Uncovering the seven deadly sins of vaginal bleeding

Vaginal bleeding is bleeding from any part of the reproductive tract. The cause of bleeding may be from systemic disease or from the reproductive tract. The bleeding may take various forms, including heavy menstrual flow, prolonged menstruation, irregular vaginal bleeding, or contact bleeding. The amount of bleeding may be more or less. According to its different causes, vaginal bleeding can be divided into the following types.

1. Endocrine-related bleeding

1. Neonatal vaginal bleeding

Under the influence of placental estrogen, the uterus and ovaries of the female fetus are affected to a certain extent, manifested as the appearance of partially developed follicles and atretic follicles in the ovaries, and endometrial hyperplasia. In a small number of baby girls, due to the interruption of estrogen supply from the mother after birth, the endometrium may undergo hormone withdrawal shedding, resulting in vaginal bleeding similar to menstruation. The bleeding usually stops on its own after a few days and does not require treatment.

2. Bleeding related to contraceptive drugs

Vaginal bleeding when taking contraceptives, also known as breakthrough bleeding, mostly occurs after missed pills. For a small number of people who have not missed pills, vaginal bleeding is related to insufficient hormone intake. If bleeding occurs in the first half of menstruation, it is often due to insufficient estrogen, causing endometrial necrosis and exfoliation bleeding, which can be improved by estrogen treatment. Vaginal bleeding caused by the use of contraceptives is often manifested as irregular spotting.

3. Dysfunctional uterine bleeding

Occurs during puberty or menopause. There is often a history of amenorrhea and menstrual cycle disorders in the early stage of bleeding. When the amount of bleeding is heavy, there are often signs of anemia. Uterine examination showed no organic changes, and anovulatory uterine bleeding should be considered. Further basal body temperature examination, premenstrual diagnostic curettage, hormone measurement, etc. can confirm the diagnosis; if it occurs in middle-aged women, the menstrual cycle is still regular but the menstrual period is prolonged, it is often considered to be ovulatory uterine bleeding. Further measurement of basal body temperature, hormone levels, and curettage on the fifth day of menstruation can usually confirm the diagnosis.

4. Intermenstrual bleeding

It usually occurs on the 12th to 16th day of the menstrual cycle, lasts 1 to 2 hours or 1 to 2 days, with a small amount, and rarely reaches the menstrual volume. The cause is probably due to the rupture of the follicle and a temporary drop in estrogen levels.

5. Postmenopausal uterine bleeding

In recent years, the rate of uterine bleeding has increased due to the increasing use of estrogen and progesterone. In addition, for some patients, although the amount of estrogen secreted by the ovaries decreases after menopause, the small amount of estrogen secreted by the adrenal glands gradually accumulates and can cause the endometrium to grow and lead to uterine bleeding.

2. Bleeding related to pregnancy and childbirth

Uterine bleeding in women of childbearing age is a common pregnancy complication or abnormal pregnancy. If vaginal bleeding occurs in early pregnancy, abortion should be considered. The type of miscarriage can be determined based on the amount of bleeding, the degree of lower abdominal pain, the degree of cervical opening, the degree of consistency between the uterus and the month of pregnancy, pregnancy tests and B-ultrasound examinations. If a woman is afraid of having a baby and has severe lower abdominal pain, and although the amount of vaginal bleeding is not large but there are signs of bleeding, ectopic pregnancy, miscarriage or rupture should be considered, and further diagnosis should be made through posterior fornix puncture, pregnancy test, B-ultrasound, etc.; if vaginal bleeding occurs in late pregnancy, placenta previa, early placental abruption, rupture of placental marginal sinusoids, circumvallate placenta, and rupture of velamentous placental vessels anterior should be considered, and the diagnosis can be confirmed through abdominal examination, B-ultrasound, and placental examination after delivery; if the reaction after pregnancy is severe, with vaginal bleeding, and the uterus is larger than the month of pregnancy, and the fetal body cannot be touched, hydatidiform mole should be considered, and further diagnosis can be made through urine human chorionic gonadotropin determination, B-ultrasound, etc.; bleeding caused by delivery is related to uterine atony, soft birth canal laceration, retained placenta, and coagulation mechanism disorder; vaginal bleeding in the puerperium should consider residual infection of the placenta or fetal membrane tissue in the uterine cavity, and special attention should be paid to infection and rupture of the uterine incision after cesarean section. The presence of residual tissue in the uterine cavity can be confirmed by B-ultrasound diagnosis and pathological examination after curettage. Severe uterine incision infection and dehiscence often require laparotomy for diagnosis.

3. Vaginal bleeding related to inflammation

This type of bleeding is mostly caused by inflammation of the female reproductive tract, which leads to ulcers, necrosis and bleeding of mucosal tissues.

1. Bleeding from the vulva

It can be seen in vulvar ulcers, urethral caruncle, etc.

2. Vaginal bleeding

It is often caused by vaginitis, among which senile vaginitis and Trichomonas vaginitis are the most common. The amount of bleeding is generally small, but occasionally more bleeding is seen.

3. Cervical bleeding

Seen in acute and chronic cervicitis, cervical polyps, etc.

4. Uterine bleeding

It is more common in acute and chronic endometritis, acute pelvic inflammatory disease, etc.

4. Vaginal bleeding associated with IUD placement

Symptoms include increased menstrual flow or irregular bleeding. The former bleeding is related to the increased activity of plasmin by the IUD, which leads to fibrinolysis; the latter bleeding is related to the local necrosis and/or superficial ulcer of the endometrium caused by the mechanical compression of the IUD in the uterus. This type of bleeding occurs after the IUD is inserted.

5. Trauma-related bleeding

1. Trauma

The vulva has rich blood circulation, and the skin and submucosal tissue are loose, which can easily cause bleeding and hematoma after injury.

2. Bleeding after sexual intercourse

It may be caused by contact bleeding due to urethral caruncle caused by sexual intercourse, vaginal or cervical tumors, cervical erosion, polyps, etc. Or the hymen may rupture and bleed during first sexual intercourse, but the amount of bleeding is generally small. If it is severe bleeding during sexual intercourse, it is often caused by laceration of the vaginal wall or posterior fornix. This type of laceration often occurs in women with vaginal hypoplasia, older women, or during first sexual intercourse after childbirth, and is often caused by fragile vaginal tissue or overly rough sexual intercourse.

3. Vaginal varicose veins

Rupture during pregnancy or childbirth can also cause vaginal bleeding.

6. Tumor-related bleeding

Tumors of the female reproductive organs, especially vaginal malignant tumors, benign and malignant tumors of the cervix and uterus can often cause vaginal bleeding.

If a young girl has irregular vaginal bleeding, vaginal grape-like sarcoma should be considered. The most common sites of occurrence are the vagina, bladder, and urethra. If the bladder or urethra is invaded, in addition to vaginal bleeding, it is often accompanied by symptoms such as frequent urination and painful urination. Vaginal examination revealed grape-like swellings in the vagina or cervical lesions.

Middle-aged and older women who experience menstrual changes, increased menstrual flow, lower abdominal swelling, enlarged uterus, irregular and hard surface should consider uterine fibroids. Submucosal fibroids can sometimes be exposed at the external cervical os. If contact bleeding or irregular vaginal bleeding occurs, cervical cancer should be considered. Early cervical cancer often has bloody leucorrhea and a history of contact bleeding, and the cervix appears smooth or eroded. In the late stage of cervical cancer, the cervix is ​​thin and the growths are obvious, and the diagnosis is usually not difficult, but the definitive diagnosis still requires pathological examination.

If vaginal bleeding occurs after menopause, endometrial cancer should also be considered, which can be confirmed by segmental curettage and endometrial pathology examination.

Vaginal bleeding caused by adnexal masses should be considered as a functional ovarian tumor, such as granulosa cell tumor, follicular cell tumor, etc.

In addition, fallopian tube cancer and uterine fibroids can also cause vaginal bleeding.

7. Bleeding Related to Systemic Disease

Vaginal bleeding caused by systemic diseases is most common in blood diseases, disseminated intravascular coagulation and liver diseases. The first two cause bleeding and thrombocytopenia. It is related to abnormal platelet quality, increased capillary permeability or coagulation dysfunction. The latter bleeding is related to the reduction of coagulation factors synthesized by the liver. Bleeding caused by the above-mentioned diseases often manifests as bleeding in multiple parts of the body, while vaginal bleeding is mainly manifested by increased menstrual volume, increased duration of menstruation, and increased amount and duration of postpartum lochia. Once disseminated intravascular coagulation occurs, it may be life-threatening due to excessive bleeding and continuous bleeding. In addition, systemic diseases such as severe hypertension and nephritis can also cause excessive menstrual flow.