Non Pregnancy-Related Abnormal Vaginal Bleeding - Causes, and Treatment

Introduction

Abnormal vaginal bleeding is a common problem and affects approximately 20 % to 30 % of women during their reproductive years. The abnormal vaginal bleeding can be due to abnormal uterine bleeding (AUB), bleeding from the intracervical vaginal structures, or bleeding from the cervix. Usually, a normal menstrual cycle will last for 4.5 to 8 days and happens at an interval of 24 to 38 days, but this can differ for each individual. Variations in the regular menstrual cycle of the individual is called abnormal vaginal bleeding. Abnormal vaginal bleeding can be a symptom of an underlying medical condition so proper attention should be given if encountered. This article provides knowledge about abnormal vaginal bleeding in non-pregnant women.

What Is Abnormal Vaginal Bleeding?

Abnormal vaginal bleeding is defined as irregularities in the normal menstrual cycle that involves frequency, duration, volume, and regularity of flow outside of pregnancy. About one-third of women will experience abnormal vaginal bleeding in their life with irregularities most common during menarche and perimenopause period. Abnormal vaginal bleeding can be classified as acute or chronic forms. Acute vaginal bleeding is defined as vaginal bleeding that requires immediate action to prevent further blood loss whereas chronic vaginal bleeding is the condition that is present for most of the previous six months.What Are the Causes of Abnormal Vaginal Bleeding in Non-pregnant Women?

Vaginal bleeding can be due to structural, nonstructural, or extrauterine causes:

Structural Cause:

• Polyps - Polyps are tissue growths that can occur in the lining of the uterus or in the inner part of the cervix. In most cases, they are benign (non-cancerous). They often cause intermenstrual bleeding which is bleeding between normally-timed periods. They can be diagnosed with the help of ultrasound or hysteroscopy.

• Adenomyosis - This condition occurs when the tissue that lines the uterus grows inside the muscular walls of the uterus. It often causes painful, heavy bleeding starting in the 30s to 40s. It usually disappears after menopause. It can be diagnosed by an ultrasound scan.

• Uterine Fibroid - They are non-cancerous growths in the uterus that can occur during the childbearing years in women. Most are asymptomatic but can cause abnormal bleeding and pelvic pain. When fibroids are large they can be diagnosed by palpation on a bimanual examination or by ultrasound.

• Malignancy - Endometrial hyperplasia can occur in women with a history of PCOS (polycystic ovarian syndrome), obesity, or unopposed estrogen. It is advisable for patients with postmenopausal bleeding to undergo an ultrasound and biopsy.

Non-structural Causes:

• Ovulatory Dysfunction - This is most often seen in adolescents and perimenopausal patients. It can also occur in patients with liver disease, renal disease, PCOS, exogenous hormone use, and thyroid disease. Eating disorders, increased stress, weight loss, and exercise can also decrease the activity of the hypothalamus-pituitary-adrenal axis and lead to anovulatory cycles. It normally causes prolonged amenorrhea (absence of period) with heavy bleeding or heavy and irregular bleeding.

• Coagulopathy - The ability of the blood to clot is called coagulopathy. It can cause up to 20 % of abnormal vaginal bleeding in young women. The common cause of blood clotting disorder is Von Willebrand’s disease. It can also cause ITP (immune thrombocytopenia), anticoagulation use, myeloproliferative disorders, and liver disease.

• Endometrial Causes - The structure of the uterine cavity is normal and the ovulatory cycles will also be normal. The common symptoms will be breast tenderness, pelvic pain, abdominal bloating, and heavy bleeding.

• Iatrogenic - Oral contraceptive pills (OCP) are the common cause of abnormal vaginal bleeding. About 40 % of women on OCPs will have abnormal bleeding in the first six months.

Extrauterine Cause:

• Infectious - Infections like pelvic inflammatory disease (PID), cervicitis, endometritis, and vaginitis can cause abnormal vaginal bleeding. It can be identified with pelvic examination and imaging tests. If the infection is treated the bleeding will be under control.

• Trauma - Any trauma to the vaginal and perineal area can be identified on pelvic examination. It may require suture repair. It is important to ask the patient privately about sexual abuse or assault.

• Retained Foreign Objects - Retained foreign objects like tampons or IUDs (intrauterine devices) can cause abnormal vaginal bleeding.

What Is the Treatment for Abnormal Vaginal Bleeding in Non-pregnant Women?

Treatment for abnormal vaginal bleeding depends on the extent of vaginal bleeding.

Stable Patient With Mild to Moderate Bleeding - The main aim of treatment is to reduce the volume and duration of blood loss, treat anemia if present, and restore quality of life. The treatment for non-pregnant patients with vaginal bleeding can be divided into hormonal or non-hormonal treatments.

1) Hormonal Treatment - Combined oral contraceptive pill (COCP) can be prescribed to stop an episode of heavy bleeding. This treatment is often effective for women with bleeding secondary to anovulation. The contraindications for oral contraceptive pills include:

• Pregnancy.

• Women who smoke.

• Liver disease.

• Severe hypertension.

• Ischaemic or cerebrovascular heart disease.

• History of stroke.

• History of breast or liver cancer.

• Hypertriglyceridemia.

2) Progesterone Only Pill (POP) - It is a safe alternative for women who are contraindicated for COCP.

3) Levonorgestrel-Releasing Intrauterine System (LIUS) - It is very effective at reducing heavy menstrual bleeding. However, it can change the bleeding pattern initially.

Non-hormonal Treatments -

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) - These drugs promote uterine vasoconstriction and reduce heavy menstrual bleeding. They also have analgesic properties that help in dysmenorrhoea. The contraindications of NSAIDs include hypersensitivity to Aspirin, use of anticoagulants, peptic ulcer disease, renal and cardiac impairment, etc.

• Tranexamic Acid - They are more effective for the treatment of heavy menstrual bleeding than oral contraceptives and NSAIDs. They do not cause many adverse effects but have some thromboembolism risk. It can also be given along with NSAIDs.

• Iron Supplementation - If the patient has any symptoms of microcytic anemia, then iron supplements are prescribed. Vitamin C can be given with iron supplements for better absorption of iron.

Stable Patient With Mild to Moderate Bleeding - Life-threatening vaginal bleeding is uncommon in non-pregnant women but can occur, particularly in uterine arteriovenous malformation or during trauma. The patients will be provided with initial resuscitation as other unstable bleeding patients:

• ABCDE (airway, breathing, circulation, disability, exposure) assessment and interventions are done, which may include activation of major transfusion if indicated.

• First-line treatment for unstable vaginal bleeding in non-pregnant patients is with high dose IV (intravenous) Estrogen to promote endometrial regrowth.

• Rarely, uterine tamponade (a device used to stop bleeding), like Bakri Balloon, may be required for uncontrolled uterine bleeding. If these are not available, a foley catheter is passed through the cervix, and the balloon is inflated, or the uterus is packed with long continuous gauze. This is done with a speculum, with analgesia, and under sterile conditions.

Conclusion

Non-pregnancy-related vaginal bleeding is more common, but it is important to keep track of the symptoms, like how long the period lasts and how heavy the period is. If it persists, it can be due to an underlying medical condition, and it is necessary to consult a physician for further management.