What are the potential causes of vaginal hemorrhage with pain in a female patient?

Causes of Vaginal Hemorrhage with Pain

Vaginal hemorrhage with pain requires immediate differentiation between pregnancy-related emergencies (placental abruption, ectopic pregnancy, uterine rupture) and non-pregnancy causes (ovarian cysts, fibroids, infection, malignancy), with the presence of pain being the critical distinguishing feature from painless bleeding conditions like placenta previa.

Pregnancy-Related Causes (Must Exclude First)

Placental Abruption

• Painful vaginal bleeding is the hallmark distinguishing feature of placental abruption, affecting approximately 1% of pregnancies, whereas placenta previa characteristically presents with painless bleeding 1, 2.
• Presents with uterine tenderness, increased uterine tone, and potential hemodynamic instability 1.
• Ultrasound identifies at most 50% of cases, making clinical suspicion and serial monitoring essential even with negative imaging 2.

Ectopic Pregnancy

• Must be excluded immediately in any woman of reproductive age with vaginal bleeding and pain, as it can rapidly progress to life-threatening hemorrhage 2.
• Transvaginal ultrasound is the primary diagnostic tool, though it may miss up to 74% of ectopic pregnancies initially 2.
• Serial beta-hCG measurements (48 hours apart) are critical when initial ultrasound is non-diagnostic 2.

Uterine Rupture

• Exceedingly rare in primigravida with no prior cesarean delivery or uterine surgery, but typically presents with severe hemodynamic instability 1.
• Particularly important to assess in patients with prior cesarean delivery, looking for myometrial disruption or lower uterine segment thickness <2.5 mm 2.

Spontaneous Abortion/Miscarriage

• Common cause of first trimester bleeding with pain, often accompanied by cramping 2.
• Requires ultrasound to confirm intrauterine pregnancy location and viability 2.

Non-Pregnancy Gynecologic Causes

Ovarian Pathology

• Ovarian cysts account for one-third of cases of acute pelvic pain in perimenopausal and postmenopausal women 3.
• Hemorrhagic ovarian cysts can cause acute pain with vaginal bleeding 4.
• Ovarian torsion presents with severe acute pain and is considered rare in postmenopausal women but must be excluded 3.
• Ovarian neoplasm accounts for 8% of acute pelvic pain cases in postmenopausal women 3.

Uterine Fibroids

• Uterine fibroids are the second most common cause of acute pelvic pain in peri/postmenopausal women, significantly more common than in premenopausal groups 3.
• Acute pain from fibroids may result from torsion of pedunculated fibroids, prolapse of submucosal fibroid, or acute infarction/hemorrhage in degenerating fibroid 3.
• Rare but life-threatening complication: intraperitoneal hemorrhage from fibroid rupture 4.
• Post-procedural complication: massive vaginal hemorrhage can occur after uterine fibroid embolization due to endometrial ulceration overlying necrotic fibroid 5.

Pelvic Infection

• Pelvic inflammatory disease accounts for 20% of acute pelvic pain cases in postmenopausal women, including tubo-ovarian abscess, oophoritis, salpingitis, endometritis, cervicitis, or peritonitis 3.
• Majority related to sexual activity, but recent instrumentation and surgery are common iatrogenic causes 3.
• Isolated endometritis can occur with cervical stenosis 3.

Cervical Pathology

• Cervicitis, cervical polyps, or cervical lesions can cause vaginal bleeding with pain 2.
• Usually identified by speculum examination showing cervical lesions, polyps, or inflammation 2.

Endometriosis

• Reported as a cause of acute pain in postmenopausal period, though considered rare 3.

Vascular Causes

Uterine Artery Pseudoaneurysm

• Uncommon but potentially life-threatening cause that typically presents 2-3 weeks postpartum or post-procedure (dilation and evacuation, cesarean section) 6.
• Presents with profuse vaginal bleeding and can cause hemodynamic instability requiring resuscitation 6.
• Diagnosed by transvaginal ultrasound showing pulsatile mass with internal "ying-yang" flow on Doppler images 6.
• Critical pitfall: Delaying diagnosis may worsen bleeding if treatment is pursued for alternative diagnosis (e.g., treating presumed retained products of conception with dilation and curettage can be catastrophic) 6.

Vulvar and Vaginal Hematomas

• Result from obstetric trauma in 90% of cases, but can occur from other causes 7.
• Patients managed conservatively have more subsequent operative intervention, more complications requiring antibiotics and transfusion, and longer hospitalization compared to operative management 7.
• Increased risk of complications when the product of longitudinal and transverse diameters is ≥15 7.

Systemic Causes

• Bleeding disorders can present with vaginal hemorrhage and should be considered, particularly with significant volume loss 8.
• Trophoblastic disease is a rare but life-threatening cause 8.

Critical Diagnostic Algorithm

Step 1: Pregnancy Status

• Obtain quantitative beta-hCG immediately in all women of reproductive age, regardless of contraceptive use or reported last menstrual period 2.

Step 2: Imaging BEFORE Examination

• Digital pelvic examination is absolutely contraindicated until ultrasound has definitively excluded placenta previa, low-lying placenta, and vasa previa, as examination can precipitate catastrophic hemorrhage 9, 2.
• Transvaginal ultrasound is the primary diagnostic tool and is safe even with placenta previa 2.

Step 3: Hemodynamic Assessment

• Assess for significant volume loss requiring resuscitation with crystalloids and blood products 6.
• Normal vital signs do not exclude significant placental pathology such as placental abruption, which can rapidly deteriorate 2.

Step 4: Age-Specific Considerations

• In postmenopausal women, CT abdomen and pelvis may be useful for poorly localized pain or broad differential diagnosis, with 89% sensitivity for urgent diagnoses and 88% overall accuracy 3.
• CT with IV contrast is particularly helpful for identifying ovarian masses, ascites, lymphadenopathy suggesting malignancy 3.

Common Pitfalls to Avoid

• Never perform digital examination before ultrasound exclusion of placenta previa in pregnant patients—this could trigger massive hemorrhage 9, 2.
• Do not assume negative ultrasound excludes placental abruption—clinical suspicion must guide management 2.
• Approximately 50% of vaginal bleeding cases in pregnancy have no identifiable cause even after complete evaluation 9, 2.
• In postpartum/post-procedure patients with delayed bleeding, always consider uterine artery pseudoaneurysm before attempting dilation and curettage 6.