Vaginal bleeding

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Vaginal bleeding
Sonohysterography.gif
Sonohysterography performed because of postmenopausal bleeding. In serial images, polyps would be more immobile than freely moving debris within the uterine cavity which are seen in the image.
Specialty Gynecology

Vaginal bleeding is any expulsion of blood from the vagina. This bleeding may originate from the uterus, vaginal wall, or cervix. [1] Generally, it is either part of a normal menstrual cycle or is caused by hormonal or other problems of the reproductive system, such as abnormal uterine bleeding.

Contents

Regular monthly vaginal bleeding during the reproductive years, menstruation, is a normal physiologic process. During the reproductive years, bleeding that is excessively heavy (menorrhagia or heavy menstrual bleeding), occurs between monthly menstrual periods (intermenstrual bleeding), occurs more frequently than every 21 days (abnormal uterine bleeding), occurs too infrequently (oligomenorrhea), or occurs after vaginal intercourse (postcoital bleeding) should be evaluated. [2] [3]

The causes of abnormal vaginal bleeding vary by age, [4] and such bleeding can be a sign of specific medical conditions ranging from hormone imbalances or anovulation to malignancy (cervical cancer, vaginal cancer or uterine cancer). [2] In young children, or elderly adults with cognitive impairment, the source of bleeding may not be obvious, and may be from the urinary tract (hematuria) or the rectum rather than the vagina, although most adult women can identify the site of bleeding. [5] When vaginal bleeding occurs in prepubertal children or in postmenopausal women, it always needs medical attention. [6] [7] [5]

Vaginal bleeding during pregnancy can be normal, especially in early pregnancy. [8] However, bleeding may also indicate a pregnancy complication that needs to be medically addressed. [8] During pregnancy bleeding is usually, but not always, related to the pregnancy itself.

The treatment of vaginal bleeding is dependent on the specific cause, which can often be determined through a thorough history, physical, and medical testing. [9]

Etiology

The parameters for normal menstruation have been defined as a result of an international process designed to simplify terminologies and definitions for abnormalities of menstrual bleeding. [10] [11] The causes of abnormal vaginal bleeding vary by age. [4]

Prepubertal

Bleeding in children is of concern if it occurs before the expected time of menarche and in the absence of appropriate pubertal development. Bleeding before the onset of pubertal development deserves evaluation. It could result from local causes or from hormonal factors. [6] [7] In children, it may be challenging to determine the source of bleeding, and "vaginal" bleeding may actually arise from the bladder or urethra, or from the rectum. [12]

Vaginal bleeding in the first week of life after birth is a common observation, and pediatricians typically discuss this with new mothers at the time of hospital discharge. [13] [14] During childhood, one of the most common causes of vaginal bleeding is presence of a foreign body in the vagina which may be caused by normal self-exploration or can be indicative of sexual abuse. This is often associated with pelvic pain, foul discharge, or recurrent genitourinary infections. [7] Other causes include trauma (either accidental or non accidental, i.e. child sexual abuse or molestation), urethral prolapse, vaginal infection (vaginitis), vulvar ulcers, vulvar skin conditions such as lichen sclerosus, and rarely, a tumor (benign or malignant vaginal tumors, or hormone-producing ovarian tumors). Hormonal causes include central precocious puberty, or peripheral precocious puberty (McCune–Albright syndrome), or primary hypothyroidism. [15] [16]

Genitourinary injury is also a common cause, and is often the most common cause of hospitalization or emergency department visits for prepubertal vaginal bleeding, comprising up to 45% of such cases. [7] The most common genitourinary injury is the straddle injury, which often occurs during a fall, often on a sharp edge, and can cause lacerations between the labial folds. [7]

While vaginal bleeding in children is typically alarming to parents, most causes are benign, although sexual abuse or tumor are particularly important to exclude. An examination under anesthesia (EUA) may be necessary to exclude a vaginal foreign body or tumor, although instruments designed for office hysteroscopy can sometimes be used in children with topical anesthesia for office vaginoscopy, precluding the need for sedation or general anesthesia and operating room time. [17]

Premenopausal

Background

In premenopausal women, bleeding can be from the uterus, from vulvar or vaginal lesions, or from the cervix. [18] A gynecologic examination can be performed to determine the source of bleeding. Bleeding may also occur as a result of a pregnancy complication, such as a spontaneous abortion (miscarriage), ectopic pregnancy, or abnormal growth of the placenta, even if the woman is not aware of the pregnancy. [18] This possibility must be kept in mind with regard to diagnosis and management.

Generally, the causes of abnormal uterine bleeding in premenopausal women who are not pregnant include fibroids, polyps, hormonal disorders such as polycystic ovary syndrome (PCOS), blood clotting disorders, and cancer. Infections such as cervicitis or pelvic inflammatory disease (PID) can also result in vaginal bleeding. Postcoital bleeding is bleeding that occurs after sexual intercourse. Lastly, a normal and common side effect of birth control includes vaginal spotting or bleeding. [2]

Clinical guidelines (FIGO classification)

A more specific clinical guideline, called the PALM-COEIN system, has been developed by FIGO (International Federation of Gynecology and Obstetrics) to classify the causes of abnormal uterine bleeding. [19] This acronym stands for Polyp, Adenomyosis, Leiomyoma, Malignancy and Hyperplasia, Coagulopathy, Ovulatory Disorders, Endometrial Disorders, Iatrogenic Causes, and Not Classified. The FIGO Menstrual Disorders Group, with input from international experts, recommended a simplified description of abnormal bleeding that discarded imprecise terms such as menorrhagia, metrorrhagia, hypermenorrhea, and dysfunctional uterine bleeding (DUB) in favor of plain English descriptions of bleeding that describe the vaginal bleeding in terms of cycle regularity, frequency, duration, and volume. [20]

The PALM causes are related to uterine structural, anatomic, and histolopathologic causes that can be assessed with imaging techniques such as ultrasound or biopsy to view the histology of a lesion. [21] The COEIN causes of abnormal bleeding are not related to structural causes. [21]

PALM - Structural causes of uterine bleeding

  • Polyps: Endometrial polyps are benign growths that are typically detected during gynecologic ultrasonography and confirmed using saline infusion sonography or hysteroscopy, often in combination with an endometrial biopsy providing histopathologic confirmation. Endocervical polyps are visible at the time of a gynecologic examination using a vaginal speculum, and can often be removed with a minor office procedure.
  • Adenomyosis: Adenomyosis is a condition in which endometrial glands are present within the muscle of the uterus (myometrium), and the pathogenesis and mechanism by which it causes abnormal bleeding have been debated. [22]
  • Leiomyoma (fibroids): Uterine leiomyoma, commonly termed uterine fibroids, are common, and most fibroids are asymptomatic. [4] The presence of leiomyomas may not be the cause of abnormal bleeding, although fibroids that are submucosal in location are the most likely to cause abnormal bleeding. [21]
  • Malignancy (pre-cancer and cancer): The Malignancy and Hyperplasia category of the PALM-COEIN system includes malignancies of the genital tract, including cancers of the vulva, the vagina, the cervix, and the uterus. Endometrial hyperplasia, included in this PALM category of abnormal bleeding, is more common in women who are obese or who have a history of chronic anovulation. When endometrial hyperplasia is associated with atypical cells, it can progress to cancer or occur concurrently with it. [4] While endometrial hyperplasia and endometrial cancer occur most commonly among post-menopausal women, most patients with endometrial cancer have abnormal bleeding, and thus the diagnosis must be considered in women during the reproductive years. [4] [21]

COEIN - Non-structural causes of uterine bleeding

  • Coagulopathies (blood clotting disorders): Heavy menstrual bleeding can be related to coagulopathies. [23] Von Willebrand disease is the most common coagulopathy, and most women with von Willebrand disease have heavy menstrual bleeding. [23] Of women with heavy menstrual bleeding, up to 20% will have a bleeding disorder. [24] Heavy menstrual bleeding since menarche is a common symptom for women with bleeding disorders, and in retrospective studies, bleeding disorders have been found in up to 62% of adolescents with heavy menstrual bleeding. [25]
  • Ovulatory dysfunction:Ovulatory dysfunction or anovulation is a common cause of abnormal bleeding that may lead to irregular and unpredictable bleeding, as well as variations in the amount of flow including heavy bleeding. Endocrine, or hormonal, causes of ovulatory disorders include polycystic ovary syndrome (PCOS), thyroid disorders, hyperprolactinemia, obesity, eating disorders including anorexia nervosa or bulimia, or to an imbalance between exercise and caloric intake. [26]
  • Endometrial:Endometrial causes of abnormal bleeding include infection of the endometrium, endometritis, which may occur after a miscarriage (spontaneous abortion) or a delivery, or may be related to a sexually-transmitted infection of the uterus, fallopian tubes or pelvis generally termed pelvic inflammatory disease (PID). Other endometrial causes of abnormal bleeding may relate to the ways that the endometrium heals itself or develops blood vessels. [21]
  • Iatrogenic (caused by medical treatment or procedures): The most common Iatrogenic cause of abnormal bleeding relates to treatment with hormonal medications such as birth control pills, patches, rings, injections, implants, and intrauterine devices (IUDs). Hormone therapy for treatment of menopausal symptoms can also cause abnormal bleeding. Unscheduled bleeding that occurs during such hormonal treatment is termed "breakthrough bleeding" (BTB) Breakthrough bleeding may result from inconsistent use of hormonal treatment, although in the initial months after initiation of a method, it may occur even with perfect use, and may ultimately affect adherence to the medication regimen. [27] The risk of breakthrough bleeding with oral contraceptives is greater if pills are missed. [28]
  • Not classified: The Not Classified category of the PALM-COEIN system includes conditions that may be rare, or whose contribution to abnormal bleeding has not been well established or understood. [21]

Pregnancy

Vaginal bleeding occurs during 15–25% of first trimester pregnancies. [29] Of these, half go on to miscarry and half bring the fetus to term. [30] There are a number of causes including complications to the placenta, such as placental abruption and placenta previa. Other causes include miscarriage, ectopic pregnancy, molar pregnancy, incompetent cervix, uterine rupture, and preterm labor. [31] Bleeding in early pregnancy may be a sign of a threatened or incomplete miscarriage. In the second or third trimester a placenta previa (a placenta partially or completely overlying the cervix) may bleed quite severely. Placental abruption is often associated with uterine bleeding as well as uterine pain. [32]

Vaginal bleeding during pregnancy can be normal, especially in early pregnancy. Light spotting early on in pregnancy can be a result of the fertilized egg implanting into the uterus. Additionally, during pregnancy, the blood supply to the cervix increases, which can cause the cervix to be more friable and bleed more easily than a non-pregnant woman's cervix. Because of this, some light spotting after intercourse can be normal. However, bleeding may also indicate a pregnancy complication that needs to be medically addressed and any vaginal bleeding during pregnancy should prompt a call to the patient's obstetric provider. [33]

Perimenopausal

While many of the causes of premenopausal bleeding still apply to perimenopausal women, there is an additional cause of abnormal uterine bleeding in this category of women, which is the hormonal changes. Around age 40, women's hormones begin to change and this can cause variation in menstrual patterns. This can last for years, with menstrual periods lasting various lengths and coming at various intervals. Menopause is considered complete after a woman has gone 12 months without a menstrual period. [34]

Postmenopausal

Endometrial atrophy, uterine fibroids, and endometrial cancer are common causes of postmenopausal vaginal bleeding. About 10% of cases are due to endometrial cancer. [35] Uterine fibroids are benign tumors made of muscle cells and other tissues located in and around the wall of the uterus. [36] Women with fibroids do not always have symptoms, but some experience vaginal bleeding between periods, pain during sex, and lower back pain. [37]

Diagnostic evaluation

The cause of the bleeding can often be discerned on the basis of the bleeding history, physical examination, and other medical tests as appropriate. The physical examination for evaluating vaginal bleeding typically includes visualization of the cervix with a speculum, a bimanual exam, and a rectovaginal exam. These are focused on finding the source of the bleeding and looking for any abnormalities that could cause bleeding. In addition, the abdomen is examined and palpated to ascertain if the bleeding is abdominal in origin. Typically a pregnancy test is performed as well. [38] If bleeding was excessive or prolonged, a CBC may be useful to check for anemia. Abnormal endometrium may have to be investigated by a hysteroscopy with a biopsy or a dilation and curettage.

In 2011, the International Federation of Gynaecology and Obstetrics (FIGO) recognized two systems designed to aid research, education, and clinical care of women with abnormal uterine bleeding (AUB) in the reproductive years. [9]

In postmenopausal vaginal bleeding, the primary goal of any diagnostic evaluations is to exclude endometrial hyperplasia and malignancy. Transvaginal ultrasonography and endometrial sampling are common methods for an initial evaluation. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) recommend transvaginal ultrasonography as an appropriate first-line procedure to identify which patients are at higher risk of endometrial cancer. [39] Endometrial sampling is indicated if having the following findings and/or symptoms: [39]

Endometrial sampling can be obtained either by an endometrial biopsy using an endometrium sampling device such as a pipelle or by dilation and curettage (D&C) with or without a hysteroscopy. [40]

FIGO System 1. The system for definition and nomenclature of normal and abnormal uterine bleeding (AUB) in the reproductive years. System 1 Nomenclature and Definitions 2016.jpg
FIGO System 1. The system for definition and nomenclature of normal and abnormal uterine bleeding (AUB) in the reproductive years.

Complications

Severe acute bleeding, such as caused by ectopic pregnancy and post-partum hemorrhage, leads to hypovolemia (the depletion of blood from the circulation), progressing to shock. [41] This is a medical emergency and requires hospital attendance and intravenous fluids, usually followed by blood transfusion. Once the circulating volume has been restored, investigations are performed to identify the source of bleeding and address it. [38] Uncontrolled life-threatening bleeding may require uterine artery embolization (occlusion of the blood vessels supplying the uterus), laparotomy (surgical opening of the abdomen), occasionally leading to hysterectomy (removal of the uterus) as a last resort. [22]

A possible complication from protracted vaginal blood loss is iron deficiency anemia, which can develop insidiously. [42] Eliminating the cause will resolve the anemia, although some women require iron supplements or blood transfusions to improve the anemia. [42]

Treatment

While many forms of vaginal bleeding are normal and do not require treatment, other forms will require medical attention. Hormonal management is usually the first option used to treat acute abnormal uterine bleeding. These hormonal medications include birth control pills, medroxyprogesterone acetate (brand name Depo-Provera), and conjugated equine estrogen. [2] [43] Long-term treatments include hormonal IUD insertion, birth control pills, progestin pills or progestin shots (Depo-Provera), and NSAIDs such as ibuprofen [2] [43] Certain medications may not be safe for certain women. Women with blood clotting disorders may also need to see a hematologist. [2]

Surgical treatments may also be considered if the bleeding is severe or if there are reasons patients cannot take the hormonal medications listed above. [2] These options include dilation & curettage, endometrial ablation, and hysterectomy (removal of the uterus). Hysterectomy will result in infertility, so surgical decisions will include women's preferences regarding future fertility when possible. [2]

See also

Related Research Articles

Dilationand curettage (D&C) refers to the dilation of the cervix and surgical removal of part of the lining of the uterus or contents of the uterus by scraping and scooping (curettage). It is a gynecologic procedure used for diagnostic and therapeutic purposes, and is the most commonly used method for first-trimester miscarriage or abortion.

<span class="mw-page-title-main">Uterus</span> Female sex organ in mammals

The uterus or womb is the organ in the reproductive system of most female mammals, including humans, that accommodates the embryonic and fetal development of one or more embryos until birth. The uterus is a hormone-responsive sex organ that contains glands in its lining that secrete uterine milk for embryonic nourishment.

Gynecologic hemorrhage represents excessive bleeding of the female reproductive system. Such bleeding could be visible or external, namely bleeding from the vagina, or it could be internal into the pelvic cavity or form a hematoma. Normal menstruation is not considered a gynecologic hemorrhage, as it is not excessive. Hemorrhage associated with a pregnant state or during delivery is an obstetrical hemorrhage.

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the surgical removal of the uterus and cervix. Supracervical hysterectomy refers to removal of the uterus while the cervix is spared. These procedures may also involve removal of the ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. The term “partial” or “total” hysterectomy are lay-terms that incorrectly describe the addition or omission of oophorectomy at the time of hysterectomy. These procedures are usually performed by a gynecologist. Removal of the uterus renders the patient unable to bear children and has surgical risks as well as long-term effects, so the surgery is normally recommended only when other treatment options are not available or have failed. It is the second most commonly performed gynecological surgical procedure, after cesarean section, in the United States. Nearly 68 percent were performed for conditions such as endometriosis, irregular bleeding, and uterine fibroids. It is expected that the frequency of hysterectomies for non-malignant indications will continue to fall given the development of alternative treatment options.

Heavy menstrual bleeding (HMB), previously known as menorrhagia or hematomunia, is a menstrual period with excessively heavy flow. It is a type of abnormal uterine bleeding (AUB).

Abnormal uterine bleeding (AUB), also known as (AVB) or as atypical vaginal bleeding, is vaginal bleeding from the uterus that is abnormally frequent, lasts excessively long, is heavier than normal, or is irregular. The term dysfunctional uterine bleeding was used when no underlying cause was present. Vaginal bleeding during pregnancy is excluded. Iron deficiency anemia may occur and quality of life may be negatively affected.

<span class="mw-page-title-main">Asherman's syndrome</span> Medical condition

Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis.

<span class="mw-page-title-main">Adenomyosis</span> Extension of endometrial tissue into the myometrium

Adenomyosis is a medical condition characterized by the growth of cells that proliferate on the inside of the uterus (endometrium) atypically located among the cells of the uterine wall (myometrium), as a result, thickening of the uterus occurs. As well as being misplaced in patients with this condition, endometrial tissue is completely functional. The tissue thickens, sheds and bleeds during every menstrual cycle.

<span class="mw-page-title-main">Endometrial polyp</span> Medical condition

An endometrial polyp or uterine polyp is a mass in the inner lining of the uterus. They may have a large flat base (sessile) or be attached to the uterus by an elongated pedicle (pedunculated). Pedunculated polyps are more common than sessile ones. They range in size from a few millimeters to several centimeters. If pedunculated, they can protrude through the cervix into the vagina. Small blood vessels may be present, particularly in large polyps.

<span class="mw-page-title-main">Uterine fibroid</span> Medical condition with benign tumors of uterus

Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumors of the uterus. Most women with fibroids have no symptoms while others may have painful or heavy periods. If large enough, they may push on the bladder, causing a frequent need to urinate. They may also cause pain during penetrative sex or lower back pain. A woman can have one uterine fibroid or many. Occasionally, fibroids may make it difficult to become pregnant, although this is uncommon.

<span class="mw-page-title-main">Uterine myomectomy</span> Surgical removal of uterine fibroid

Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. It still may impact hormonal regulation and the menstrual cycle.

<span class="mw-page-title-main">Uterine artery embolization</span>

Uterine artery embolization is a procedure in which an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body. The procedure is primarily done for the treatment of uterine fibroids and adenomyosis. Since uterine fibroids are the most common indication, it is also often referred to as uterine fibroid embolization. Compared to surgical treatment for fibroids such as a hysterectomy, in which a woman's uterus is removed, uterine artery embolization may be beneficial in women who wish to retain their uterus. Other reasons for uterine artery embolization are postpartum hemorrhage and uterine arteriovenous malformations.

Intermenstrual bleeding (IMB) is vaginal bleeding at irregular intervals between expected menstrual periods. It may be associated with bleeding with sexual intercourse.

<span class="mw-page-title-main">Endometrial ablation</span> Medical procedure

Endometrial ablation is a surgical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstrual periods. Endometrial ablation is most often employed in people with excessive menstrual bleeding, who do not wish to undergo a hysterectomy, following unsuccessful medical therapy.

<span class="mw-page-title-main">Menstrual disorder</span> Medical condition affecting menstrual cycle

A menstrual disorder is characterized as any abnormal condition with regards to a woman's menstrual cycle. There are many different types of menstrual disorders that vary with signs and symptoms, including pain during menstruation, heavy bleeding, or absence of menstruation. Normal variations can occur in menstrual patterns but generally menstrual disorders can also include periods that come sooner than 21 days apart, more than 3 months apart, or last more than 10 days in duration. Variations of the menstrual cycle are mainly caused by the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, and early detection and management is required in order to minimize the possibility of complications regarding future reproductive ability.

<span class="mw-page-title-main">Hematometra</span> Medical condition

Hematometra is a medical condition involving collection or retention of blood in the uterus. It is most commonly caused by an imperforate hymen or a transverse vaginal septum.

Uterine clear-cell carcinoma (CC) is a rare form of endometrial cancer with distinct morphological features on pathology; it is aggressive and has high recurrence rate. Like uterine papillary serous carcinoma CC does not develop from endometrial hyperplasia and is not hormone sensitive, rather it arises from an atrophic endometrium. Such lesions belong to the type II endometrial cancers.

<span class="mw-page-title-main">Postcoital bleeding</span> Medical condition

Postcoital bleeding (PCB) is non-menstrual vaginal bleeding that occurs during or after sexual intercourse. Though some causes are with associated pain, it is typically painless and frequently associated with intermenstrual bleeding.

Müllerian duct anomalies are those structural anomalies caused by errors in Müllerian duct development during embryonic morphogenesis. Factors that precipitate include genetics, and maternal exposure to teratogens.

<span class="mw-page-title-main">FIGO classification of uterine bleeding</span>

The International Federation of Gynecology and Obstetrics is an international organization that links about 125 international professional societies of Obstetricians and Gynecologists. In 2011 FIGO recognized two systems designed to aid research, education, and clinical care of women with abnormal uterine bleeding (AUB) in the reproductive years. This page is a summary of the systems and their use in contemporary gynecology.

References

  1. ↑ "Vaginal Bleeding | Uterine Fibroids | MedlinePlus" . Retrieved 2018-11-07.
  2. 1 2 3 4 5 6 7 8 "Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women". www.acog.org. Retrieved 2021-09-13.
  3. ↑ "Abnormal Uterine Bleeding". www.acog.org. Retrieved 2021-09-13.
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  16. ↑ Dumitrescu, Claudia E; Collins, Michael T (2008-05-19). "McCune-Albright syndrome". Orphanet Journal of Rare Diseases. 3: 12. doi: 10.1186/1750-1172-3-12 . ISSN   1750-1172. PMC   2459161 . PMID   18489744.
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  19. ↑ Munro, Malcolm G.; Critchley, Hilary O.D.; Fraser, Ian S. (2011). "The FIGO classification of causes of abnormal uterine bleeding in the reproductive years". Fertility and Sterility. 95 (7): 2204–2208.e3. doi: 10.1016/j.fertnstert.2011.03.079 . PMID   21496802.
  20. ↑ Fraser, Ian S.; Critchley, Hilary O. D.; Munro, Malcolm G.; Broder, Michael; Writing Group for this Menstrual Agreement Process (2007). "A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding". Fertility and Sterility. 87 (3): 466–476. doi: 10.1016/j.fertnstert.2007.01.023 . ISSN   1556-5653. PMID   17362717.
  21. 1 2 3 4 5 6 Munro, Malcolm G.; Critchley, Hilary O.D.; Fraser, Ian S. (2011). "The FIGO classification of causes of abnormal uterine bleeding in the reproductive years". Fertility and Sterility. 95 (7): 2204–2208.e3. doi: 10.1016/j.fertnstert.2011.03.079 . PMID   21496802.
  22. 1 2 Abbott, Jason A. (2017). "Adenomyosis and Abnormal Uterine Bleeding (AUB-A)—Pathogenesis, diagnosis, and management". Best Practice & Research Clinical Obstetrics & Gynaecology. 40: 68–81. doi:10.1016/j.bpobgyn.2016.09.006. PMID   27810281.
  23. 1 2 James, Andra H.; Kouides, Peter A.; Abdul-Kadir, Rezan; Edlund, Mans; Federici, Augusto B.; Halimeh, Susan; Kamphuisen, Pieter W.; Konkle, Barbara A.; Martínez-Perez, Oscar (2009). "Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel". American Journal of Obstetrics and Gynecology. 201 (1): 12.e1–12.e8. doi:10.1016/j.ajog.2009.04.024. PMID   19481722.
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  25. ↑ Zia, Ayesha; Rajpurkar, Madhvi (2016). "Challenges of diagnosing and managing the adolescent with heavy menstrual bleeding". Thrombosis Research. 143: 91–100. doi:10.1016/j.thromres.2016.05.001. PMID   27208978.
  26. ↑ "Amenorrhea: Absence of Periods". www.acog.org. Retrieved 2021-09-13.
  27. ↑ Rosenberg, Michael J.; Burnhill, Michael S.; Waugh, Michael S.; Grimes, David A.; Hillard, Paula J.A. (1995). "Compliance and oral contraceptives: A review". Contraception. 52 (3): 137–141. doi:10.1016/0010-7824(95)00161-3. ISSN   0010-7824. PMID   7587184.
  28. ↑ Talwar, P. P.; Dingfelder, J. R.; Ravenholt, R. T. (1977-05-26). "Increased risk of breakthrough bleeding when one oral-contraceptive tablet is missed". The New England Journal of Medicine. 296 (21): 1236–1237. doi:10.1056/NEJM197705262962122. ISSN   0028-4793. PMID   854070.
  29. ↑ "Bleeding During Pregnancy - ACOG". www.acog.org. Retrieved 2018-11-07.
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  32. ↑ "Placenta abruptio: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2018-11-07.
  33. ↑ "ACOG Committee Opinion No. 804: Physical Activity and Exercise During Pregnancy and the Postpartum Period: Correction". Obstetrics & Gynecology. 138 (4): 683–683. October 2021. doi:10.1097/AOG.0000000000004558. ISSN   0029-7844.
  34. ↑ Parihar, Mandakini; Vij, Anu (2015), "Perimenopausal Bleeding", Clinical Practice Guidelines on Menopause, Jaypee Brothers Medical Publishers (P) Ltd., pp. 35–35, retrieved 2024-02-16
  35. ↑ Clarke MA, Long BJ, Del Mar Morillo A, Arbyn M, Bakkum-Gamez JN, Wentzensen N (September 2018). "Association of Endometrial Cancer Risk With Postmenopausal Bleeding in Women: A Systematic Review and Meta-analysis". JAMA Intern Med. 178 (9): 1210–1222. doi:10.1001/jamainternmed.2018.2820. PMC   6142981 . PMID   30083701.
  36. ↑ "Uterine Fibroids | Fibroids | MedlinePlus" . Retrieved 2018-10-23.
  37. ↑ "What are the symptoms of uterine fibroids?". NICHD.NIH.gov. Retrieved 2018-10-23.
  38. 1 2 Morrison, LJ; Spence, JM (2011). Vaginal Bleeding in the Nonpregnant Patient. New York City: McGraw-Hill.{{cite book}}: |work= ignored (help)
  39. 1 2 "ACOG Committee Opinion No. 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding". Obstetrics & Gynecology. 131 (5): e124–e129. May 2018. doi: 10.1097/AOG.0000000000002631 . ISSN   0029-7844. PMID   29683909.
  40. ↑ "Tests for Endometrial Cancer". www.cancer.org. Retrieved 2021-09-13.
  41. ↑ Newsome, Janice; Martin, Jonathan G.; Bercu, Zachary; Shah, Jay; Shekhani, Haris; Peters, Gail (December 2017). "Postpartum Hemorrhage". Techniques in Vascular and Interventional Radiology. 20 (4): 266–273. doi:10.1053/j.tvir.2017.10.007. ISSN   1557-9808. PMID   29224660.
  42. 1 2 Mansour, Diana; Hofmann, Axel; Gemzell-Danielsson, Kristina (January 2021). "A Review of Clinical Guidelines on the Management of Iron Deficiency and Iron-Deficiency Anemia in Women with Heavy Menstrual Bleeding". Advances in Therapy. 38 (1): 201–225. doi:10.1007/s12325-020-01564-y. ISSN   1865-8652. PMC   7695235 . PMID   33247314.
  43. 1 2 Sweet, Mary Gayle; Schmidt-Dalton, Tarin A.; Weiss, Patrice M.; Madsen, Keith P. (2012-01-01). "Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women". American Family Physician. 85 (1): 35–43. ISSN   0002-838X. PMID   22230306.
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