What are the causes of significant vaginal bleeding (metrorrhagia)?

From the Guidelines

Significant vaginal bleeding is most commonly caused by uterine fibroids, which can lead to heavy and prolonged uterine bleeding, as well as other symptoms such as pelvic pain and bulk symptoms, as noted in the 2024 study 1. The causes of significant vaginal bleeding can be diverse and require prompt medical attention to determine the underlying cause and appropriate treatment. Some of the possible causes include:

• Pregnancy-related complications such as miscarriage, ectopic pregnancy, or placental abnormalities like placenta previa
• Hormonal imbalances leading to dysfunctional uterine bleeding, particularly in adolescents beginning menstruation or women approaching menopause
• Structural issues within the reproductive tract, including uterine fibroids, polyps, or adenomyosis, which frequently cause heavy bleeding, as supported by the 2024 study 1
• Infections such as pelvic inflammatory disease or cervicitis that may present with abnormal bleeding
• Certain medications like anticoagulants (warfarin, heparin) or hormonal contraceptives that can disrupt normal bleeding patterns
• More serious causes including gynecological cancers (cervical, uterine, or vaginal) and bleeding disorders like von Willebrand disease
• Trauma to the genital tract, whether from injury or sexual assault, which can cause significant bleeding
• Endocrine disorders affecting the thyroid or adrenal glands that may manifest with abnormal vaginal bleeding It is essential to consider an underlying gynecological problem, such as interactions with other medications, an STD, pregnancy, or new pathologic uterine conditions (e.g., polyps or fibroids), as suggested in the 2013 studies 1. The most recent and highest quality study, published in 2024 1, highlights the importance of uterine fibroids as a common cause of significant vaginal bleeding, and thus, it is crucial to prioritize this cause when evaluating patients with heavy and prolonged uterine bleeding.

From the Research

Causes of Significant Vaginal Bleeding

• Uterine fibroids (UFs) are a common cause of abnormal uterine bleeding, affecting over 60% of patients aged 30-44 years 2
• Fibroids can cause heavy menstrual bleeding, iron deficiency, and iron deficiency anemia, affecting the quality of life and women's health 2, 3
• Other symptoms associated with uterine fibroids include pelvic pressure, bowel dysfunction, urinary frequency and urgency, urinary retention, low back pain, constipation, and dyspareunia 3
• Heavy vaginal bleeding can be caused by various factors, including structural and nonstructural causes, and can be stratified using the International Federation of Gynecology and Obstetrics classification system 4
• Inherited bleeding disorders, such as leiomyoma, can also cause abnormal uterine bleeding, and hormonal methods, tranexamic acid, and gonadotropin-releasing hormone agonists can be used to treat these conditions 5

Diagnosis and Treatment

• Ultrasonography is the preferred initial imaging modality for diagnosing uterine fibroids 3
• Expectant management is recommended for asymptomatic patients, as most fibroids decrease in size during menopause 3
• Medical therapy, including hormonal contraceptives, tranexamic acid, and nonsteroidal anti-inflammatory drugs, can be used to reduce heavy menstrual bleeding 3, 5
• Surgical treatment options, such as hysterectomy, myomectomy, uterine artery embolization, and magnetic resonance-guided focused ultrasound surgery, are available for patients who require more invasive treatment 2, 3