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Causes of Female Genital Tract Bleeding - UpToDate
Causes of Female Genital Tract Bleeding - UpToDate
All topics are updated as new evidence becomes available and our peer review process is complete.
INTRODUCTION
Females with abnormal bleeding noted in the genital area often present with a complaint of
vaginal bleeding. Clinicians often attribute the bleeding to a uterine source, but it may arise
from disease at any anatomic site in the lower genital tract (cervix, vagina, vulva) or upper
genital tract (uterine corpus, fallopian tubes, ovaries). The source of bleeding may also be a
nongynecologic site, such as the urethra, bladder, anus, or other bowel site. Causes of genital
tract bleeding are listed in the table ( table 1) and vary by age group ( table 2).
Causes of female genital tract bleeding will be reviewed here. The evaluation of patients with
vaginal bleeding is discussed separately:
● Pregnant patients (see "Evaluation and differential diagnosis of vaginal bleeding before 20
weeks of gestation").
Cervical bleeding — Bleeding from the cervix often causes sporadic spotting, which commonly
occurs postcoitally. A cervical lesion is often visualized on speculum examination.
Polyps — Cervical polyps may cause postcoital spotting and sporadic bleeding, although they
are often asymptomatic. The majority are benign endocervical polyps, which can be seen on
visual examination of the cervix and endocervix. (See "Benign cervical lesions and congenital
anomalies of the cervix", section on 'Polyps'.)
Pelvic organ prolapse — Defects in pelvic floor support can lead to herniation of the anterior,
posterior, or apical portion of the vagina. If part or all of the vagina and cervix is exteriorized,
bleeding occasionally occurs secondary to ulceration, trauma and infection. This type of
bleeding often occurs after straining. (See "Pelvic organ prolapse in females: Epidemiology, risk
factors, clinical manifestations, and management".)
Trauma — Bleeding can occur after both consensual sexual intercourse and sexual assault and
may be the result of a cervical laceration. In one retrospective review including 114 sexual
assault victims presenting to an acute care hospital, injuries to the cervix were found in 12
percent of patients [1].
Other benign conditions — Ectopic endometriosis can be found in the cervix, especially if the
patient has a history of cervical procedures (such as cone biopsy). Postcoital bleeding,
intermenstrual bleeding, as well as acute bleeding due to cervical endometriosis have been
reported [2-4]. (See "Endometriosis: Clinical features, evaluation, and diagnosis", section on
'Clinical features'.)
Cervical cancer — Sporadic bleeding, postcoital spotting, and vaginal discharge that is watery,
mucoid, or purulent and malodorous are often noted in patients with cervical cancer.
Accordingly, cervical cytology and biopsy, when indicated, should not be postponed in this
setting. (See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and
diagnosis", section on 'Clinical manifestations'.)
Direct extension from other pelvic tumors, such as uterine cancer, can cause cervical bleeding.
Choriocarcinoma commonly can extend to the cervix, causing bleeding. Rarely, leukemias,
lymphomas [5], and other nongynecologic cancers involve the cervix.
Vaginal bleeding — As with cervical lesions, vaginal lesions typically cause sporadic or
postcoital bleeding and can be visualized on speculum examination. By contrast, traumatic
vaginal lacerations can cause major internal and/or external hemorrhage.
Vaginal atrophy — Atrophic vaginitis results from estrogen deficient states, which occur in
postmenopausal, postpartum lactating, and premenarchal patients. Bleeding or spotting, which
may be related to sexual activity, may occur. (See "Genitourinary syndrome of menopause
(vulvovaginal atrophy): Clinical manifestations and diagnosis".)
Vaginitis and vaginal ulcers — Vaginal infection or inflammation may lead to friability of the
vaginal mucosa with bleeding. (See "Vaginitis in adults: Initial evaluation".)
Ulcerative diseases with vaginal involvement (eg, lichen planus) can cause postcoital bleeding.
Genital ulcers may be caused by infection, but non-infection-related etiologies should also be
considered. (See "Approach to the patient with genital ulcers".)
Benign growths — Gartner duct cysts, vaginal polyps, and aberrant glandular tissue (vaginal
adenosis) rarely lead to vaginal bleeding in the absence of friction and trauma. (See "Congenital
anomalies of the hymen and vagina".)
Vaginal trauma — Bleeding from the vagina or vulva can occur from genital tract trauma
related to intercourse (eg, tearing of an intact hymen during coitarche or laceration of the
vaginal fornix mucosa), foreign bodies that cause ulceration (eg, neglected tampon, pessary,
sexual aids), sexual assault, pelvic trauma (eg, from a motor vehicle accident), and straddle-type
injuries (eg, falling on a bicycle frame, fence, or table edge) that result in lacerations or
abrasions of the labia. (See "Evaluation and management of female lower genital tract trauma".)
Female circumcision or infibulation reduces the vaginal opening; vaginal bleeding and
lacerations can occur when intercourse is attempted. (See "Female genital cutting".)
Radiation therapy — Vaginal bleeding can represent a late effect of radiation therapy [7].
Obliterative endarteritis and the vascular narrowing of aging and arteriosclerosis lead to
devascularization of the radiated tissues. Tissue necrosis causes viscus perforation, tissue
sloughing, and bleeding. Hemorrhagic cystitis and proctitis can lead to significant blood loss.
Vaginal vault necrosis may cause uncontrolled bleeding and pain. (See "Treatment-related
toxicity from the use of radiation therapy for gynecologic malignancies".)
Vaginal cancer — Primary vaginal cancer is a less common gynecologic malignancy. The
majority of patients present with vaginal bleeding, either postmenopausal or postcoital. Other
symptoms include a watery, blood-tinged, or malodorous vaginal discharge or a vaginal mass.
The upper posterior vaginal wall is the most frequent site of vaginal cancer. It is important to
carefully palpate the lateral, anterior, and posterior vaginal walls since the lesion may be
obscured by the speculum blades during examination [8]. (See "Vaginal cancer".)
Advanced bladder or colorectal cancer may invade the vagina and cause vaginal bleeding [9],
and the vagina may be the site of metastatic disease from distant organs.
Vulvar bleeding — As with cervical and vaginal lesions, vulvar lesions typically cause sporadic
bleeding and can be visualized on physical examination.
Infection — Sexually transmitted diseases can cause characteristic lesions on the vulva, some
of which may bleed easily on contact (friability). Examples include the syphilitic chancre
(although this usually produces drainage that is more serous than bloody), herpes simplex
virus, Haemophilus ducreyi (Chancroid), granuloma inguinale (Donovanosis), and
lymphogranuloma venereum. Pediculosis pubis (ie, pubic lice or "crabs") can also cause a small
amount of bleeding. (See "Approach to the patient with genital ulcers" and "Pediculosis pubis
and pediculosis ciliaris".)
Benign lesions — Benign lesions, such as sebaceous (epidermal) cysts, condylomata, and
angiokeratoma, may occasionally bleed due to trauma related to friction from clothing or
scratching. (See "Vulvar lesions: Diagnostic evaluation" and "Vulvar lesions: Differential
diagnosis of vesicles, bullae, erosions, and ulcers".)
Vulvar lichen sclerosus occasionally may result in bleeding and, rarely, hemorrhage. (See "Vulvar
lichen sclerosus: Clinical manifestations and diagnosis", section on 'Clinical manifestations and
natural history'.)
to the fragile nature of lesions and frictional trauma. Older lesions may be cloudy or
hemorrhagic. Beçhet syndrome is a systemic vascular disorder that can cause genital ulcers.
(See "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers".)
Vulvar trauma — The vulva may bleed from trauma due to forceful sexual activity/assault or
accidents (eg, sports or exercise related, motor vehicle). (See "Evaluation and management of
female lower genital tract trauma".)
Vulvar cancer — Vulvar cancer is less common than other gynecologic malignancies. Early
vulvar cancer is asymptomatic; bleeding occurs when a lesion is extensive enough to ulcerate.
Vulvar cancer and vulvar intraepithelial neoplasia are often misdiagnosed. Delay may be related
to patient embarrassment, denial, reluctance to be examined, or health care practitioners who
prescribe topical medications to a patient with vulvar complaints without performing a physical
examination. All ulcers associated with skin thickening or mass must be biopsied. (See "Vulvar
cancer: Epidemiology, diagnosis, histopathology, and treatment" and "Vulvar squamous
intraepithelial lesions (vulvar intraepithelial neoplasia)".)
Vulvar melanoma presents with a hyperpigmented lesion, which may bleed. (See "Locoregional
mucosal melanoma: Epidemiology, clinical diagnosis, and treatment", section on 'Vulvovaginal
melanoma'.)
Uterine bleeding — The uterus is the most likely source of genital tract bleeding. The likelihood
of a particular etiology of uterine bleeding depends on the reproductive status of the patient
(premenarchal, reproductive-age, postmenopausal) and the pattern of bleeding (cyclic or
noncyclic). The characteristics of normal and abnormal uterine bleeding (AUB) bleeding are
listed in the table ( table 3) and are described in detail separately. (See "Normal menstrual
cycle", section on 'Definitions of normal uterine bleeding (menstruation)' and "Abnormal uterine
bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to
diagnosis", section on 'Definitions'.)
A revised terminology system for abnormal uterine bleeding (AUB) in nongravid reproductive-
age patients was introduced in 2011 by the International Federation of Gynecology and
Obstetrics (FIGO) [10]. This classification system, referred to as FIGO System 2, or the PALM-
COEIN system, stratifies possible causes of AUB into nine basic categories: polyp, adenomyosis,
leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial,
iatrogenic, and not yet classified ( figure 1). An example of a worksheet to facilitate
documentation is found in the table ( table 4).
Polyps (AUB-P) — Endometrial polyps are a common cause of AUB; most endometrial polyps
are benign and the prevalence of endometrial polyps increases with age. Intermenstrual
bleeding is the most frequent symptom, and bleeding after straining or heavy lifting can also
occur. Less frequent symptoms include heavy or prolonged bleeding, postcoital bleeding,
postmenopausal bleeding, prolapse through the cervical os, and unscheduled (breakthrough)
bleeding during hormonal therapy. (See "Endometrial polyps".)
Leiomyomas (AUB-L) — Leiomyomas (also referred to as myomas or fibroids) are the most
common pelvic tumors in females. The majority of patients have small myomas and are
asymptomatic; however many patients with leiomyomas have AUB. When leiomyomas are
present, the uterus often feels enlarged and lobular/asymmetric on bimanual pelvic
examination.
AUB-L is further classified based on the FIGO Leiomyoma Subclassification System ( figure 2).
(See "Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural
history", section on 'Terminology and location'.)
Uterine leiomyomas are discussed in detail separately. (See "Uterine fibroids (leiomyomas):
Epidemiology, clinical features, diagnosis, and natural history" and "Uterine fibroids
(leiomyomas): Treatment overview".)
The risk of endometrial neoplasia increases with age and with exposure to endogenous or
exogenous estrogen unopposed by a progestin (eg, obesity, anovulation, menopausal use of
estrogen alone, or tamoxifen). (See "Endometrial carcinoma: Epidemiology, risk factors, and
prevention" and "Approach to the patient with postmenopausal uterine bleeding".)
Less common types of uterine cancer include uterine sarcomas (eg, endometrial stromal
sarcoma, leiomyosarcoma) or gestational trophoblastic neoplasia. Rarely, the endometrium is
the site of metastatic disease from a nongynecologic malignancy (eg, melanoma).
(See "Uterine sarcoma: Classification, epidemiology, clinical manifestations, and diagnosis" and
"Gestational trophoblastic neoplasia: Epidemiology, clinical features, diagnosis, staging, and risk
stratification".)
Coagulopathy (AUB-C) — Bleeding disorders can cause AUB, usually heavy menstrual
bleeding (HMB). The approach to identifying these patients starts with a structured history to
assess symptoms or risk factors for coagulation disorders ( table 5) [20]. Laboratory testing
must confirm coagulopathy for a diagnosis of AUB-C.
In patients with VWD, the menopausal transition is associated with an increased prevalence of
excess bleeding due to decreasing estrogen levels. Estrogen promotes von Willebrand factor
(VWF) synthesis. Conversely, patients with mild VWD who take birth control pills or menopausal
estrogen therapy may increase their slightly low VWF levels into the normal range and, during
pregnancy, VWF levels also increase. (See "Clinical presentation and diagnosis of von Willebrand
disease", section on 'Changes with aging and pregnancy'.)
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Bleeding defects may also be due to renal failure (platelet dysfunction), liver disease (reduced
synthesis of coagulation factors), hematologic malignancy [27], anticoagulants, or
chemotherapeutic agents. (See "Approach to the adult with a suspected bleeding disorder",
section on 'Patient history'.)
AUB due to bleeding disorders is discussed in more detail separately. (See "Approach to the
adult with a suspected bleeding disorder", section on 'Patient history' and "Abnormal uterine
bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to
diagnosis", section on 'Medical history' and "Factor XI (eleven) deficiency", section on 'Heavy
menstrual bleeding'.)
AUB-O can be further categorized according to the presumed primary source (and referred to
by the acronym "HyPO-P") [28]:
● Type I: Hypothalamic
The pathophysiology in patients with AUB-O is that sex steroids are not produced cyclically. In
many anovulatory patients, estrogen production unopposed by adequate progesterone
production allows continued proliferation of the endometrium. Eventually, the thickened
endometrium outgrows its blood supply and undergoes focal necrosis with partial shedding.
Since shedding is not uniform and progesterone and prostaglandin-related changes have not
occurred, bleeding is usually irregular (varies by >7 to 9 days, depending on age) and can be
prolonged and/or heavy (see "Abnormal uterine bleeding in nonpregnant reproductive-age
patients: Terminology, evaluation, and approach to diagnosis", section on 'Definitions'). In
patients with oligo-ovulation, some episodes of bleeding represent partial endometrial
shedding and others are normal (postovulatory) menses.
● For a few years following menarche, the hypothalamic-pituitary-ovarian axis is not fully
mature and ovulatory cycles may not consistently occur. Thus, amenorrhea or infrequent
menses may alternate with unpredictable episodes of uterine bleeding. Less commonly,
AUB in this age group may be related to other causes, such as pregnancy or a
coagulopathy. (See "Abnormal uterine bleeding in adolescents: Evaluation and approach to
diagnosis", section on 'Causes of vaginal bleeding in adolescents'.)
● Stress and poor nutrition: Stress, weight loss, poor nutrition, or strenuous exercise can
disturb the hypothalamic-pituitary-ovarian axis and may cause AUB. Although the
menstrual pattern most characteristic of hypothalamic dysfunction is amenorrhea, some
patients with this entity may present with infrequent (ie, >38 day) cycles. (See "Functional
hypothalamic amenorrhea: Pathophysiology and clinical manifestations" and
"Epidemiology and causes of secondary amenorrhea", section on 'Hypothalamic
dysfunction'.)
● Hormone-producing ovarian (eg, granulosa cell tumor) or adrenal tumors (rare). (See "Sex
cord-stromal tumors of the ovary: Epidemiology, clinical features, and diagnosis in adults"
and "Clinical presentation and evaluation of adrenocortical tumors".)
● Liver and kidney disease: Liver disease can affect estrogen metabolism, synthesis of
coagulation factors, and cause thrombocytopenia, thereby potentially leading to both
anovulation and bleeding diathesis. Chronic renal disease is associated with both
hypothalamic-pituitary-gonadal and platelet dysfunction. (See 'Coagulopathy (AUB-C)'
above.)
The evaluation of patients with AUB-O is discussed separately. (See "Abnormal uterine bleeding
in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to
diagnosis", section on 'Irregular bleeding'.)
Endometrial dysfunction (AUB-E) — Patients with AUB-E have all of the following [31]:
- Stimulating stromal cell production of tissue factor (TF), a cell surface protein that
participates in the extrinsic pathway of coagulation through the binding of
activated Factor VII [34].
• Copper IUD – Copper IUDs cause a foreign body reaction in the uterus that creates an
inflammatory response. The endometrium may hypertrophy at the site of inflammation
with normal cyclic estrogen stimulation, resulting in heavier or longer menstrual flow
as well as intermenstrual bleeding. (See "Intrauterine contraception: Background and
device types", section on 'Copper IUD'.)
● Menopausal HT – Patients who use menopausal hormone therapy (HT) may develop
uterine bleeding; the frequency depends upon the regimen used, and whether uterine
conditions including fibroids, adenomyosis, or endometrial polyps are present. (See
"Treatment of menopausal symptoms with hormone therapy", section on 'Side effects'.)
● Other – Medications that cause an endocrine disruption may cause AUB. Some data
suggest that epidural glucocorticoid injections (40 to 80 mg of triamcinolone or
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methylprednisolone acetate) are associated with AUB [39]. Drugs that cause
hyperprolactinemia are shown in the table ( table 7). (See 'Ovulatory dysfunction (AUB-
O)' above and "Causes of hyperprolactinemia".)
Not otherwise classified (AUB-N) — AUB-N encompasses additional entities that may cause
AUB and include:
● Cesarean scar defect – A cesarean scar defect (also known as an isthmocele or niche) at
the site of a prior hysterotomy (or less commonly, myomectomy) incision is an increasingly
common cause of AUB [40-46]. The usual presentation is postmenstrual spotting, which
may reflect intermittent expulsion of menstrual blood retained in the defect after
menstruation is completed. Poor contractility of the myometrium in the area of the
hysterotomy site may also contribute to postmenstrual spotting [47]. When symptoms (eg,
postmenstrual bleeding) are present, the term "cesarean scar disorder" may be used [48].
In a prospective study including over 370 patients evaluated with sonohysterography six
months after cesarean birth, patients with (46 percent) versus without a cesarean scar
defect were more likely to have postmenstrual spotting (20 versus 8 percent, odds ratio
[OR] 2.8, 95% CI 1.4-5.4) [49].
Some AVMs are acquired and present with sudden uterine bleeding after surgical
instrumentation (eg, dilation and curettage in a nonpregnant patient), while others are
congenital and occur without any prior history of surgical instrumentation ( image 1)
[50,51]. Congenital AVMs are thought to develop from a failure of embryologic
differentiation leading to abnormal vascular connections [52].
If an AVM is suspected in a patient with AUB, imaging studies should be performed prior
to further intrauterine instrumentation [53]. Pelvic ultrasound with Doppler is typically the
first-line imaging study ( image 2) [54-56]. MRI with angiography may also be
performed.
● Other – Rarely, sarcoidosis affects the female genital tract and the uterus is the most
common site [59]. Patients with uterine sarcoidosis may present with AUB. Most patients
have concomitant pulmonary involvement. (See "Overview of extrapulmonary
manifestations of sarcoidosis", section on 'Endocrine and reproductive'.)
Fallopian tube bleeding — Blood from the fallopian tube may rarely pass through the uterus
and present as vaginal bleeding. However, this is unusual and most fallopian tube bleeding
presents as intraperitoneal bleeding. Etiologies of fallopian tube bleeding include tubal
pregnancy, neoplastic disease, trauma, and infection.
Salpingitis — Salpingitis is generally not an isolated infection but is usually associated with
PID. In patients with PID, the source of bleeding may be the uterus or the fallopian tube. (See
'Endometrial dysfunction (AUB-E)' above.)
Hysteroscopic sterilization — A dislodged tubal microinsert may result in bleeding [60]. (See
"Hysteroscopic female permanent contraception", section on 'Short-term complications and
outcomes'.)
Fallopian tube cancer — Fallopian tube cancer may also present with vaginal bleeding. (See
'Ovarian cancer' below and "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum:
Clinical features and diagnosis", section on 'Vaginal bleeding'.)
Ovarian bleeding — Similar to bleeding from the fallopian tube, bleeding from the ovary rarely
presents as vaginal bleeding and more commonly presents as intraperitoneal bleeding (eg, a
bleeding corpus luteum, which may occur in anticoagulated patients). Infrequently, bleeding
from an ovarian mass, trauma, or infection may pass through the fallopian tube and continue to
the lower genital tract.
Diseases of the tissue and organs surrounding the female genital tract may initially be mistaken
for genital tract bleeding; nongenital tract sources include: urethra (eg, urethritis, diverticulum,
urethral prolapse or caruncle, or atrophy), bladder (eg, cancer, stone, or infection), anus (eg,
hemorrhoids, anal cancer), bowel (eg, inflammatory bowel disease, rectal cancer), or
dermatologic conditions of the perineum or skin beyond the vulva. (See "Urethral caruncle" and
"Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation,
and approach to diagnosis", section on 'Gynecologic and obstetric history'.)
SPECIAL POPULATIONS
Children — Common causes of vaginal bleeding prior to menarche include vaginal foreign
bodies (eg, toilet paper, pencil erasers), urethral prolapse, bacterial infections, trauma (including
sexual assault), and condyloma. Less commonly, bleeding may result from a reproductive tract
neoplasm, such as sarcoma botryoides. (See "Evaluation of vulvovaginal bleeding in children
and adolescents" and "Overview of vulvovaginal conditions in the prepubertal child".)
Pregnant patients — Bleeding from the vagina is a common event at all stages of pregnancy;
the source is virtually never fetal. Causes of vaginal bleeding in pregnant patients are discussed
in detail separately. (See "Evaluation and differential diagnosis of vaginal bleeding before 20
weeks of gestation".)
Vaginal bleeding is also a common presentation of ectopic pregnancy; in such patients, the
presumptive source of this bleeding is sloughing of the decidualized endometrium rather than
bleeding from the tube itself [63,64]. While the fallopian tube is the most common site of
ectopic pregnancy, other sites of extrauterine gestations include the abdomen, ovary, or cervix.
Cesarean scar pregnancies can also occur. (See "Ectopic pregnancy: Clinical manifestations and
diagnosis", section on 'Vaginal bleeding' and "Ectopic pregnancy: Epidemiology, risk factors, and
anatomic sites", section on 'Anatomic sites'.)
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Abnormal uterine
bleeding".)
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Beyond the Basics topics (see "Patient education: Abnormal uterine bleeding (Beyond the
Basics)" and "Patient education: Heavy or prolonged menstrual bleeding (menorrhagia)
(Beyond the Basics)" and "Patient education: Absent or irregular periods (Beyond the
Basics)")
● Sources – Females with abnormal bleeding noted in the genital area often present with a
complaint of vaginal bleeding. Clinicians often attribute the bleeding to a uterine source,
but it may arise from disease at any anatomic site in the lower genital tract (cervix, vagina,
vulva) or upper genital tract (uterine corpus, fallopian tubes, ovaries). The source of
bleeding may also be a nongynecologic site, such as the urethra, bladder, anus, or other
bowel site ( table 1 and table 2). (See 'Introduction' above.)
● Lower genital tract sources – Causes of cervical, vaginal, and vulvar bleeding include
trauma, infection, neoplasia, and genital manifestations of systemic disease. Bleeding
from these areas often causes sporadic or postcoital bleeding, but hemorrhage can occur.
A lesion is often visualized on examination. (See 'Cervical bleeding' above and 'Vaginal
bleeding' above and 'Vulvar bleeding' above.)
• Uterus – The uterus is the most likely source of genital tract bleeding. The etiology of
uterine bleeding depends on the reproductive status of the patient (premenarchal,
reproductive-age, postmenopausal) and the pattern of bleeding (cyclic or noncyclic).
Possible causes of abnormal uterine bleeding (AUB) are divided into nine basic
categories: polyp, adenomyosis, leiomyoma, malignancy and hyperplasia,
coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified
( figure 1). (See 'Uterine bleeding' above.)
Uterine bleeding is also a common event at all stages of pregnancy; the source is
virtually never fetal. Ectopic pregnancy must also be considered. (See 'Pregnant
patients' above.)
• Fallopian tube – Fallopian tube bleeding may rarely present as vaginal bleeding.
Etiologies of fallopian tube bleeding include ectopic pregnancy and salpingitis, typically
as part of pelvic inflammatory disease. (See 'Fallopian tube bleeding' above.)
• Ovary – Although bleeding from the ovary usually collects intraperitoneally, vaginal
bleeding may occur if blood passes through the fallopian tube and continues to the
lower genital tract. Etiologies of ovarian bleeding include benign neoplasms and
ovarian cancer. (See 'Ovarian bleeding' above.)
● Nongenital tract bleeding – Diseases of the urethra (eg, urethritis, diverticulum), bladder
(eg, cancer, stone, infection), and bowel (eg, inflammatory bowel disease, hemorrhoids)
may cause bleeding that is misdiagnosed as genital tract bleeding. (See 'Nongenital tract
disease' above.)
ACKNOWLEDGMENT
The UpToDate editorial staff acknowledges Annekathryn Goodman, MD, MPH, MS, who
contributed to earlier versions of this topic review.