Vaginal Bleeding (Non-Pregnant) MDM

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Contents

Last reviewed: March 2026

MDM Templates

Abnormal Uterine Bleeding — Stable Discharge

Patient presents with vaginal bleeding in the setting of confirmed negative pregnancy test. Hemodynamically stable. Hemoglobin ***. No coagulopathy on labs. History and exam lower suspicion for ectopic pregnancy, coagulopathy, trauma, or other emergent cause. Presentation most likely secondary to abnormal uterine bleeding from *** (fibroids/anovulatory cycle/hormonal). Plan: Iron supplementation. Outpatient pelvic ultrasound referral. Disposition: Discharge with OBGYN follow-up within 1–2 weeks. Return for heavy bleeding, lightheadedness, or passage of large clots.

Abnormal Uterine Bleeding — Moderate (Hormonal Management)

Patient presents with prolonged moderate vaginal bleeding. Hemodynamically stable but symptomatic. Plan: Medroxyprogesterone acetate 20 mg TID for 7 days to stabilize endometrium, then taper. Iron supplementation. Disposition: Discharge with OBGYN follow-up in 1 week. Return for heavy bleeding, lightheadedness, or hemodynamic instability.

Vaginal Bleeding — Severe/Admit

Patient presents with severe vaginal bleeding with hemodynamic instability or significant anemia (Hgb ***). Plan: IV access, type and crossmatch, transfuse as indicated. IV conjugated estrogen (Premarin) 25 mg q4–6h if refractory. Tranexamic acid 1 g IV. OBGYN consulted emergently. Disposition: Admit for monitoring, possible surgical intervention (D&C, embolization).

Clinical Education

Approach to Non-Pregnant Vaginal Bleeding in the ED

Always confirm pregnancy status with a sensitive beta-hCG before attributing bleeding to other causes. Assessment of hemodynamic stability guides urgency: check orthostatic vital signs and peripheral perfusion in all patients. A complete blood count assesses baseline hemoglobin and helps quantify blood loss; coagulation studies (PT, aPTT) are obtained if heavy bleeding, anticoagulation use, or family history of bleeding disorder is present[1]. Pelvic ultrasound or gynecologic exam may identify structural pathology (fibroids, polyps) and guide disposition and outpatient management.

PALM-COEIN Classification

The PALM-COEIN framework organizes the causes of abnormal uterine bleeding (AUB) into structural and non-structural categories: PALM refers to structural pathology (Polyps, Adenomyosis, Leiomyoma/fibroids, Malignancy), while COEIN encompasses non-structural causes (Coagulopathy, Ovulatory dysfunction, Endometrial disorder, Iatrogenic, Not otherwise classified)[2]. This classification is useful for organizing outpatient workup and explaining findings to patients. In the ED, identification of hemodynamic instability or anemia severity is more immediately relevant than definitive categorization, which is often determined in the outpatient/gynecology setting.

Medical Management of Abnormal Uterine Bleeding

Acute hormonal stabilization of the endometrium is the cornerstone of ED management for moderate AUB. Medroxyprogesterone acetate 20 mg orally three times daily for 7 days effectively stabilizes endometrial tissue; patients then taper the dose over subsequent weeks[1]. Combined oral contraceptive pills given at higher frequency (e.g., one tablet q6h for 7 days) can also control bleeding but are typically reserved for outpatient management due to thrombotic risk. Tranexamic acid 1 g orally TID (or IV 1 g in severe cases) reduces fibrinolysis and decreases menstrual bleeding; it is safe and increasingly used in acute settings[3]. Iron supplementation should be offered to all patients with significant blood loss to prevent anemia progression.

Severe Hemorrhage Management

Hemodynamically unstable patients or those with hemoglobin <7 g/dL require aggressive resuscitation and consideration of admission. Establish at least two large-bore IV lines, obtain type and crossmatch, and initiate PRBCs if hemodynamically unstable or symptomatic anemia is present. IV conjugated estrogen (Premarin) 25 mg IV every 4–6 hours is a potent endometrial hemostatic agent useful for refractory bleeding; it works within hours and carries risk of thromboembolic events so should be reserved for severe cases[1]. Tranexamic acid 1 g IV is given concurrently. OBGYN consultation is emergent for possible D&C (mechanical endometrial ablation) or interventional radiology for uterine artery embolization if bleeding is intractable.

Von Willebrand Disease and Abnormal Uterine Bleeding

Von Willebrand disease (vWD) is the most common inherited bleeding disorder (affecting ~1% of the population) and is significantly overrepresented in women with heavy menstrual bleeding since menarche. Young women presenting with AUB, particularly those with a family history of bleeding disorder or lifelong heavy menses, should be screened with vWF antigen and activity panels[2]. Treatment with desmopressin or vWF concentrates can reduce menstrual bleeding in affected patients; early diagnosis allows for counseling and definitive management prior to elective procedures or pregnancy.

Postmenopausal Bleeding

Any vaginal bleeding in a postmenopausal woman (>12 months without menses) is abnormal and must be evaluated for endometrial malignancy. Even light spotting requires formal workup with endometrial biopsy or office sonogram with saline infusion (SIS) to exclude cancer. The differential includes atrophic vaginitis (usually spotting with visible atrophy), endometrial polyps, fibroids, endometrial hyperplasia, and endometrial cancer; malignancy cannot be clinically excluded without sampling[4]. In the ED, ensure urgent OBGYN or gynecology oncology referral for same-week evaluation and biopsy.

References

  1. Munro MG, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2018;143(1):5–13.
  2. James AH. More than just a heavy period: hemorrhagic disorders and other bleeding issues in women. Hemophilia. 2005;11(3):295–308.
  3. Shakur H, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients: a randomized, controlled trial. Lancet. 2010;376(9734):23–32.
  4. American College of Obstetricians and Gynecologists. Evaluation and management of abnormal uterine bleeding in nonpregnant reproductive-aged women. ACOG Practice Bulletin. 2018;(218).
  5. Marjoribanks J, et al. Long-acting reversible contraception versus other forms of reversible contraceptives or routinely used contraceptive methods for contraception. Cochrane Database Syst Rev. 2016;(3):CD002341.

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