Editing Vaginal bleeding (section)

== 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.<ref>{{Cite journal|last1=Fraser|first1=Ian S.|last2=Critchley|first2=H. O. D.|last3=Munro|first3=M. G.|last4=Broder|first4=M.|date=2007|title=Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding?|journal=Human Reproduction (Oxford, England)|volume=22|issue=3|pages=635–643|doi=10.1093/humrep/del478|issn=0268-1161|pmid=17204526|doi-access=free}}</ref><ref>{{Cite journal|last1=Fraser|first1=Ian S.|last2=Critchley|first2=Hilary O. D.|last3=Munro|first3=Malcolm G.|last4=Broder|first4=Michael|last5=Writing Group for this Menstrual Agreement Process|date=2007|title=A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding|journal=Fertility and Sterility|volume=87|issue=3|pages=466–476|doi=10.1016/j.fertnstert.2007.01.023|issn=1556-5653|pmid=17362717|doi-access=free}}</ref>  The causes of abnormal vaginal bleeding vary by age.<ref name="Berek"/>

=== 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.<ref name=":12"/><ref name=":22"/> 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.<ref>{{Cite journal|last1=Aprile|first1=Anna|last2=Ranzato|first2=Cristina|last3=Rizzotto|first3=Melissa Rosa|last4=Arseni|first4=Alessia|last5=Da Dalt|first5=Liviana|last6=Facchin|first6=Paola|date=2011|title="Vaginal" bleeding in prepubertal age: A rare scaring riddle, a case of the urethral prolapse and review of the literature|journal=Forensic Science International|language=en|volume=210|issue=1–3|pages=e16–e20|doi=10.1016/j.forsciint.2011.04.017|pmid=21592695}}</ref>

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.<ref>{{Cite journal|last=Langan|first=R.C.|date=2006|title=Discharge procedures for healthy newborns.|url=https://www.aafp.org/afp/2006/0301/p849.html#afp20060301p849-b19|journal=Am Fam Physician|volume=73|issue=5|pages=849–52|via=PUBMED|pmid=16529093}}</ref><ref>{{Cite web|url=https://www.uptodate.com/contents/newborn-appearance-the-basics?topicRef=5068&source=see_link|title=Patient Education: Newborn Appearance (The Basics)|website=UpToDate|access-date=August 29, 2019}}</ref>  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.<ref name=":22" /> Other causes include trauma (either accidental or non accidental, i.e. [[child sexual abuse]] or [[Sexual assault|molestation]]), urethral prolapse, vaginal infection ([[vaginitis]]), [[Genital ulcer|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]].<ref>{{Cite journal|last1=Elmaoğulları|first1=Selin|last2=Aycan|first2=Zehra|date=September 2018|title=Abnormal Uterine Bleeding In Adolescents|journal=Journal of Clinical Research in Pediatric Endocrinology|volume=10|issue=3|pages=191–197|doi=10.4274/jcrpe.0014|issn=1308-5727|pmc=6083466|pmid=29537383}}</ref><ref>{{Cite journal|last1=Dumitrescu|first1=Claudia E|last2=Collins|first2=Michael T|date=2008-05-19|title=McCune-Albright syndrome|journal=Orphanet Journal of Rare Diseases|volume=3|pages=12|doi=10.1186/1750-1172-3-12|issn=1750-1172|pmc=2459161|pmid=18489744 |doi-access=free }}</ref>

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.<ref name=":22" /> 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.<ref name=":22" />

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.<ref>{{Cite journal|last=Simms-Cendan|first=Judith|date=2018|title=Examination of the pediatric adolescent patient|journal=Best Practice & Research. Clinical Obstetrics & Gynaecology|volume=48|pages=3–13|doi=10.1016/j.bpobgyn.2017.08.005|issn=1532-1932|pmid=29056510}}</ref>

=== Premenopausal ===

==== Background ====
In premenopausal women, bleeding can be from the uterus, from vulvar or vaginal lesions, or from the cervix.<ref name=":7">{{Cite book |last1=Berek |first1=Jonathan S. |url=http://archive.org/details/novaksgynecology00bere |title=Novak's gynecology |last2=Adashi |first2=E. Y. |last3=Hillard |first3=Paula Adams |last4=Jones |first4=Howard W. (Howard Wilbur) |date=1996 |publisher=Baltimore : Williams & Wilkins |others=Internet Archive |isbn=978-0-683-00593-6}}</ref> 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.<ref name=":7" /> 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 [[Uterine fibroid|fibroids]], [[Endometrial polyp|polyps]], hormonal disorders such as [[polycystic ovary syndrome]] (PCOS), [[Coagulopathy|blood clotting disorders]], and [[Uterine cancer|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.<ref name=":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.<ref>{{Cite journal |last1=Munro |first1=Malcolm G. |last2=Critchley |first2=Hilary O.D. |last3=Fraser |first3=Ian S. |date=2011 |title=The FIGO classification of causes of abnormal uterine bleeding in the reproductive years |journal=Fertility and Sterility |language=en |volume=95 |issue=7 |pages=2204–2208.e3 |doi=10.1016/j.fertnstert.2011.03.079 |pmid=21496802 |doi-access=free}}</ref> This acronym stands for ''P''olyp, ''A''denomyosis, ''L''eiomyoma, ''M''alignancy and Hyperplasia, ''C''oagulopathy, ''O''vulatory Disorders, ''E''ndometrial Disorders, ''I''atrogenic Causes, and ''N''ot 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.<ref>{{Cite journal |last1=Fraser |first1=Ian S. |last2=Critchley |first2=Hilary O. D. |last3=Munro |first3=Malcolm G. |last4=Broder |first4=Michael |last5=Writing Group for this Menstrual Agreement Process |date=2007 |title=A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding |journal=Fertility and Sterility |volume=87 |issue=3 |pages=466–476 |doi=10.1016/j.fertnstert.2007.01.023 |issn=1556-5653 |pmid=17362717 |doi-access=free}}</ref>

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.<ref name=":42">{{Cite journal|last1=Munro|first1=Malcolm G.|last2=Critchley|first2=Hilary O.D.|last3=Fraser|first3=Ian S.|date=2011|title=The FIGO classification of causes of abnormal uterine bleeding in the reproductive years|journal=Fertility and Sterility|language=en|volume=95|issue=7|pages=2204–2208.e3|doi=10.1016/j.fertnstert.2011.03.079|pmid=21496802|doi-access=free}}</ref> The COEIN causes of abnormal bleeding are not related to structural causes.<ref name=":42" />

'''PALM - Structural causes of uterine bleeding'''

* '''Polyps:''' [[Endometrial polyp]]s are benign growths that are typically detected during gynecologic [[Gynecologic ultrasonography|ultrasonography]] and confirmed using [[saline infusion sonography]] or [[hysteroscopy]], often in combination with an [[endometrial biopsy]] providing [[Histopathology|histopathologic]] confirmation. Endocervical polyps are visible at the time of a gynecologic examination using a [[Speculum (medical)|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.<ref name=":4">{{Cite journal|last=Abbott|first=Jason A.|date=2017|title=Adenomyosis and Abnormal Uterine Bleeding (AUB-A)—Pathogenesis, diagnosis, and management|journal=Best Practice & Research Clinical Obstetrics & Gynaecology|language=en|volume=40|pages=68–81|doi=10.1016/j.bpobgyn.2016.09.006|pmid=27810281}}</ref>
* '''Leiomyoma (fibroids):''' [[Uterine leiomyoma]], commonly termed uterine fibroids, are common, and most fibroids are asymptomatic.<ref name="Berek" /> 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.<ref name=":42" /> 
* '''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 [[Vulvar cancer|vulva]], the [[Vaginal cancer|vagina]], the [[Cervical cancer|cervix]], and the [[Uterine cancer|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 in polycystic ovary syndrome|anovulation]]. When endometrial hyperplasia is associated with atypical cells, it can progress to cancer or occur concurrently with it.<ref name="Berek" /> While endometrial hyperplasia and [[endometrial cancer]] occur most commonly among [[Post menopausal|post-menopausal]] women, most patients with endometrial cancer have abnormal bleeding, and thus the diagnosis must be considered in women during the reproductive years.<ref name="Berek" /><ref name=":42" />

'''COEIN - Non-structural causes of uterine bleeding'''
* '''Coagulopathies (blood clotting disorders):''' [[Heavy menstrual bleeding]] can be related to [[Coagulopathy|coagulopathies]].<ref name=":5">{{Cite journal|last1=James|first1=Andra H.|last2=Kouides|first2=Peter A.|last3=Abdul-Kadir|first3=Rezan|last4=Edlund|first4=Mans|last5=Federici|first5=Augusto B.|last6=Halimeh|first6=Susan|last7=Kamphuisen|first7=Pieter W.|last8=Konkle|first8=Barbara A.|last9=Martínez-Perez|first9=Oscar|date=2009|title=Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel|journal=American Journal of Obstetrics and Gynecology|language=en|volume=201|issue=1|pages=12.e1–12.e8|doi=10.1016/j.ajog.2009.04.024|pmid=19481722}}</ref> [[Von Willebrand disease]] is the most common coagulopathy, and most women with von Willebrand disease have heavy menstrual bleeding.<ref name=":5" />  Of women with heavy menstrual bleeding, up to 20% will have a bleeding disorder.<ref>{{Cite journal|last1=Davies|first1=Joanna|last2=Kadir|first2=Rezan A.|date=2017|title=Heavy menstrual bleeding: An update on management|journal=Thrombosis Research|language=en|volume=151|pages=S70–S77|doi=10.1016/S0049-3848(17)30072-5|pmid=28262240}}</ref> 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.<ref>{{Cite journal|last1=Zia|first1=Ayesha|last2=Rajpurkar|first2=Madhvi|date=2016|title=Challenges of diagnosing and managing the adolescent with heavy menstrual bleeding|journal=Thrombosis Research|language=en|volume=143|pages=91–100|doi=10.1016/j.thromres.2016.05.001|pmid=27208978}}</ref>  
* '''Ovulatory dysfunction:''' ''O''vulatory 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]], [[Hyperprolactinaemia|hyperprolactinemia]], obesity, eating disorders including [[anorexia nervosa]] or [[Bulimia nervosa|bulimia]],  or to an imbalance between exercise and caloric intake.<ref>{{Cite web|title=Amenorrhea: Absence of Periods|url=https://www.acog.org/en/womens-health/faqs/amenorrhea-absence-of-periods|access-date=2021-09-13|website=www.acog.org|language=en}}</ref>
* '''Endometrial:''' ''E''ndometrial 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|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.<ref name=":42" /> 
* '''Iatrogenic (caused by medical treatment or procedures):''' The most common [[Iatrogenic|''I''atrogenic]] 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.<ref>{{Cite journal|last1=Rosenberg|first1=Michael J.|last2=Burnhill|first2=Michael S.|last3=Waugh|first3=Michael S.|last4=Grimes|first4=David A.|last5=Hillard|first5=Paula J.A.|date=1995|title=Compliance and oral contraceptives: A review|journal=Contraception|volume=52|issue=3|pages=137–141|doi=10.1016/0010-7824(95)00161-3|pmid=7587184|issn=0010-7824}}</ref>  The risk of breakthrough bleeding with oral contraceptives is greater if pills are missed.<ref>{{Cite journal|last1=Talwar|first1=P. P.|last2=Dingfelder|first2=J. R.|last3=Ravenholt|first3=R. T.|date=1977-05-26|title=Increased risk of breakthrough bleeding when one oral-contraceptive tablet is missed|journal=The New England Journal of Medicine|volume=296|issue=21|pages=1236–1237|issn=0028-4793|pmid=854070|doi=10.1056/NEJM197705262962122}}</ref>  
* '''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.<ref name=":42" />

=== Pregnancy ===
Vaginal bleeding occurs during 15–25% of first trimester [[Pregnancy|pregnancies]].<ref>{{Cite web|url=https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy|title=Bleeding During Pregnancy - ACOG|website=www.acog.org|access-date=2018-11-07}}</ref> Of these, half go on to [[miscarriage|miscarry]] and half bring the fetus to term.<ref name=Preg09>{{cite journal|last=Snell|first=BJ|title=Assessment and management of bleeding in the first trimester of pregnancy.|journal=Journal of Midwifery & Women's Health|date=Nov–Dec 2009|volume=54|issue=6|pages=483–91|pmid=19879521|doi=10.1016/j.jmwh.2009.08.007}}</ref> There are a number of causes including complications to the [[placenta]], such as [[placental abruption]] and [[Placenta praevia|placenta previa]]. Other causes include [[miscarriage]], [[ectopic pregnancy]], [[molar pregnancy]], incompetent cervix, [[uterine rupture]], and [[Preterm birth|preterm labor]].<ref>{{Cite web|title=Bleeding during pregnancy Causes|url=https://www.mayoclinic.org/symptoms/bleeding-during-pregnancy/basics/definition/sym-20050636|access-date=2020-10-29|website=Mayo Clinic|language=en}}</ref> Bleeding in early pregnancy may be a sign of a [[threatened miscarriage|threatened]] or [[incomplete miscarriage|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.<ref>{{Cite web|url=https://medlineplus.gov/ency/patientinstructions/000605.htm|title=Placenta abruptio: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|access-date=2018-11-07}}</ref>

Vaginal bleeding [[Obstetrical bleeding|during pregnancy]] can be normal, especially in [[Early pregnancy bleeding|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.<ref>{{Cite journal |date=October 2021 |title=ACOG Committee Opinion No. 804: Physical Activity and Exercise During Pregnancy and the Postpartum Period: Correction |url=https://journals.lww.com/10.1097/AOG.0000000000004558 |journal=Obstetrics & Gynecology |language=en |volume=138 |issue=4 |pages=683 |doi=10.1097/AOG.0000000000004558 |pmid=34623087 |issn=0029-7844}}</ref>

=== 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.<ref>{{Citation |last1=Parihar |first1=Mandakini |title=Perimenopausal Bleeding |date=2015 |work=Clinical Practice Guidelines on Menopause |pages=35 |url=http://dx.doi.org/10.5005/jp/books/12591_10 |access-date=2024-02-16 |publisher=Jaypee Brothers Medical Publishers (P) Ltd. |last2=Vij |first2=Anu|doi=10.5005/jp/books/12591_10 |isbn=978-93-5152-127-3 |url-access=subscription }}</ref>

=== Postmenopausal ===
Endometrial atrophy, uterine fibroids, and [[endometrial cancer]] are common causes of postmenopausal vaginal bleeding. About 10% of cases are due to endometrial cancer.<ref name="pmid30083701">{{cite journal | vauthors = Clarke MA, Long BJ, Del Mar Morillo A, Arbyn M, Bakkum-Gamez JN, Wentzensen N | title = Association of Endometrial Cancer Risk With Postmenopausal Bleeding in Women: A Systematic Review and Meta-analysis | journal = JAMA Intern Med | volume = 178 | issue = 9 | pages = 1210–1222 | date = September 2018 | pmid = 30083701|pmc = 6142981| doi = 10.1001/jamainternmed.2018.2820 }}</ref> Uterine fibroids are benign tumors made of muscle cells and other tissues located in and around the wall of the [[uterus]].<ref>{{Cite news|url=https://medlineplus.gov/uterinefibroids.html|title=Uterine Fibroids {{!}} Fibroids {{!}} MedlinePlus|access-date=2018-10-23}}</ref> Women with fibroids do not always have symptoms, but some experience vaginal bleeding between periods, pain during sex, and lower back pain.<ref>{{Cite web|url=https://www.nichd.nih.gov/health/topics/uterine/conditioninfo/symptoms|title=What are the symptoms of uterine fibroids?|website=NICHD.NIH.gov|access-date=2018-10-23}}</ref> <!--This article has a delayed release (embargo) and will be available in PMC on August 6, 2019-->