss | Pap test Colposcopy (examination of the cervix under a microscope, often with biopsy of the cervix) Sometimes imaging of the pelvis such as ultrasound or CT scan | |
At any age | ||
Bleeding disorders due to medications, liver disorders, or hereditary disorders (such as von Willebrand disease) | Easy bruising Excessive bleeding during toothbrushing or after minor cuts A rash of tiny reddish purple dots (petechiae) or larger splotches (purpura), indicating bleeding in the skin | A complete blood cell count, including the number of platelets Blood tests to assess the blood’s ability to clot |
Injury (including that resulting from sexual abuse) | Sometimes a history of injuries Often vaginal discharge | Sometimes a doctor's examination alone If sexual abuse is suspected:
|
* Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present. | ||
† Thinning of the lining of the vagina is part of the genitourinary syndrome of menopause, which also includes pain during sexual intercourse, urinary urgency, and urinary tract infections. | ||
CT = computed tomography; MRI = magnetic resonance imaging. | ||