Abnormal uterine bleeding or abnormal vaginal bleeding is a common patient presentation. A few causes of lower genitourinary tract bleeding (abnormal vaginal bleeding) such as atrophic vaginitis, trauma, and cervical pathology are not discussed here. Patients or clinicians may not be able to differentiate between these causes based upon symptoms or bedside evaluation, but certain clues in a history and a physical exam can help differentiate between these causes. For example, patients with atrophic vaginitis will likely be older/post-menopausal, have an atrophic vagina on a physical exam, and patients with cervical pathology may have a history of abnormal pap smears.

A further breakdown of probable diagnoses is based upon a patient’s age because certain diagnoses are more common in certain age groups than others. However, certain diagnoses may cross over age groups, such as endometrial cancer, which may occur in reproductive age groups, and cervical cancer, which may occur in older age groups. Most women who are undergoing menopause experience abnormal/irregular bleeding during a peri-menopausal period, such that their bleeding may appear as a part of normal transition to menopause. However, their symptoms should be carefully evaluated because of prevalence of endometrial cancer in this age group, and peri-menopause should be considered only as a condition of exclusion. Most causes of abnormal uterine bleeding during reproductive age are either related to hormone imbalance, such as anovulatory or thyroid, or a structural disorder, such as endometrial or cervical. Medications, coagulation disorders and systemic diseases can cause bleeding in any age group. However, these disorders must be very severe to cause vagina/uterine bleeding, and at that stage, patients may well be bleeding from other orifices as well, which makes these diagnoses relatively easy to make. Like other patient presentations, overlapping diagnoses may occur in any one patient. History related questions for these specific diagnoses and a careful physical exam can help a clinician narrow the differential diagnoses.

            Urgent/emergent situations include excessive bleeding resulting in hemodynamic instability and can be due to any underlying pathology. Common causes are benign and malignant endometrial or uterine lesions. Excessive bleeding, even if not obvious, may result in abnormal vital signs.

Weighing and removing anchor bias involves asking pertinent questions for all the probable diagnoses discussed earlier, and based upon clinical evaluation, the specific labs and tests that a clinician can order. Helpful mnemonics to memorize disorders of the reproductive age include PAP-BET and disorders of pre-pubertal age include PEC.