Bleeding from the genital tract is of variable significance and its management depends upon the age of the patient, and the volume of blood that is being lost. Apart from bleeding as a complication of pregnancy, it is only rarely so heavy and life-threatening that urgent first-aid measures are required. Thus, for those women aged between 15 and 50 years, the possibility of pregnancy must always be considered before suggesting certain investigations and treatments.

Although many of the causes for bleeding will apply in all age-groups—prepubertal, during the menstrual years, and postmenopausally—some are very uncommon at certain ages, are unlikely to result in excessive blood loss, and need not be considered in detail. However, management of individual causes is generally the same, irrespective of age, but precise treatments vary and need to be discussed separately.

Serious vaginal bleeding in a young girl is most likely to be due to trauma—and usually accidental, such as falling astride furniture. Sexual abuse, if very traumatic, may rupture the intact hymenal ring, and this should always be considered as a possibility, with appropriate investigation and follow-up. The source of bleeding will generally be obvious on inspection of the external genitalia, revealing a laceration of the labia or hymen, or a vulval haematoma. If the bleeding is issuing through the introitus and showing no signs of ceasing, examination under anaesthetic is necessary to explore the vagina for possible penetrating injuries; adequate examination will not be possible in most young girls, and should probably not be attempted. Examination under anaesthetic is best performed using a hysteroscope or cystoscope passed into the vagina in the very young girl, and in older children a paediatric laryngoscope may be used to view the cervix and upper vagina. Consideration should be given to ensuring that the bladder and rectum have not been damaged; if the anterior or posterior wall is lacerated, bladder or rectal examinations should also be performed. Packing the vagina with 1-inch ribbon gauze (2.5 cm) dampened with proflavine cream will control bleeding from superficial lacerations if it is not too heavy and the trauma not penetrating; an indwelling urinary catheter may be necessary until the pack is removed 24 h later. Suturing of any actively bleeding lacerations, using No. 2/0 catgut or other absorbable material, may be required. If a vulval haematoma has developed, drainage by incision and ligation of the bleeding point should be performed; occasionally, oozing continues and one or two deep No. 2/0 catgut sutures will usually control any persisting loss.

Rarely, the bleeding might come from a tumour of the lower genital tract. Adenosis vaginae, clear cell adenocarcinoma of the vagina, and sarcoma botryoides of the vagina or cervix are possibilities. Biopsy specimens should be taken to obtain a histological diagnosis and packing of the vagina should control active bleeding. If blood is coming through the cervix, this might be due to precocious puberty or the result of an oestrogen-secreting tumour of the ovaries. A bimanual pelvic examination with one finger introduced into the rectum should be performed to feel the size of the uterus and feel for the ovaries; the ovaries should not be palpable unless they are enlarged by tumour. If suspected, further investigation is necessary with plasma gonadotropin and steroid assays and pelvic ultrasound, followed by laparoscopy or laparotomy if the investigations suggest a tumour. If heavy bleeding persists, curettage under anaesthesia, using a 3-mm aspiration curette and not requiring any cervical dilatation, is atraumatic; it must be remembered that the uterocervical canal in young girls is usually only 5 cm (2 inches) in length and care must be taken to avoid the use of excessive force, which might lead to a perforation. Oral progestogens, such as norethisterone (5 mg twice a day), should control any continuing bleeding within 24 h. Subsequent referral to a specialist is advised.

A foreign body ‘lost’ in the vagina by a young child may result in infection and some bloodstained discharge, and should be considered; the vagina should be examined under anaesthetic as described above to retrieve the foreign body. Table 1 418 lists causes of vaginal bleeding found in 52 girls aged 10 years or younger referred to a specialist unit for investigation.

Acute vaginal bleeding may be either provoked or spontaneous, and may occur in non-pregnant women or in association with pregnancy. In the non-pregnant, unprovoked bleeding may occur at the time of expected menstruation, following a delay in menstruation, or between menstrual periods (intermenstrual bleeding). Provoked bleeding may follow coitus (postcoital bleeding), be associated with the insertion or removal of an intrauterine contraceptive device, or result from some ‘surgical’ procedure involving the uterus or cervix, including criminal attacks upon a pregnancy to procure abortion. The relationship of the bleeding to the menstrual cycle and the onset of the last menstrual period are thus of major importance in deciding which are the most probable differential diagnoses and the most appropriate management strategy. Table 2 419 lists possible causes and likely amounts of bleeding for the different types of bleeding that might be encountered in the non-pregnant woman.

General examination should be performed, with particular attention paid to possible pre-existing anaemia and cardiac decompensation. Lymphadenopathy, particularly in the supraclavicular fossae (Troisier's sign) might herald possible malignant disease; chest examination is important for the same reason. If pregnancy is a possibility, the breasts may be full and tender with areolar pigmentation, prominent Montgomery's tubercles, and skin marbling from subdermal venous dilatation. Abdominal examination is necessary to detect any organomegaly, presence of pelvic tumours, and ascites.

Inspection of the vulva will indicate the rate of blood loss and the nature of the bleeding, whether fresh or old. Speculum examination will identify vaginal and cervical causes; examination during the acute phase will allow confirmation of the site of the bleeding, whether from a lower genital tract lesion or from the uterus. Bimanual examination should be performed to assess cervical consistency and surface texture, and to note whether the internal os is closed. Cervical excitation should be determined, which will be positive in cases of ectopic tubal pregnancy. The position, size, shape, and consistency of the uterus should be assessed and a note made of its mobility and tenderness. Other pelvic masses should be sought, most notably ovarian and tubal, and whether there is any associated tenderness.

Following resuscitation that might be required to restore the circulating intravascular volume, some urgent investigations are appropriate. In all cases, haemoglobin, blood group, and Rhesus type should be checked; in certain ethnic groups, a haemoglobin electrophoresis should be performed. Pregnancy should always be considered and, if it is a possibility from the history and clinical findings, it can be further confirmed by checking a urine or serum immunological test. The result will be positive 28 days after conception; with the specific tests using monoclonal antibody to &bgr;-human chorionic gonadotropin (&bgr;-hCG), it will be positive within 14 days of conception; a negative result can be misleading. Pelvic ultrasound, ideally using a vaginal probe, may be particularly helpful in the very early weeks of pregnancy and in difficult obese cases, although it may prove unhelpful or give confusing results unless the ultrasonographer is experienced in the examination of early pregnancy.

Management depends initially upon the volume of blood lost, the clinical condition, and whether the patient is pregnant or not.

If a bleeding cervical polyp on a narrow stalk is seen, this can be avulsed with polyp forceps, grasping the polyp between the blades and twisting the forceps until the polyp comes away: the base will not bleed as a rule, but if it does, touching with a silver nitrate stick will be sufficient to control the loss. In patients in whom vaginal bleeding is heavy and a local lesion is not obvious or not amenable to ‘first-aid’ treatment, examination under anaesthetic, combined with uterine curettage, should be performed.

If bleeding is not excessive, this procedure can be performed with a paracervical nerve block, but if the loss is heavy, a general or regional anaesthetic is preferable. Following asepsis and draping, the vulva is inspected and then a bimanual pelvic examination is performed to determine the uterine size, position, consistency, shape, and mobility. Palpation in the fornices is necessary to detect any adnexal masses. A Sim's speculum is passed to inspect the vaginal walls and the cervix. The anterior lip of the cervix is then stabilized with a volsellum forceps and the uterocervical canal sounded: in the normal non-pregnant woman, it is usually approximately 7.5 cm (3 inches) long. Cervical dilatation is then performed using graduated dilators to a maximum of 7 mm, taking care not to insert the dilators with excessive force, so perforating the uterine fundus. If a broad-based cervical polyp is present, it should be avulsed by excision at the base and a haemostatic No. 1 catgut, or other absorbable suture, on a trocar pointed needle should be inserted into the defect. The uterine cavity should then be explored with polyp forceps, passed in the closed position to the uterine fundus and then opened, rotated through 180°, closed, rotated back through 180°, and withdrawn. Having repeated this survey twice, noting whether any polyps have been recovered, the endometrial cavity should be systematically curetted with a sharp curette passed to the fundus and withdrawn, applying pressure against the uterine wall. This procedure should be repeated until the anterior, posterior, and both lateral surfaces have been curetted. Finally, the fundus should be curetted with two or three strokes. All the tissue removed should be collected and sent in 10 per cent formalin solution for histological examination.

If the bleeding is coming from the cervix or vagina, and there are some inflammatory changes or ulcerated areas, these should be biopsied; a wedge of tissue from the suspect area is excised and one or two No. 1 chromic catgut sutures on a trocar pointed needle will be required to provide haemostasis. The tissue specimen should be sent for urgent histological examination. If an intrauterine contraceptive device is in position and it is thought that it may be responsible for the bleeding, this should be removed with a pair of polyp forceps, used as described above for intrauterine examination: it is imperative to advise the patient that she is no longer protected against conception.

If a laceration of the vagina is encountered, which will probably have been anticipated from the history, it should be carefully examined to determine its position, depth, and extent. Anterior wall trauma could involve bladder or urethra, and a careful exploration of both by cystoscopy may be appropriate while posterior wall trauma might involve the rectum, and a rectal examination should be performed to determine whether the mucosa has been damaged. In the event of either bladder or rectal mucosa being breached, a careful formal repair of the damage will be required, ideally by an expert to reduce the chances of fistula formation.

In most instances, acute bleeding will subside following the surgical procedure. In some cases of severe menorrhagia in which no pathology is found, the bleeding may be controlled by the oral administration of high doses of a progestagen such as norethisterone 10 mg 6 hourly until the loss ceases and then continue at 10 mg 12 hourly for a total treatment time of 3 weeks. On discontinuing, a menstrual loss which should not be heavy will occur. Alternative treatment using other medications such as danazol or ethamsylate may be used and more recently, uterine tamponade using a distensible intrauterine balloon has been described to control bleeding as an emergency procedure.

Rarely the bleeding is due to an ulcerated prolapsed pedunculated intraluminal fibroid presenting at the cervix, the os being widely dilated to accommodate the tumour. It may be appropriate to remove the fibroid transvaginally by applying traction to the fibroid with tissue forceps to bring the pedicle into view, which can then be transfixed with No. 2 chromic catgut, or similar material, on a trocar pointed needle, and the pedicle divided distal to the transfixion. If this is not possible, a hysterectomy may then be necessary.

Initial management depends upon the volume of bleeding, uterine size, and the state of the cervix. Table 3 420 lists the likely nature of the bleeding that may be encountered in different situations. During the first trimester, an initial pelvic examination is essential to determine whether the cervix is closed and abortion threatened, or open and abortion inevitable. For the former, treatment involves bed rest with some light sedation, if necessary until the bleeding abates, when slow mobilization can begin. If the patient is Rhesus (D) negative, anti-D immunoglobulin (250 IU) should be given by intramuscular injection. At 8 weeks' gestation or later, an ultrasound examination is helpful to demonstrate a live fetus and continuing pregnancy. Subsequent pregnancy management is essentially unchanged from the usual routine. Bleeding at later gestations is dealt with in Section 30.11 216.

An inevitable abortion is diagnosed when vaginal bleeding is associated with menstrual-like cramps, which may be severe, and the internal cervical os is dilated sufficiently for the introduction of a finger. If products of conception are felt in the os, they should be removed with sterile sponge holding forceps, especially if the patient is in marked pain or is hypotensive with a bradycardia due to vagal stimulation. If bleeding is excessive, ergometrine (0.5 mg intramuscularly) should be given to make the uterus contract and to reduce bleeding. All Rhesus (D)-negative women should be given 250 IU anti-D immunoglobulin within 60 h of the start of bleeding. Since many spontaneous abortions between 8 and 13 weeks' gestation are ‘incomplete’, with pieces of placental tissue retained within the uterine cavity, surgical evacuation should be performed.

Adequate anaesthesia, such as a paracervical block, regional block, or induction anaesthesia, and strict aseptic precautions are essential. Following skin and vaginal preparation and draping, urinary voiding having been previously advised, the size and position of the uterus are determined on bimanual examination. Ergometrine, 0.5 mg given intramuscularly before the start of the surgical procedure, should ensure a contracted, firm-walled uterus, reducing bleeding and the chance of uterine perforation. A uterine sound should not be passed at the start of the procedure for fear of perforating the soft pregnant uterine wall. Cervical dilatation should not be necessary and, in some instances, the index finger can be passed through the dilated cervix into the uterine cavity and the retained products felt, dislodged, and expelled through the open cervix. Subsequent retrieval of any remaining pieces of placental tissue is achieved by stabilizing the cervix and uterus with a sponge holding forceps, grasping the anterior cervical lip, and introducing a second sponge holding forceps through the cervix to the uterine fundus, where it should be opened, rotated through 180°, closed, and withdrawn. Systematic curettage of the entire cavity with a blunt or flushing curette will ensure that all tissue is removed. If the tissue removed from the uterus has the typical features of ‘grape-like vesicles’, it should be sent for histological examination to identify any trophoblastic tumour.

On completion, there should be minimal bleeding and, once recovery from anaesthesia is complete and observations are satisfactory, the patient can be discharged.

If a criminal abortion attempt is suspected, broad-spectrum antibiotic cover should be given after bacteriological specimens have been collected. A check for consumptive coagulopathy should be made in cases of Gram-negative septicaemia. Evacuation of the uterus should be performed, as previously described, as soon as possible. Trauma to the vaginal wall and uterus should be searched for carefully, and, if either exists, close observations must be instituted to watch for evidence of the development of peritonitis or of damage to the bowel or bladder. Postoperative recovery observations must also include the monitoring of hepatic and renal function for evidence of impending failure during the first 48 h after admission.

In the event of hydatiform molar change being identified on histological examination of the evacuated products, the patient should be recalled 2 weeks after the initial evacuation and, if heavy bleeding is persisting, a further curettage should be performed, and any tissue recovered sent for histological examination. At the same time, a urine or serum sample should be collected and sent for assay of &bgr;-hCG. If the levels are maintained or rising when retested 2 weeks later, referral to a specialist centre for further investigation and possible chemotherapy should be arranged. If the levels are falling, repeated checks should be instituted at 1- to 2-monthly intervals for the subsequent 24 months, to ensure that levels remain at non-pregnant values; further pregnancy should be prevented for this period, but the combined oral contraceptive pill is best avoided since recurrent disease rates may be increased. If &bgr;-hCG levels start to rise, a new pregnancy needs to be excluded, and referral to the specialist centre will be required.

Patients with ectopic pregnancies frequently faint and may notice a small volume of vaginal blood loss or ‘prune-juice’ discharge, but virtually never experience heavy vaginal bleeding. Ectopic pregnancy may occur in any women in whom pregnancy is a possibility and the diagnosis must be considered in the presence of vaginal bleeding and lower abdominal pain, even without a history of amenorrhoea.

This is defined as bleeding from the genital tract 12 months or more after the last menstrual period in a woman aged 45 years or older. Its causes are essentially the same as those described for intermenstrual bleeding and menorrhagia, with a greater emphasis on cervical and endometrial malignancy (see Table 2 419). Oestrogen-secreting ovarian tumours, such as granulosa cell and theca cell tumours, most frequently present as heavy postmenopausal bleeding. Additionally, the possibility of endogenous steroids given to relieve menopausal symptoms should be considered and specific enquiry made.

All cases of postmenopausal bleeding require investigation by uterine curettage, irrespective of the volume of blood loss. Although only urgent if bleeding is excessive, the need to investigate is imperative since endometrial pathology is present in 20 per cent of cases and endometrial carcinoma in 10 per cent.

Vaginal bleeding can be very heavy and life-threatening. It is important in the first instance to decide whether the patient could be pregnant. The management required to control the bleeding may then be urgent, especially if the patient is pregnant. In the non-pregnant woman, the diagnosis is of prime importance in the majority, but, in some, the bleeding can be sufficiently heavy to render the patient anaemic and threaten her life; curettage may control acute bleeding and allow a more relaxed diagnosis to be made and appropriate treatment to be instituted.

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