Vaginal bleeding, excessive/irregular/abnormal

Rationale

Vaginal bleeding is considered excessive, irregular, and/or abnormal when it occurs at an unexpected time, such as before menarche or after menopause, or when it varies from the normal expected amount or pattern. It may be associated with significant morbidity and mortality, depending on the underlying cause.

Causal Conditions

(list not exhaustive)

1. Premenarchal (e.g., due to trauma or child sexual abuse)
2. Premenopausal
   1. Ovulatory
      1. Intermenstrual bleeding (e.g., due to oral contraceptive use or benign growths)
      2. Menorrhagia
      3. Neoplasms and coagulation disorders
      4. Other (e.g., endometritis, hypothyroidism)
   2. Anovulatory
      1. Age-related endocrine or metabolic disorders (e.g., thyroid dysfunction)
      2. Neoplasms (e.g., prolactinoma, ovarian tumour)
      3. Other (e.g., polycystic ovary syndrome; weight loss, exercise, and/or stress; structural disease)
   3. Pregnancy-related bleeding
3. Postmenopausal – structural and/or systemic
   1. Genital tract disease (excluding trauma)
   2. Neoplastic systemic disease
   3. Medications (e.g., menopause hormone therapy, anticoagulants)

Key Objectives

Given a patient who presents with excessive, irregular, and/or abnormal vaginal bleeding, the candidate will diagnose the cause, severity, and complications, and initiate an appropriate management plan.

Enabling Objectives

Given a patient who presents with excessive, irregular, and/or abnormal vaginal bleeding, the candidate will

1. list and interpret critical clinical findings, including those based on
   1. first and foremost, the patient’s hemodynamic stability,
   2. whether the bleeding is related to pregnancy or not,
   3. information gathered to determine the underlying cause (e.g., other bleeding, medications) if pregnancy has been ruled out, and
   4. an appropriate physical examination, including a pelvic examination unless contraindicated (e.g., suspected placenta previa);
2. list critical clinical investigations and interpret the results of the investigations, including
   1. a complete blood count, pregnancy test, and in patients with recent pregnancy, qualitative and quantitative β-human chorionic gonadotropin (β-hCG) tests,
   2. determining ovulatory status and ordering clinically indicated diagnostic tests, and
   3. determining whether a referral for investigation is required;
3. construct an effective initial management plan, including
   1. resuscitating the patient if hemodynamically unstable,
   2. initiating first-line medical therapy for control of abnormal vaginal bleeding and referring the patient for specialized surgical care as appropriate,
   3. determining if the patient requires other urgent or specialized care,
   4. outlining legal responsibilities (e.g., mandatory reporting obligations) if sexual abuse is suspected, and
   5. recognizing the need for counselling and support in case of sexual abuse.