Operational Medicine Medical Education and Training

Abnormal Bleeding

Normal menstrual bleeding:

  • Occurs approximately once a month (every 26 to 35 days).
  • Lasts a limited period of time (3 to 7 days).
  • May be heavy for part of the period, but usually does not involve passage of clots.
  • Often is preceded by menstrual cramps, bloating and breast tenderness, although not all women experience these premenstrual symptoms.

Abnormal Bleeding

Abnormal bleeding (DUB or dysfunctional uterine bleeding) includes:

  • Too frequent periods (more often than every 26 days).
  • Heavy periods (with passage of large, egg-sized clots).
  • Any bleeding at the wrong time, including spotting or pink-tinged vaginal discharge
  • Any bleeding lasting longer than 7 days.
  • Extremely light periods or no periods at all

Abnormal Bleeding

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Any woman complaining of abnormal vaginal bleeding should of course be examined. Occasionally, you will find a laceration of the vagina, a bleeding lesion, or bleeding from the surface of the cervix due to cervicitis. Much more commonly, you will find bleeding from the uterus coming out of the cervical os.

Excluding pregnancy, there are really only three reasons for abnormal uterine bleeding:

  • Mechanical Problems
  • Hormonal Problems
  • Malignancy

The limited number of possibilities makes your caring for these patients very simple. First, before examining the patient, obtain a pregnancy test. If it is positive, then don't do anything more until you've read about the different possible causes.

Next, obtain a blood count and assess the rate of blood loss to determine how much margin of safety you have. Someone with a good blood count (hematocrit) and minimal rate of blood loss (less than a heavy period), can tolerate this rate of loss for many days to weeks before the bleeding itself becomes a threat.

Pregnancy Problems

A variety of pregnancy problems can cause vaginal bleeding. These include:

  • Abortion (threatened, incomplete, complete, missed, or inevitable)

  • Ectopic Pregnancy

  • Placental Abruption

  • Placenta Previa

If the bleeding patient has a positive pregnancy test, a careful search should be made for each of these problems. However, if the pregnancy test is negative, pregnancy-related bleeding problems are effectively ruled out.

Mechanical Problems

Such problems as uterine fibroids or polyps are examples of mechanical problems inside the uterus.

Since mechanical problems have mechanical solutions, these patients will need surgery of some sort (Polypectomy, D&C, Hysteroscopy, Hysterectomy, Myomectomy, etc.) to resolve their problem.

In the meantime, have them lie still and the bleeding will improve or temporarily go away. Giving hormones (like birth control pills) in an effort to stop the bleeding will not help this condition, but neither will it be harmful.

Polyps visible protruding from the cervix are usually coming from the cervix and can be easily twisted off. However, they will need microscopic evaluation, so removal in many operational settings may not be desired. Instead, they can await return to a non-deployed setting.

Another form of mechanical problem is an IUD causing abnormal bleeding. These should always be removed.


Operational Obstetrics & Gynecology
2nd Edition

Bureau of Medicine and Surgery
Department of the Navy

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