Table of Contents
Overview – Abnormal PV Bleeding
Abnormal per vaginal (PV) bleeding is a broad clinical presentation that requires a tailored differential diagnosis based on age, reproductive status, and sexual history. From childhood through to postmenopause, abnormal bleeding may signify anything from benign hormonal imbalances to life-threatening conditions such as ectopic pregnancy or genital tract malignancy. A structured diagnostic approach is essential for appropriate management.
Definition
Abnormal PV bleeding refers to any vaginal bleeding outside of normal menstruation, in terms of timing, frequency, duration, or volume. It includes intermenstrual bleeding, postcoital bleeding, and bleeding in childhood, pregnancy, or postmenopause.
Differential Diagnosis
1. Children
- Precocious puberty
- Foreign body in vagina
- Molestation
- Vaginitis
- Rare tumours
2. Premenopausal Women
- Menstrual irregularities:
- Menorrhagia (heavy bleeding)
- Hypomenorrhoea (light bleeding)
- Intermenstrual bleeding
- Dysfunctional uterine bleeding (often hormonal; may relate to polycystic ovarian syndrome)
- Uterine fibroids
- Cervical cancer – typically causes postcoital bleeding
- Uterine cancer
- Endometritis or retained products of conception (postpartum or post-miscarriage)
- Vaginal trauma, infections, lesions or cancers
- Condylomata acuminata of cervix
- Pelvic inflammatory disease
- Ovarian cysts
- Contraceptive-related bleeding:
- Intrauterine device (IUD)
- Oral contraceptive pills
- Post-pap smear bleeding
3. Pregnant Women
- Bleeding in 15–25% of first trimester pregnancies
- 50% result in miscarriage, 50% continue to term
- Rupture of placental vein
- Miscarriage
- Ectopic pregnancy
- Placenta previa
- Placental abruption
4. Postmenopausal Women
- All postmenopausal bleeding warrants investigation
- Causes include:
- Unopposed oestrogen (30%)
- Atrophic endometritis/vaginitis (30%)
- Endometrial cancer (15%)
- Endometrial/cervical polyps (10%)
- Endometrial hyperplasia (5%)
- Other causes (10%):
- Vaginal dryness or trauma
- Anticoagulant use
- Inherited bleeding disorders
Diagnostic Approach
- Detailed bleeding history:
- Last episode
- Menstrual cycle history (LMP, duration, frequency, regularity)
- Postcoital or intermenstrual bleeding
- Pregnancy history and current status
- Birth control usage
- Sexual activity and STI risk
- Medical history (clotting, recent procedures)
- Physical examination
- Pregnancy test
- Hormonal profile
- Full blood count + clotting screen
- Thyroid function tests (if indicated)
- Pap smear
- Transvaginal ultrasound
- Management is guided by cause
Intermenstrual Bleeding
Definition
Bleeding between normal menstrual periods, not associated with intercourse.
Causes
Pregnancy-Related
- Ectopic pregnancy
- Gestational trophoblastic disease
Iatrogenic
- Insufficient dose of combined contraceptives
- Side effect of progesterone-only contraception
- Intrauterine device
Cervical Causes
- Cervicitis (e.g. chlamydia, gonorrhoea)
- Cervical polyps
- Cervical cancer
Uterine Causes
- Fibroids
- Adenomyosis
- Endometrial cancer
Postcoital Bleeding
Definition
Vaginal bleeding that occurs immediately after intercourse, unrelated to the menstrual cycle.
Causes
- Traumatic sex (especially in postmenopausal women with vaginal atrophy)
- Infections:
- Bacterial vaginosis
- Cervicitis (chlamydia, gonorrhoea)
- Vaginal cancer
- Cervical cancer
Summary – Abnormal PV Bleeding
Abnormal PV bleeding encompasses a wide range of gynaecological, hormonal, and structural causes across all age groups. A systematic approach considering the patient’s age and reproductive status is essential. Intermenstrual and postcoital bleeding, in particular, may signal underlying malignancy and require thorough assessment. For a broader context, see our Reproductive Health Overview page.