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Abnormal genital tract bleeding

The Australian Centre for Female Pelvic and Vaginal Rejuvenation
The Australian Centre for Female Pelvic and Vaginal Rejuvenation

When is genital tract bleeding abnormal?

The genital tract is defined as the lower urinary and reproductive tract

To identify what is abnormal, one needs to know what is considered to be normal

  • Menstrual blood loss should not be prolonged or excessive.
  • There should be no vaginal bleeding in-between the menses.
  • There should be no vaginal bleeding after the menopause (unless on HRT).
  • There should be no bleeding from the bladder.

Types of abnormal genital tract bleeding

Menstrual
  • Menorrhagia
  • Polymenorrhoea
  • Polymenorrhagia
  • Intermenstrual bleeding
  • Oligomenorrhoea
  • Amenorrhoea
  • Postcoital bleeding
Bleeding after the menopause
  • Postmenopausal bleeding
HRT related
  • Hormone replacement therapy (HRT) related unscheduled genital tract bleeding
Bladder
  • Haematuria

Menorrhagia

  • Excessively heavy menstrual flow with cycles of normal length.

Polymenorrhoea

  • Abnormally frequent/prolonged menstruation.

Polymenorrhagia

  • Abnormally frequent &/or prolonged menstruation.

Definitions

Intermenstrual bleeding (IMB)

  • Bleeding inbetween the times of normal menstrual loss.

Oligomenorrhoea

  • Very light or infrequent periods.

Amenorrhoea

  • Absence of menses between the menarche (first period) and menopause (last period).

Postcoital bleeding

  • Reproductive system bleeding that occurs after coitus.

Postmenopausal bleeding

  • Bleeding from the reproductive system that occurs six months or more after menstrual periods have stopped due to menopause.

HRT related unscheduled genital tract bleeding

  • Unscheduled reproductive system bleeding associated with use of HRT.

Haematuria

  • Blood in the urine. It may result from infection, inflammation, tumours, kidney stones, or other disorders.

Symptoms of genital tract bleeding

The essential symptom is the presence of blood that is assumed to be coming from the genitourinary tract

In order to make an accurate diagnosis and to facilitate appropriate treatment, your doctor will need to:

  • Exclude the possibility of blood arising from an area outside of the lower genitourinary tract.
  • Confirm the exact source of the bleeding.

Your doctor will formulate a differential diagnosis, encompassing the most likely causes of the abnormal genital tract bleeding. This differential diagnosis will be based on knowledge of possible causes and explored to reach a conclusion through a variety of tailored investigations.

Possible causes of abnormal genital tract bleeding

Uterus
  • Endometrial polyp
  • Atrophy
  • Cancer
  • Unrecognised pregnancy (threatened miscarriage)
  • IUCD (Mirena) related
  • HRT related

Abnormal uterine bleeding in the absence of demonstrated pathology is called “dysfunctional uterine bleeding.”

Cervix
  • Cervical polyp
  • Erosion
  • Cancer

Cervical erosions are caused by the local hormonal environment. Pap smears are not used to detect cancer. This form of screening picks up pre-cancerous (dysplastic) cells.

Fallopian tubes
  • Cancer

Fallopian tube cancer was, until recently, thought to be quite rare. There is increasing evidence that the majority of so-called ovarian cancers arise from the fallopian tubes.

Vaginal wall or introitus
  • Atrophy
  • Tears & lacerations
  • Polyps
  • Granulation tissue
  • Exposed foreign body

Vaginal wall atrophy is one of the earliest changes that takes place in the perimenopause. The dryness becomes more symptomatic over time. The thinned vaginal epithelium results in fragile, exposed blood vessels. Tears and lacerations have numerous aetiologies including trauma, atrophy and surgery.

Bladder
  • Cystitis
  • Urinary tract infection
  • Calculus
  • Foreign body
  • Cancer

Cystitis is inflammation of the bladder, most commonly (but not exclusively) caused by bacterial infection. Visible blood in the urine is know as ‘macroscopic.’ When blood is only identified under the microscope, this is known as ‘microscopic.’

Lower ureters
  • Stone
  • Cancer

Benign and cancerous conditions of the upper renal tract (kidneys and upper ureters) are managed by urologists. Urologists also manage cancer in the bladder and lower renal tract.

Making a diagnosis

History

Examination

Investigations
Laser Vaginal Rejuvenation Institute of Adelaide
Laser Vaginal Rejuvenation Institute of Adelaide