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How to Evaluate Vaginal Bleeding and Discharge

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How to Evaluate Vaginal Bleeding and Discharge How to Evaluate Vaginal Bleeding and Discharge Is the bleeding normal or abnormal? When does vaginal discharge reflect something as innocuous as irritation caused by a new soap? And when does it signal something more serious? The authors’ discussion of eight actual patient presentations will help you through the next differential diagnosis for a woman with vulvovaginal complaints. By Vincent Ball, MD, MAJ, USA, Diane Devita, MD, FACEP, LTC, USA, and Warren Johnson, MD, CPT, USA bnormal vaginal bleeding or discharge is typically due to either inadequate levels of estrogen one of the most common reasons women or a persistent corpus luteum. Structural causes of come to the emergency department.1,2 bleeding include leiomyomas, endometrial polyps, or Because the possible underlying causes malignancy. Infectious etiologies include pelvic in- Aare diverse, the patient’s age, key historical factors, flammatory disease (PID). Additionally, a variety of and a directed physical examination are instrumental bleeding dyscrasias involving platelet or clotting fac- in deciding on diagnosis and treatment. This article tors can complicate the normal menstrual period. Iat- will review some common case presentations of rogenic causes of vaginal bleeding include hormone nonpregnant female patients with abnormal vaginal replacement therapy, steroid hormone contraception, bleeding, inflammation, or discharge. and contraceptive intrauterine devices.3-5 Anovulatory bleeding is common in perimenar- ABNORMAL VAGINAL BLEEDING chal girls as a result of an immature hypothalamic- To ensure appropriate patient management, “Is she pituitary axis and in perimenopausal women due to pregnant?” should be the first question addressed, declining levels of estrogen. During reproductive since some vulvovaginal signs and symptoms will years, dysfunctional uterine differ in significance and urgency depending on the bleeding (DUB) is the most >>FAST TRACK<< answer. If the patient is not pregnant, the gyneco- common cause of abnormal During reproductive logic causes of abnormal vaginal bleeding can be vaginal bleeding.5 Almost years, dysfunctional functionally grouped into three categories: ovula- 90% of DUB results from uterine bleeding is the tory, anovulatory, and nonuterine bleeding.3 anovulation.5 During an an- most common cause Ovulatory bleeding is associated with regular men- ovulatory cycle, the corpus of abnormal vaginal strual periods. This form of bleeding can be further luteum does not form, caus- bleeding. subdivided as hormonal, structural, infectious, or iat- ing a failure of progesterone rogenic.3 Premenstrual spotting or delayed menses is secretion. This results in continued unopposed es- tradiol, stimulating endometrial proliferation and Dr. Ball is a staff physician and the medical student subsequent irregular vaginal bleeding. Continued clerkship director, Dr. Devita is a staff physician and the chief of emergency department operations, and Dr. elevated levels of estrogen place a woman at risk for Johnson is a resident in the department of emergency developing endometrial cancer. Conversely, break- medicine at Madigan Army Medical Center in Fort Lewis, through bleeding may occur in patients taking oral Washington. The opinions or assertions contained contraceptives that have inadequate doses of estro- herein are the private views of the authors and are not to be construed as official or reflecting the views of the gen and progestin for the patient or in perimeno- Department of the Army or the Department of Defense. pausal women with declining levels of estrogen. 3-5 www.emedmag.com APRIL 2009 | EMERGENCY MEDICINE 27 VAGINAL BLEEDING AND DISCHARGE Suspect DUB when the patient (typically an ado- risk of venous thromboembolic disease, or hepatic lescent or a woman over 40) presents with unpredict- dysfunction. Typical dosing of micronized oral pro- able vaginal bleeding despite a normal pelvic exami- gesterone is 200 mg once daily for the first 10 to 12 nation. As we said earlier, first and foremost, rule out days of each month.7 Menses should occur within pregnancy. Perform a pelvic ultrasound to rule out one week of the last dose of progesterone. Other structural abnormalities, such as leiomyoma, ovarian formulations and dosing schedules are available.3-7 cysts, and endometrial polyps. Patients who have had Mild DUB is defined as longer than normal menses irregular menses since menarche may have polycystic for more than two months.7 Hormonal therapy is not ovarian syndrome, which is characterized by anovula- necessary but may be offered if symptoms worsen. All tion or oligo-ovulation and hyperandrogenism. These patients treated for abnormal vaginal bleeding must patients will classically be obese, infertile, hirsute, and follow up with their gynecologist or primary doctor possibly hyperinsulinemic. Patients with adrenal en- for the completion of their DUB workup.3 zyme defects, hyperprolactinemia, thyroid disease, or other metabolic disorders might also present with SIGNS AND SYMPTOMS OF VAGINITIS vaginal bleeding with anovulation. Thyroid hormone Vaginitis or, more correctly, vulvovaginitis, is inflam- studies and a head computed tomography (CT) scan mation of the vulva and vaginal tissues. Typical signs may be required to confirm the diagnosis.5 and symptoms are vulvar itching, vaginal discharge, Dysfunctional uterine bleeding can be catego- and a vaginal odor. The most common causes of acute rized as severe, moderate, or mild.6 Severe bleed- vulvovaginitis include infections, irritant or allergic ing is associated with hemodynamic instability. Such contact, and atrophic vaginitis.2,9 The three most patients will require resuscitation with intravenous frequent infections are bacterial vaginosis caused by fluids, parenteral estrogen, and possibly dilation an imbalance of the normal flora by Gardnerella vagi- and curettage, necessitating hospital admission. The nalis; candidiasis, most commonly caused by Candida dose of intravenous estrogen is 25 mg every four to albicans; and trichomoniasis caused by Trichomonas six hours until the bleeding stops.6 The minimum vaginalis.9 Infectious vulvovaginitis is typically found amount of estrogen to stop the bleeding should be in sexually active women, while candidiasis, contact administered to avoid the potential complication vaginitis, and atrophic vaginitis can occur in women of venous thromboembolism. Giving an antiemetic who are not sexually active.2,8,9 prior to the estrogen will alleviate the side effects of Obtain a detailed gynecological and sexual history nausea and vomiting.5,6 and perform a pelvic examination in all women with Moderate DUB is associated with prolonged symptoms of vulvovaginitis. Ascertain the use of soaps, bleeding and mild anemia without hemodynamic in- douches, and tight clothing or other irritants that may stability. Treatment typically involves hormonal ther- cause inflammation. A history of improperly treated apy with combined estrogen-progesterone four times sexually transmitted diseases (STDs), unprotected sex- a day for seven days.5 Estrogen stimulates hemostasis, ual intercourse, and immunosuppression place women which will curtail vaginal bleeding. Advise patients of at higher risk for infectious vulvovaginitis. Key aspects the increased risk of venous thromboembolic events of the pelvic examination include the presence and while on estrogen, especially if they smoke. Such type of discharge, odor, ulcerations, cervical abnor- oral contraception may also malities, cervical discharge, and cervical motion or >>FAST TRACK<< aggravate an immature hy- adnexal tenderness to palpation. A urine pregnancy Candidiasis, contact pothalamic-ovarian axis and test should be performed on all female patients: Some vaginitis, and atrophic is recommended only for infectious causes of discharge are associated with ad- vaginitis can occur in patients with an established verse pregnancy outcomes if not treated.2,9 women who are not menstrual history.3-6 The cause of vaginal symptoms can typically be sexually active. Progestin-only hormones determined by history, physical examination, dis- are recommended if the pa- charge pH determination, and examination of a wet tient is not actively bleeding, can take oral medica- mount. If PID is suspected, a “dirty” or initial-stream tion, and has a contraindication to high-dose estro- urine sample can be obtained for testing of gonor- gen, such as an estrogen-dependent tumor, a high rhea and chlamydia if that modality is available. Al- 28 EMERGENCY MEDICINE | APRIL 2009 www.emedmag.com VAGINAL BLEEDING AND DISCHARGE ternatively, endocervical samples may be obtained • laceration for gonorrhea and chlamydia testing. Also obtain a • coagulopathy midstream urine sample for urinalysis if there is a • menarche suspicion of urinary tract infection. • nonaccidental trauma/assault Because symptoms of vulvovaginitis are nonspecific, • vaginal foreign body checking a pH with phenaphthazine (nitrazine) paper • infection/STD and obtaining a wet preparation are recommended for The diagnosis is menarche. (This might seem proper diagnosis of discharge. Obtain two discharge obvious, but a surprising number of parents bring samples. Dilute one sample in one to two drops of their daughters in for evaluation under these cir- 0.9% normal saline solution and the second in one to cumstances.) The average age of menarche in North two drops of 10% potassium hydroxide (KOH) solu- America is 12.5 years, with 10 years being the lower tion.9 An amine odor after applying the KOH
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