Abnormal Vaginal Bleeding

The International Federation of Gynaecology and Obstetrics (FIGO) divides AUB in women of reproductive age into structural and non-structural causes using the PALM-COEIN classification system.¹⁵ Structural causes (PALM) include polyps, adenomyosis, leiomyomas (fibroids), and malignancy whereas non-structural causes (COEIN) include coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not otherwise classified.¹⁵ It is important to note that the cause of the bleeding may be multi factorial and several causes may coexist.¹⁴

• Structural causes for AUB
  • Polyps
    • Localized tumours of the endocervix or endometrium⁴
    • Usually benign but some have atypical or malignant features¹⁵
    • Often asymptomatic can contribute to AUB¹⁵
  • Adenomyosis
    • Invasion of the myometrium by endometrial tissue⁴
  • Leiomyoma (fibroid)
    • Benign fibromuscular tumours of the uterus
    • Oten asymptomatic but can contribute to AUB^4,15
  • Malignancy and hyperplasia
    • Serious but relatively uncommon cause of AUB¹⁵
• Non-structural causes for AUB
  • Coagulopathy
    • 13% of those with HMB may have von Willebrands Disease¹⁸
    • Other patients may have single factor deficiencies or platelet disorders¹⁷
  • Ovarian dysfunction
    • Often no known cause but polycystic ovarian syndrome, hypothyroidism, hyperprolactinaemia, stress, obesity, weight loss, anorexia or extreme exercise can all affect ovarian function¹⁵
  • Endometrial
    • Primary disorder of local endometrial haemostasis¹⁵
  • Iatrogenic
    • A number of drugs and devices can cause or alter uterine bleeding, including:
      • Intrauterine devices particularly in the first 6 months¹⁵
      • Breakthrough bleeding on oral contraceptives¹⁵
      • Tricyclic antidepressants¹⁵
      • Antipsychotics⁴
      • Anticonvulsants⁴
      • Anticoagulants¹⁵
  • Not yet classified

While the PALM-COEIN system sets out the causes for AUB in women of reproductive age, remember that not all vaginal bleeding is uterine in origin and not all patients are in this age cohort.

Non-uterine causes of vaginal bleeding include:

• Ovarian bleeding
  • More commonly presents with intraperitoneal bleeding but may occasionally present with vaginal bleeding. Causes include cancer, torsion, ruptured cyst.¹⁹
• Foreign body^6,13,17,20
  • E.g. retained tampon, condom
• Trauma of the lower genital tract^21,22
  • Vulva, vagina or cervix
  • Blunt or penetrating trauma
  • May relate to a sexual assault or rape but may have another explanation such as an accidental injury
• Gynaecological infections
  • Pelvic inflammatory disease (PID) is an ascending pelvic infection. It may cause tubo-ovarian abscess, salpingitis or endometritis²² and can present with bleeding.
• Bleeding that is mistakenly reported to be vaginal bleeding e.g. rectal bleeding or haematuria²³

SPECIFIC CAUSES OF VAGINAL BLEEDING IN DIFFERENT AGE COHORTS (1,6,13,22,24)

Learning bite

• Vaginal bleeding can be uterine, or from elsewhere in the genital tract
• Uterine bleeding has structural and non-structural causes
• Differential diagnosis changes depending on the age cohort