Obstetrics & Gynaecology
A 56 year old woman presents to the Emergency Department with a 3 day history of vaginal bleeding. She has had 2 previous vaginal deliveries and tells you she experienced the menopause 4 years ago. Her observations are all within normal limits and her haemoglobin is normal. Which of the following management plans is most appropriate for this patient?
Answer:
Postmenopausal bleeding is always abnormal. Refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer if they are aged 55 years and over with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause). Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer in women aged under 55 years with post-menopausal bleeding.Vaginal Bleeding
Obstetrics & Gynaecology
Last Updated: 3rd February 2021
Causes of intermenstrual bleeding
- Physiological
- STIs with cervicitis
- Endometritis/PID
- Vaginal cancer
- Cervical cancer
- Cervical or endometrial polyps
- Cervical ectropion
- Uterine fibroids
- Endometrial polyps
- Endometrial cancer
- Adenomyosis
- Oestrogen-secreting ovarian cancers
- Breakthrough bleeding on hormonal contraceptives
- Hormonal fluctuation during the perimenopause
- PCOS
- Pregnancy-related causes, including ectopic pregnancy and gestational trophoblastic disease
Causes of postcoital bleeding
- STIs/PID with cervicitis
- Cervical ectropion
- Cervical or endometrial polyps
- Vaginal cancer
- Cervical cancer
- Endometrial cancer
- Trauma or sexual abuse
- Atrophic vaginitis
Causes of menorrhagia
- Dysfunctional uterine bleeding (DUB)
- Uterine fibroids
- Endometriosis/Adenomyosis
- PID/endometritis
- Endometrial polyps
- Endometrial hyperplasia/carcinoma
- Coagulation disorders (for example von Willebrand disease)
- Hypothyroidism
- Diabetes mellitus
- Hyperprolactinaemia
- Liver or renal disease
- Anticoagulant treatment
- Chemotherapy
- Herbal supplements (for example ginseng, ginkgo, and soya)
- Intrauterine contraceptive device
Causes of bleeding in pregnancy
- First trimester
- Spontaneous miscarriage
- Ectopic pregnancy
- Molar pregnancy
- Second trimester
- Spontaneous miscarriage
- Molar pregnancy
- Placental abruption
- Placenta praevia
- Third trimester
- Placental abruption
- Placenta praevia
- Vasa praevia
- Uterine rupture
Causes of postmenopausal bleeding
This is always abnormal. Refer women using a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer if they are aged 55 years and over with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause). Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for endometrial cancer in women aged under 55 years with post-menopausal bleeding.
- Atrophic vaginitis
- Endometrial atrophy
- Endometrial hyperplasia
- Endometrial polyps
- Endometrial cancer
- Uterine fibroids
- Cervical polyps
- Cervical cancer
- Ovarian cancer
- Vaginal cancer
- HRT
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
