Vaginal Bleeding

Vaginal bleeding during menstruation is physiological and marks the shedding/ sloughing of uterine blood vessels (and endometrial layers) as a result of changes in the rhythm of major female hormones. Since menstrual bleeding is physiological; therefore no intervention is generally needed if flow is normal. However, there are a few situations when vaginal bleeding may pose a serious threat to the health of affected female.

Some examples of abnormal vaginal bleeding include:

• Vaginal bleeding between two menstrual cycles (also known as intermenstrual bleeding or spotting): This is a fairly common problem in adolescent females. Common causes of intermenstrual bleeding include, hormonal imbalance, endometrial polyp or uterine fibroids (non-cancerous, benign masses in the wall of endometrium of sexually active, premenopausal women), sexually transmitted infections (or infection in any other part of the female genital tract), vaginal dryness etc.
• Vaginal bleeding during pregnancy: Pregnancy marks the temporary cessation of monthly menstrual cycles. If you are experiencing vaginal bleeding, seek immediate medical help as it suggests endangered pregnancy (or impending abortion/ miscarriage)
• Vaginal bleeding after menopause: Menopause marks the permanent cessation of monthly menstrual cycles and is usually achieved by most females in mid-to late 50s. If you are experiencing vaginal bleeding after menopause; you should see a doctor to explore the possibility of an organic lesion (such as carcinoma).

What are the complications of poorly managed abnormal vaginal bleeding?

It is very important to take timely interventions if you are experiencing abnormal vaginal bleeding. For example:

• Blood loss anemia: Due to excessive blood flow during menstruation or between two cycles, affected female may develop anemia due to blood loss. In all such cases, treatment must be initiated to maintain normal circulatory pressure.
• High risk of miscarriage: The risk of miscarriage is almost inevitable if vaginal bleeding is not controlled during pregnancy. Rest, leg elevation, intake of warm fluids and restriction of excessive locomotion are some strategies that usually help in preventing miscarriage.
• Interference with fertility: If the cause of vaginal bleeding is an ongoing infection or a sexually transmitted disease, the risk of infertility increases several-fold.
• Unplanned pregnancy: Likewise, if you are experiencing an infection (marked by fever, rigors, chills, lower abdominal pain, changes in the gut functions etc.) due to a displaced IUD (intrauterine device); your chances of an unplanned

• pregnancy increases.

How to manage abnormal vaginal bleeding?

Abnormal vaginal bleeding is a serious gynecological issue that must be managed on emergent basis. It is however important to mention that all cases of vaginal bleeding are not serious.

The management options depend largely on several factors; such as:

• Age of the patient (pre-menopausal or post-menopausal)
• Nature of vaginal bleeding (intermittent/ continuous; moderate or severe etc.)
• Presence or absence of other serious symptoms
• Overall condition of the patient (stable or serious due to excessive blood loss)

Depending upon your history and findings of vaginal examination, your doctor may advice a variety of serological and radiological investigations (such as X-ray pelvis, Ultrasound abdomen/ pelvis and trans-vaginal ultrasound etc.)

Likewise based on the pathophysiology of vaginal bleeding, simple modifications in the lifestyle can help in addressing the symptoms (without needing any pharmacological or surgical solution). For example maintenance of normal body weight and healthy lifestyle via diet regulation and/or exercise can help in addressing vaginal bleeding due to polycystic ovarian disease.

Other therapeutic options include:

• Use of birth control pills or hormonal supplements to restore physiological/ biochemical hormonal balance. Likewise, estrogen creams are recommended if the cause of bleeding is vaginal thinning or dryness (as seen in most menopausal women).
• Assessment of overall health to diagnose other medical ailments such as malignancy or endometrial polyps. If vaginal bleeding is due to an organic lesion (such as cervical cancer or malignancy of any other part of female genital tract), surgical intervention is generally needed followed by chemotherapy.
• Re-assessment of drug history to rule out dose-dependent side effects of blood thinning medications.
• Antibiotics against sexually transmitted infections is generally recommended if vaginal bleeding is due to STDs. If the cause of infection is an infected/ displaced intrauterine device, your physician would perform removal of IUD (often in the OPD setting).

References

1. Deligeoroglou, E., Karountzos, V., & Creatsas, G. (2013). Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology. Gynecological Endocrinology, 29(1), 74-78.

2. Sweet, M. G., Schmidt-Dalton, T. A., Weiss, P. M., & Madsen, K. P. (2012). Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician, 85(1), 35-43.