Most Common Causes of Vaginal Bleeding in Women
The most common causes of vaginal bleeding in women include structural abnormalities (polyps, adenomyosis, leiomyomas, malignancy), ovulatory dysfunction, coagulopathies, endometrial disorders, and iatrogenic causes such as medications and intrauterine devices. 1
Classification of Vaginal Bleeding Causes
The PALM-COEIN classification system provides a comprehensive framework for understanding the causes of abnormal uterine bleeding:
Structural Causes (PALM):
- Polyps - endometrial or cervical
- Adenomyosis - presence of endometrial tissue within the myometrium
- Leiomyomas (fibroids) - particularly submucosal fibroids
- Malignancy and hyperplasia - including endometrial, cervical, vaginal, and vulvar cancers 1, 2
Non-structural Causes (COEIN):
- Coagulopathy - including von Willebrand disease and other bleeding disorders
- Ovulatory dysfunction - including PCOS, hypothyroidism, hyperprolactinemia
- Endometrial disorders - primary dysfunction of local endometrial hemostasis
- Iatrogenic causes - hormonal medications, anticoagulants, intrauterine devices
- Not yet classified - rare or poorly understood causes 1, 2, 3
Age-Specific Considerations
Adolescents
- Anovulatory cycles (most common)
- Coagulation disorders (particularly von Willebrand disease)
- Pregnancy complications
- Infections 2, 3
Reproductive Age
- Pregnancy complications (threatened abortion, ectopic pregnancy, gestational trophoblastic disease)
- Structural abnormalities (fibroids, polyps)
- Ovulatory dysfunction
- Endometriosis/adenomyosis
- Iatrogenic causes (contraceptives, anticoagulants) 1, 2
Perimenopausal Women
- Anovulatory cycles
- Structural abnormalities (fibroids, polyps)
- Endometrial hyperplasia
- Endometrial cancer 1, 2
Postmenopausal Women
- Endometrial cancer (most concerning)
- Endometrial or cervical polyps
- Endometrial atrophy
- Hormone therapy effects 1, 2
Pregnancy-Related Causes
In pregnant women, the most common causes of vaginal bleeding include:
- Placenta previa (most common, affecting 1 in 200 pregnancies)
- Placental abruption (affects approximately 1% of pregnancies)
- Threatened abortion
- Ectopic pregnancy
- Vasa previa (rare but potentially fatal to the fetus) 4
Important Clinical Considerations
Key Diagnostic Principles
- Abnormal uterine bleeding in reproductive age women should be considered pregnancy-related until proven otherwise 2
- Abnormal bleeding in perimenopausal or postmenopausal women should be considered malignancy until proven otherwise 2
- Menorrhagia in adolescents should be attributed to coagulopathy until proven otherwise 2, 3
Special Populations
Women on Anticoagulants
Women on direct oral factor Xa inhibitors commonly experience vaginal bleeding complications, particularly heavy menstrual bleeding. In a case series of 178 women of reproductive age on these medications, 57 (32%) experienced vaginal bleeding events, with most cases (86%) manageable with conservative treatment 5.
Post-Hysterectomy Bleeding
Though rare, vaginal bleeding can occur after hysterectomy due to:
- Vault endometriosis
- Atrophic vaginitis
- Cervical stump cancer (if subtotal hysterectomy)
- Infiltrating ovarian tumors 6
Common Pitfalls in Diagnosis
- Failing to rule out pregnancy in women of reproductive age
- Not considering coagulation disorders in adolescents with heavy menstrual bleeding
- Overlooking medication effects (hormonal contraceptives, anticoagulants)
- Missing underlying anatomical abnormalities in women with recurrent bleeding
- Delaying evaluation of postmenopausal bleeding 2, 5, 3
By understanding the diverse causes of vaginal bleeding across different age groups and clinical contexts, clinicians can develop a systematic approach to diagnosis and management that prioritizes ruling out serious conditions while addressing the underlying cause.