Vaginal Bleeding Non-Pregnant
This essay discusses vaginal bleeding (VB) that is non-traumatic. It does not address resuscitation - obviously a hemodynamically compromised patient needs IV access, a monitor, lab tests, type and screen or cross, O2, etc.

Evaluation of a patient with VB begins with a binary decision. Is this patient pregnant? The DDx and work-up differ substantially for pregnant and non-pregnant (NP) patients. The best/easiest way to determine pregnancy status is a bedside urine HCG. The test is virtually 100% sensitive and specific.
  • There is almost never a reason to send a serum B-hCG is the urine test is negative
This essay predominantly is concerned with the commonest kind of VB we see in the ED. Painless (or just with menstrual type cramping) bleeding from the cervical os (i.e. the bleeding originates in the uterus).

There are only a couple of decisions which need to be made in the NP VB patient. First, is the patient bleeding heavily enough that checking an H + H, possible transfusion, or even admission/surgery may be needed? The H+P needs to be addressed primarily to this end. The relevant points will be addressed in a moment, but if there appears to be no need for further testing or treatment in the ED, the NP VB patient may be discharged for follow up with a Family Medicine or OB/GYN physician. IOW, you don't need a definitve dx, just to assure yourself (and the patient) that the patient is stable and has access to follow up.
  • Quantifying Bleeding in the non-pregnant VB patient
    • Everybody always asks about pad count. I find this pretty useless. After all, the threshold for changing the pad or tampon must differ widely between individuals as does the absorbancy of what they are using. It is still reasonable to ask how their pad usage compares with the number/frequency used in a normal period.
      • I ask (and document) if the bleeding is less, equally, or heavier than a normal period as well as the duration of the bleeding.
        • Example: "The patient reports 10 days of vaginal bleeding about as heavy as her normal periods which ar usually 3-4 days."
      • I sitll ask for (and document) a pad count, because it's likely whoever will follow/consult will want to know.
      • Ask if there are clots and if so, how many and how large (related to size of common objects if possible). Clots imply heavier or non-menstrual bleeding. Especially so if they are larger (diameter of a quarter or greater)
    • Look! The best way to determine how heavily someone is bleeding is to look (a speculum exam). 
      • Blood may pool in the vagina obscuring visualization, remove it with large absorbent swabs if present
      • Visualize the source of  bleeding, it's almost always the cervical os
        • Rarely there will be a bleeding vaginal or cervical lesion or unexpected laceration
      • Categorize bleeding from the os as:
        • absent - no active bleeding noted
        • light or minimal - occasional drop of blood
        • moderate - constant dripping or light trickling which may be intermittent
        • heavy - steady flow, may have clots
  • Indications for lab testing in the non-pregnant VB patient
    • Urine hCG to verify not pregnant
    • CBC to check the H/H if there are signs or symptoms of volume depletion/anemia (orthostasis, tachycardia, dizziness, marked fatigue or dyspnea on exertion) or moderate/ heavy bleeding
      • For when moderate or heavy bleeding is found on PE or by history (bleeding a lot heaver or more prolonged than a normal period)
    • CBC to check the platelet count when there is a reason to suspect thrombocytopenia (petechia, purpura, ecchymosis, medications associated with thrombocytopenia, chemotherapy, history of thrombocytopenia)
      • VB may be the presenting sign/symptom in thrombocytopenia. I have personally seen petechia, purpura, and/or ecchymosis and NOT vaginal bleeding as the primary manifestion. But then clinically signficant thrombocytopenia is not a common ED complaint so my N is small. A quick lit search failed to clarify this issue
    • PT/INR/PTT for patients on anticoagulants or with a known or suspected bleeding disorder 
    • Von Willebrand disease (WVD) is relatively common though usually not severe. VB may be the presenting symptoms as menorrhagia has an odds ratio of 2.5-5.4 for WVD
      • PTT is elevated only in the relatively uncommon more severe variants of WVD
        • Obtain "coags" onl;y in the patient with severe bleeding 
    • No other lab testing is usually indicated.
      • Obviously, if the patient is on warfarin check the PT/INR
  • Treatment of VB in the Non-Pregnant Patient 
    • Notice we haven't talked about diagnosis. 
      • This is topsy-turvy. The usual treatment paradigm starts with diagnosis. Here, in the case of NP VB, if the bleeding is heavy and or really bothering the patient it is often ok to proceed with treatment w/o a DX. Regard it as "symptomatic treatment", kind of like Tylenol for a fever.
    • High dose estrogen is usually very effective at stopping NP VB from the uterus (eg. the blood is coming from the os). It is not a "cure" as it doesn't solve the underlying problem
      • Premarin, 2.5mg po bid-qid. for up to a week
        • Causes nausea, also prescribe an anti-emetic. 
      • Estrogen increases risk for venous thrombosis and is contraindicated in the following:
          • History of VTE disease
          • Severe CAD or CVD
          • Active cancer
            • Smokers are also at increased risk, warn them and urge them to stop smoking, at least while on estrogen
        • Warn patient of potential complications, they may elect not to take it. This is a form of self triage that is to be encouraged. Maybe the bleeding isn't so bad after all?
      • If hormones are presecribed the patient must follow-up with a FP or GYN within a week
  • DDx of NP VB (from the cervical os)
    • Fibroids, endometrial hyperplasia, adenomas, carcinoma, anovulatory bleeding
      • Not necessary to decide which it is in the ED
    • Acquired or hereditary bleeding disorder
  • DDx of non-uterine NP VB
    • Growths/cancers of the cervix, vagina, vulva
    • Trauma (hopefully revealed by the history, but people are funny)
    • Acquired or hereditary bleeding disorder
  • Imaging
    • Not typically useful in the ED for a patient with painless VB from the uterus
      • Ultrasound can be useful in dx, but as described above it isn't always necessary to have a diagnosis per se