II. Causes: Age-Specific uterine bleeding Causes

  1. Prepubertal Years (before Menarche)
    1. Newborn girls
      1. Occurs within 6 weeks of delivery
      2. Maternal placental Estrogen withdrawal bleeding
    2. Vaginal foreign body with secondary Vaginitis
      1. Presents as non-malodorous discharge and Vaginal Bleeding
      2. Peak Incidence: 3 to 9 years old
      3. Accounts for 4% of pediatric gynecologic ambulatory visits
    3. Vaginitis (most comon)
      1. Contact Vulvovaginitis from soaps, bubble bath, scented toilet paper
      2. Bacterial vulvovaginitis (Shigella, Streptococcus Pyogenes)
    4. Accidental Trauma (bike accidents or straddle injuries)
    5. Prolapse of Urethral meatus
    6. Sexual abuse
    7. Ingestion of Estrogen containing products
    8. Precocious Puberty (Menses before age 8 years)
    9. Malignancy
  2. Early Reproductive Years
    1. Anovulatory cycles with Menarche (initially 55-85%)
      1. Persists 18 months on average
      2. Menorrhagia at Menarche is a common presentation of underlying Bleeding Disorder (up to 24% of cases)
        1. Consider focused evaluation for cause including Von Willebrand Disease (most common)
    2. Primary coagulation disorders (19%)
      1. See below
    3. Pregnancy related disorders
  3. Later reproductive and postmenopausal years (includes age >35 years)
    1. See Postmenopausal Bleeding
    2. See Menopause
    3. Extra-uterine source
      1. Cervical, vaginal, vulvar and Adnexal bleeding
      2. Hematuria (Urethra, Bladder, ureter or Kidney)
      3. Lower Gastrointestinal Bleeding (e.g. rectal bleeding)
    4. Evaluate for Malignancy!
      1. Postmenopausal Bleeding is due to malignancy (esp Endometrial Cancer) in up to 40% of cases
      2. Peak Incidence of Endometrial Cancer is age 60-64 years
    5. Atrophic Vaginitis
      1. Most common cause of Postmenopausal Bleeding
    6. Postmenopausal Endometrial Hyperplasia
      1. If no Estrogen Replacement, find Estrogen source

III. Causes: Coagulation Bleeding Disorders (common)

IV. Causes: Pregnancy-related uterine bleeding complications

V. Causes: Endocrine-related uterine bleeding complications

VI. Causes: Medication-related Uterine Bleeding Disorders

VII. Causes: Structural-related uterine Bleeding Disorders

  1. Local infection
    1. Cervicitis
    2. Endometritis
    3. Salpingitis
  2. Adenomyosis Cervicitis
  3. Endometrial and Endocervical Polyps
  4. Endometrial Hyperplasia
  5. Endometrial Cancer
  6. Ovarian Cancer
  7. Functional ovarian tumors (produce sex hormones)
  8. Cervical Dysplasia
  9. Cervical Cancer
  10. Submucosal or intramural leiomyoma
  11. Uterine Fibroids
  12. Sarcoidosis
  13. Tuberculosis of the endometrium
  14. Vaginal Trauma (foreign body, sexual abuse, Laceration)

VIII. References

  1. Mace (2013) Crit Dec Emerg Med 27(2): 13-21

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