Vaginal Bleeding

An overarching framework for the clinical approach to abnormal vaginal bleeding across the reproductive lifespan.

It encompasses bleeding occurring outside the context of pregnancy (addressed with age-stratified consideration spanning prepubertal, reproductive-age, and postmenopausal bleeding) and bleeding occurring during pregnancy (addressed with specific reference to the relevant trimester and underlying differential diagnosis).

This entry provides the essential diagnostic framework complementing the more detailed, condition-specific entries addressed under dysmenorrhoea, the menstrual cycle, menopause, and the various specific gynaecological and obstetric conditions addressed throughout this Atlas.

Age-stratified and context-specific differential diagnosis

• Prepubertal vaginal bleeding is always abnormal and warrants prompt, thorough evaluation. Relevant causes include precocious puberty, vulvovaginitis, a vaginal foreign body, trauma, and, rarely, a genital tract tumour. Trauma requires careful, sensitive consideration of possible sexual abuse.
• Reproductive-age abnormal uterine bleeding has a broad range of causes, conventionally organised using the PALM-COEIN classification system. Structural causes are polyp, adenomyosis, leiomyoma, and malignancy/hyperplasia. Non-structural causes are coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified.
• Pregnancy-related causes require essential, first-line exclusion in any woman of reproductive age presenting with abnormal bleeding.
• Postmenopausal bleeding is always abnormal and warrants prompt evaluation to exclude endometrial malignancy. This is the single most important, essential diagnosis to actively consider and exclude in this age group and clinical context.
• Substantially more common, benign causes (including endometrial or vaginal atrophy) account for the majority of postmenopausal bleeding presentations.
• Bleeding in early pregnancy encompasses miscarriage, ectopic pregnancy, and, less commonly, molar pregnancy. Bleeding in later pregnancy encompasses placenta praevia and placental abruption.
• The essential, immediate priority in any pregnant woman presenting with vaginal bleeding is prompt assessment of maternal and, where relevant to gestational age, fetal wellbeing, alongside diagnostic evaluation of the specific underlying cause.

• Careful characterisation of the specific bleeding pattern provides essential diagnostic guidance directly relevant to the likely underlying cause. Assess timing relative to the menstrual cycle (where relevant), volume, duration, and any associated symptoms.
• Associated pain may suggest a specific underlying cause. In the pregnant context this includes ectopic pregnancy or miscarriage; in the non-pregnant context, dysmenorrhoea-associated pathology.
• A full menstrual, obstetric, sexual, and contraceptive history, together with relevant medication history (including anticoagulant use and hormonal medication), forms an essential foundation of assessment across the full range of presenting contexts.
• Signs of haemodynamic compromise, including tachycardia and hypotension, warrant immediate, urgent assessment and resuscitation regardless of the specific underlying cause or clinical context. There is potential for significant, ongoing blood loss from a range of underlying causes across this broad differential diagnosis.
• The specific pattern and context of the presentation, together with the woman's age and relevant reproductive status, directly informs the appropriate, structured diagnostic evaluation pathway, following the age-stratified and context-specific framework.

• Pregnancy testing represents an essential, first-line investigation in any woman of reproductive age presenting with abnormal vaginal bleeding. It directs subsequent diagnostic evaluation toward either the pregnancy-related or non-pregnancy-related differential diagnosis pathway.
• Full pelvic examination forms an essential component of assessment across the great majority of presenting contexts. It includes speculum examination (assessing for any visible cervical or vaginal pathology, and confirming the source of bleeding as genital tract in origin) and bimanual examination, together with cervical screening where relevant and not recently performed.
• Pelvic ultrasound represents a valuable, frequently essential investigation across numerous presenting contexts. It supports assessment for structural pathology (including fibroids, polyps, and adnexal masses) and confirmation and characterisation of pregnancy location and viability where relevant. It also assesses endometrial thickness, particularly relevant to the evaluation of postmenopausal bleeding.
• Endometrial biopsy or sampling represents an essential component of evaluation for postmenopausal bleeding and for abnormal uterine bleeding in reproductive-age women with relevant risk factors for endometrial pathology.
• Full laboratory investigation includes full blood count (assessing for anaemia related to significant or prolonged bleeding). Where clinically indicated by the specific presentation and history, add coagulation studies and thyroid function testing. These support evaluation of relevant non-structural contributing causes.

• Management is directed entirely according to the specific underlying diagnosis identified through the structured, context-specific diagnostic approach, following the detailed, condition-specific principles addressed under the relevant individual conditions throughout this Atlas.
• Immediate resuscitation and stabilisation takes priority in any presentation with significant, ongoing bleeding and associated haemodynamic compromise, regardless of the specific underlying cause, with definitive management of the underlying cause proceeding once initial stabilisation has been achieved.
• Any pregnant woman presenting with vaginal bleeding requires prompt, full assessment of both maternal and, where relevant to gestational age, fetal wellbeing, with management directed according to the specific underlying cause identified, following the detailed principles addressed under the relevant individual obstetric conditions.
• Any postmenopausal woman presenting with vaginal bleeding requires prompt, thorough evaluation specifically directed at excluding endometrial malignancy, given the essential, critical importance of this specific diagnostic consideration in this particular clinical context, with definitive management directed according to the specific underlying diagnosis established.
• Full, clear patient communication and appropriate follow-up arrangements, together with clear safety-netting advice regarding any feature that would warrant prompt reassessment, underpins full, safe, and systematic management of this common, diagnostically broad presenting complaint across the full spectrum of relevant clinical contexts.