Bleeding coming from the uterus, the cervix, and/or the vagina itself.

Normal vaginal bleeding is menstruation.



CAH, congenital adrenal hyperplasia; HRT, hormone replacement therapy; OCP, oral contraceptive pill; PCOS, polycystic ovarian syndrome; PID, pelvic inflammatory disease.



Causes Clinical Presentation Most Commonly Associated Bleeding Pattern
Contraception Known OCP/Depo use

OCP: spotting

Depo: irregular or continuous bleeding

HRT Known HRT use

Sequential: menorrhagia or spotting

Continuous: irregular spotting

Fibroids Asymptomatic, pelvic pain, and/or dysmenorrhea Menorrhagia
Adenomyosis Dysmenorrhea Menorrhagia
Endometrial polyps Asymptomatic Intermenstrual spotting, metrorrhagia and/or menorrhagia
Cervical polyps Asymptomatic Intermenstrual and/or postcoital bleeding
PID High-risk sexual behavior, fever, pelvic pain, tenderness Menorrhagia and/or metrorrhagia
PCOS, adult-onset CAH Hirsutism, acne, central obesity, or asymptomatic Oligomenorrhea, menometrorrhagia
Hyperthyroidism Nervousness, heat intolerance, diarrhea, palpitations, weight loss Oligomenorrhea, amenorrhea, polymenorrhea, or menorrhagia
Hypothyroidism Fatigue, cold intolerance, dry skin, hair loss, constipation, weight gain Menorrhagia, polymenorrhea, oligomenorrhea, amenorrhea
Bleeding disorder Asymptomatic mucocutaneous bleeding, easy bruising Menorrhagia
Endometrial hyperplasia Asymptomatic Menorrhagia and/or metrorrhagia
Endometrial cancer Asymptomatic

Postmenopausal: irregular spotting

Perimenopausal: menometrorrhagia

Cervical cancer Asymptomatic Irregular spotting, postcoital bleeding

You are consulted after an episode of postpartum hemorrhage in a 24-year-old woman. This was her first pregnancy, and she successfully delivered a healthy child at 39 weeks and 4 days. The child weighed 7 lb 12 oz, and the delivery was an uncomplicated spontaneous vaginal delivery. The uterine fundus contracted appropriately, but over the course of the next 12 hours, the patient had more than 1 L of bloody discharge. She has felt increasingly weak and has lightheadedness on standing. Her heart rate is 126 bpm, and blood pressure is 92/50 mmHg. She appears pale. Her pulses are thready. Cardiovascular examination shows regular tachycardia. Her hemoglobin prior to delivery was 9.2 g/dL. It is now 6.0 g/dL. Her prothrombin time (PT) is 12.0, INR is 1.1, and activated partial thromboplastin time (aPTT) is 42.5 seconds. Upon further questioning, the patient describes one other episode of prolonged oral bleeding in childhood at about age 7. At that time, she had a cap placed on a tooth and subsequently experienced significant bleeding. She bruises easily but has not had hemarthroses. She says she stopped playing soccer in grade school due to large bruises after minor injuries that were painful and embarrassing to her. She has had no other surgeries. She is taking iron supplements and prenatal vitamins. She has no allergies. She has a family history of excessive bleeding after a surgical procedure in her father from whom she is estranged. What do you suspect as the cause of the patient’s illness?


The answer is E.  This individual has experienced significant bleeding that is primarily mucosal in origin (postpartum hemorrhage, prior oral bleeding). This suggests a disorder of primary hemostasis, or platelet plug formation. von Willebrand disease (vWD) is the only disease listed that is a disorder of primary hemostasis. Bleeding symptoms that are common in vWD include prolonged bleeding after surgery, including dental procedures, menorrhagia, postpartum hemorrhage, and large bruises or hematomas, even with minor trauma. Epistaxis is also common but occurs in many other diseases as well. Therefore, a clinician should assess for other symptoms prior to ascribing the symptom to a disorder of platelet function. The postpartum hemorrhage can be delayed beyond the immediate period of delivery. Hemarthroses are rare in vWD unless the disease is very severe. All of the other disorders listed affect anticoagulant levels.

End quiz and return to Harrison's™ Principles of Internal Medicine: Self-Assessment and Board Review, 19e Review Questions


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