Vaginal Bleeding, NonpregnantAPPROACH

WOMEN'S HEALTH, PREGNANCY, AND GU · 19 SECTIONS

⚲

459 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Vaginal Discharge Hyperemesis Gravidarum Concern Hypertensive Disorders Of Pregnancy Symptoms Postpartum Hemorrhage Concern Postpartum Infection Concern Sexual Assault Medical Evaluation Overview Pelvic Pain Vaginal Bleeding, Nonpregnant Vaginal Bleeding In Pregnancy Pelvic Pain In Pregnancy Post Procedure Or Post Abortion Complications Concern

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx60

Presenting bleeding pattern

›Bleeding characterization

›Onset and duration

›First day of current episode

›Continuous vs intermittent

›Amount

›Pads or tampons per hour

›Clots

›Timing relative to menses

›Intermenstrual bleeding

›Postcoital bleeding

OPQRST

›Onset

›Sudden vs gradual

›Trigger event

›Provocation/Palliation

›Worse with intercourse

›Worse with exertion

›Quality

›Bright red

›Dark brown

›Region/Radiation

›Pelvic pain location

›Back or flank radiation

›Severity

›Bleeding severity estimate

›Pain 0 to 10

›Timing

›Constant vs episodic

›Cyclic pattern

Gynecologic and obstetric context

›Reproductive history

›Last menstrual period date

›Typical cycle length and regularity

›Prior abnormal uterine bleeding episodes

›Prior pregnancy history

›Sexual history and STI risk

›New partners

›Barrier protection

›Prior STI history

›Contraception and devices

›Intrauterine device presence

›Hormonal contraception type

Associated symptoms

›Hemodynamic and anemia symptoms

›Lightheadedness or syncope

›Chest pain

›Dyspnea

›Fatigue

›Infection symptoms

›Fever

›Pelvic pain

›Vaginal discharge

›Endocrine and systemic symptoms

›Weight change

›Galactorrhea

›Hirsutism

Prior testing and procedures

›Screening history

›Last cervical cancer screening result

›Prior abnormal cytology

›Gynecologic procedures

›Prior endometrial biopsy

›Prior hysteroscopy

›Prior fibroid treatment

02Alarm Features/alarm33

First 5 minutes and escalation triggers

›Critical pathway

›Immediate escalation if

›Systolic blood pressure < 90 mmHg

›Heart rate > 120 per minute with symptoms

›Syncope

›Ongoing heavy bleeding

›Monitoring and access

›Cardiac monitor

›Two large bore IVs if unstable or heavy bleeding

›Immediate labs if unstable

›Type and screen

›Hemoglobin

›Immediate pregnancy exclusion

›Urine or serum beta hCG

›Treat as pregnant until excluded

High risk bleeding features

›Heavy bleeding indicators

›Soaking 1 pad per hour for 2 hours

›Large clots with ongoing brisk bleeding

›Bleeding causing presyncope or syncope

High risk etiologies

›Malignancy risk features

›Postmenopausal bleeding

›Persistent intermenstrual bleeding

›Postcoital bleeding with abnormal cervix

›Infection and sepsis risk features

›Fever with pelvic tenderness

›Purulent discharge

High risk exam findings

›Concerning pelvic findings

›Cervical mass

›Friable cervix

›Adnexal mass with pain

›Hemodynamic compromise

›Altered mental status

›Poor perfusion

03Medications/meds21

Bleeding and thrombosis relevant medications

›Anticoagulants and antiplatelets

›Warfarin

›Direct oral anticoagulants

›Heparin products

›Aspirin

›P2Y12 inhibitors

›Hormonal agents

›Combined oral contraceptives

›Progestin only pills

›Depot medroxyprogesterone

›Levonorgestrel IUD

›Other contributors

›NSAIDs

›SSRI and SNRI agents

›Herbal supplements affecting bleeding

Recent changes and adherence

›Recent medication changes

›New anticoagulant start

›Missed hormonal doses

›Adherence pattern

›Missed doses in last 7 days

›Variable dosing

04Diet/diet6

Intake and contributors

›Intake pattern

›Poor oral intake

›Dehydration indicators

›Substance exposure

›Alcohol use

›Caffeine and energy drinks

05Review of Systems/ros21

System review focused to bleeding etiologies

›General

›Fever

›Weight change

›Night sweats

›Cardiopulmonary

›Chest pain

›Dyspnea

›Palpitations

›Gastrointestinal

›Abdominal pain

›Hematochezia or melena

›Genitourinary

›Dysuria

›Vaginal discharge

›Pelvic pain

›Endocrine

›Heat or cold intolerance

›Galactorrhea

›Hematologic

›Easy bruising

›Gum bleeding

06Collateral History and Family History/chafh12

Collateral and reliability

›Additional sources

›Partner or caregiver report

›Prior records review

Family history relevant to bleeding and malignancy

›Inherited bleeding disorders

›von Willebrand disease

›Hemophilia carriers

›Gynecologic malignancy

›Endometrial cancer

›Ovarian cancer

›Thrombosis history

›Venous thromboembolism

›Known thrombophilia

07Risk Factors/rf21

Bleeding and coagulopathy risks

›Coagulopathy risks

›Known bleeding disorder

›Liver disease

›Thrombocytopenia history

›Medication risks

›Anticoagulant use

›Antiplatelet use

Structural and malignancy risks

›Endometrial hyperplasia and cancer risks

›Age 45 years or older

›Obesity

›Chronic anovulation

›Polycystic ovary syndrome (E28.2)

›Diabetes mellitus type 2 (E11.9)

›Tamoxifen exposure

›Cervical cancer risks

›Inadequate screening

›HPV history

Infection risks

›STI and PID risks

›New partner in last 3 months

›Prior PID

›Barrier nonuse

08Differential Diagnosis/ddx46

Life threatening

›Life threatening causes

›Pregnancy related bleeding despite history

›Ectopic pregnancy (O00.9)

›Miscarriage (O03.9)

›Severe hemorrhage with shock

›Acute blood loss anemia (D62)

›Coagulopathy associated bleeding (D68.9)

›Gynecologic malignancy with significant bleeding

›Endometrial carcinoma (C54.1)

›Cervical cancer (C53.9)

Common

›Common causes

›Abnormal uterine bleeding (N93.9)

›Ovulatory dysfunction (AUB O)

›Endometrial causes (AUB E)

›Leiomyoma fibroids (D25.9)

›Heavy menstrual bleeding

›Bulk related symptoms

›Endometrial polyp (N84.0)

›Intermenstrual bleeding

›Postcoital bleeding

›Iatrogenic bleeding

›Hormonal contraception breakthrough bleeding

›Anticoagulant associated bleeding

Less common

›Less common causes

›Adenomyosis (N80.0)

›Dysmenorrhea

›Enlarged tender uterus

›Cervicitis

›Chlamydia infection (A56.2)

›Gonorrhea infection (A54.01)

›Pelvic inflammatory disease (N73.9)

›Cervical motion tenderness

›Fever

›Ovulatory bleeding

›Mid cycle spotting

›Self limited

Key distinguishing clues

›Distinguishing features

›Postmenopausal bleeding

›Endometrial evaluation priority

›Malignancy exclusion priority

›Postcoital bleeding

›Cervical pathology evaluation

›Cervicitis evaluation

›Heavy prolonged menses

›Fibroids and adenomyosis likelihood

›Coagulopathy screen if lifelong pattern

09Past Medical History/pmh15

Relevant conditions and procedures

›Prior gynecologic history

›Prior fibroids

›Prior endometrial hyperplasia

›Prior cervical dysplasia

›Bleeding and hematologic history

›Known coagulopathy

›Prior transfusions

›Medical comorbidities

›Thyroid disease (E03.9)

›Chronic kidney disease (N18.9)

›Liver disease (K76.9)

›Surgeries and procedures

›Cesarean delivery

›Myomectomy

›Endometrial ablation

10Physical Exam/exam29

General and hemodynamics

›Clinical status

›Overall appearance

›Pallor

›Diaphoresis

›Vital signs pattern

›Orthostatic vitals if stable

›Fever pattern

›Perfusion assessment

›Capillary refill

›Peripheral pulses

Abdominal exam

›Abdominal findings

›Suprapubic tenderness

›Peritoneal signs

›Distension or mass

Pelvic exam

›External and speculum

›Active bleeding source

›Cervical lesions or mass

›Discharge

›Bimanual

›Uterine size and tenderness

›Adnexal mass or tenderness

›Cervical motion tenderness

Focused systems

›Cardiopulmonary

›Tachycardia

›Flow murmur

›Skin and mucosa

›Petechiae

›Ecchymoses

›Gum bleeding

11Lab Studies/labs27

Core labs for acute bleeding

›Initial labs

›Urine beta hCG

›CBC

›Hemoglobin trend if prior available

›Platelet count

›Type and screen

›Crossmatch if heavy bleeding or unstable

›Coagulation studies if indicated

›INR

›aPTT

›Metabolic and systemic labs when indicated

›Electrolytes

›Creatinine

›Liver enzymes

Etiology targeted testing

›Infection testing when indicated

›NAAT for chlamydia

›NAAT for gonorrhea

›Vaginal wet mount if discharge

›Endocrine testing when indicated

›TSH

›Prolactin

Interpretation pearls and pitfalls

›Key limitations

›Normal hemoglobin early in acute hemorrhage

›Coagulation tests may not reflect platelet dysfunction

›Thresholds impacting management

›Hemoglobin < 70 g/L

›Platelets < 50 x 10^9 per L with bleeding

12Imaging/img41

Scoring Systems

›PALM COEIN framework

›Structural causes

›Polyp

›Adenomyosis

›Leiomyoma

›Malignancy and hyperplasia

›Non structural causes

›Coagulopathy

›Ovulatory dysfunction

›Endometrial

›Iatrogenic

›Not otherwise classified

›Endometrial cancer risk prioritization

›Postmenopausal bleeding pathway

›Age 45 years or older with AUB

MRI

›Indications

›Problem solving after ultrasound

›Adenomyosis evaluation

›Complex fibroid mapping pre procedure

›Key considerations

›Gadolinium use local protocol dependent

›Contraindications

›Non MRI compatible implant

›Severe claustrophobia without support

›Indications

›Alternative abdominal source of bleeding concern

›Suspected malignancy staging discussion

›Key considerations

›Radiation exposure

›IV contrast risk

›Prior severe contrast reaction

›Significant kidney dysfunction

Ultrasound

›Transvaginal ultrasound

›First line for structural evaluation

›Endometrial thickness assessment in postmenopausal bleeding

›POCUS adjuncts

›Free fluid assessment if unstable

›Bladder volume if urinary retention symptoms

›Pitfalls

›Limited views with obesity

›Endometrial measurement unreliable with intracavitary blood

13Special Tests/spec13

Bedside and procedural diagnostics

›Speculum source identification

›Cervical bleeding vs uterine bleeding

›Vaginal laceration consideration

›Endometrial sampling indications

›Postmenopausal bleeding

›Age 45 years or older with AUB

›Persistent AUB with risk factors

›Cervical screening follow up

›Visible cervical lesion

›Overdue screening history

Hemostasis interventions when unstable

›Mechanical temporizing measures

›Vaginal packing local protocol dependent

›Foley catheter uterine tamponade local protocol dependent

14ECG/ecg8

Indications and high risk patterns

›ECG indications

›Chest pain

›Syncope

›Significant anemia symptoms

›High risk findings

›Ischemic ST changes

›New arrhythmia

›Prolonged QT with electrolyte issues

15Assessment/ax14

Problem representation and severity

›Vaginal bleeding severity

›Hemodynamically unstable vs stable

›Ongoing heavy bleeding vs controlled

›Working diagnosis categories

›Abnormal uterine bleeding (N93.9)

›Structural cause suspected

›Infection suspected

›Medication associated bleeding suspected

Complications and exclusions

›Cannot miss exclusions

›Pregnancy related bleeding excluded by beta hCG

›Malignancy risk stratified by age and pattern

›Anemia and end organ risk

›Symptomatic anemia

›Demand ischemia risk in older patients

16Plan/plan40

Stabilization and resuscitation

›Hemodynamic support

›IV crystalloid bolus if hypotension

›Massive transfusion protocol local protocol dependent

›Packed red blood cells if

›Hemodynamic instability with bleeding

›Hemoglobin < 70 g/L with symptoms

›Hemostatic medication options for heavy uterine bleeding

›Tranexamic acid IV 1 g over 10 minutes

›Repeat 1 g after 30 minutes if ongoing severe bleeding local protocol dependent

›Avoid if active arterial or venous thrombosis

›High dose combined oral contraceptive regimen local protocol dependent

›Avoid if migraine with aura

›Avoid if active thromboembolism

›High dose progestin regimen local protocol dependent

›Option if estrogen contraindicated

›Adherence critical

›Pain and nausea control

›Acetaminophen 1000 mg PO

›Ondansetron ODT 4 mg

Diagnostic sequencing

›Immediate diagnostics

›Beta hCG

›CBC

›Type and screen

›Targeted diagnostics

›STI NAAT if cervicitis or PID concern

›TSH if ovulatory dysfunction suspected

›Ultrasound if structural cause suspected or persistent bleeding

Etiology specific treatment

›Cervicitis and PID treatment local protocol dependent

›Ceftriaxone IM dosing local protocol dependent

›Doxycycline dosing local protocol dependent

›Anticoagulant associated bleeding

›Anticoagulant hold decision with prescribing indication context

›Reversal agents local protocol dependent

Reassessment loop

›Reassessment timing

›Repeat vitals every 15 to 30 minutes if moderate bleeding

›Repeat pelvic bleeding assessment after interventions

›Escalation triggers

›Worsening tachycardia

›New hypotension

›Ongoing pad soaking despite therapy

17Disposition/dispo19

Admission and higher level of care criteria

›ICU or resuscitation bay criteria

›Ongoing hemorrhagic shock

›Transfusion requirement with continued bleeding

›Inpatient admission criteria

›Hemoglobin < 80 g/L with ongoing bleeding

›Requires procedural intervention

›Suspected malignancy needing urgent workup

›PID with systemic illness

Observation and discharge criteria

›Observation pathway criteria

›Moderate bleeding requiring serial hemoglobin

›Uncertain trajectory after initial therapy

›Discharge criteria

›Hemodynamically stable

›Bleeding controlled or clearly improving

›Hemoglobin stable for clinical context

›Reliable follow up within 72 hours when needed

Follow up timing

›Outpatient follow up

›Gynecology within 1 to 2 weeks for persistent AUB

›Urgent within 72 hours for high risk features without admission

18Discharge Instructions/di18

Copy discharge instructions

›Vaginal bleeding evaluated and pregnancy test negative

›Bleeding may be from hormonal or uterine causes, but some causes need follow up testing

›Return to the emergency department now for

›Fainting or near fainting

›Chest pain

›Shortness of breath

›Fever

›Severe worsening pelvic pain

›Soaking 1 pad per hour for 2 hours

›Medications

›Take prescribed medications exactly as directed

›Avoid NSAIDs if on blood thinners unless told otherwise

›Activity

›Avoid intercourse until bleeding stops and infection ruled out if discharge or pelvic pain present

›Avoid heavy exertion if lightheaded

›Follow up

›Follow up with primary care or gynecology within recommended timeframe

›If age 45 years or older or postmenopausal, endometrial evaluation may be needed

19References/r15

Guidelines and key sources

›ACOG Practice Bulletin on abnormal uterine bleeding, evaluation and management, year varies local protocol dependent

›PALM COEIN framework

›Endometrial sampling indications

›ACOG guidance on management of acute abnormal uterine bleeding in nonpregnant reproductive aged patients, year varies local protocol dependent

›Medical therapy options

›Escalation to procedural management

›NICE guideline on heavy menstrual bleeding, year varies local protocol dependent

›First line investigations

›Treatment options and sequencing

›Society of Gynecologic Oncology and major society statements on postmenopausal bleeding and endometrial cancer evaluation, year varies local protocol dependent

›Ultrasound and endometrial thickness use

›Biopsy thresholds and follow up

›CDC STI Treatment Guidelines, cervicitis and PID management, year varies local protocol dependent

›Recommended regimens

›Follow up and partner management

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Vaginal Bleeding, NonpregnantAPPROACH

WOMEN'S HEALTH, PREGNANCY, AND GU · 19 SECTIONS

⚲

459 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx60

Presenting bleeding pattern

›Bleeding characterization

›Onset and duration

›First day of current episode

›Continuous vs intermittent

›Amount

›Pads or tampons per hour

›Clots

›Timing relative to menses

›Intermenstrual bleeding

›Postcoital bleeding

OPQRST

›Onset

›Sudden vs gradual

›Trigger event

›Provocation/Palliation

›Worse with intercourse

›Worse with exertion

›Quality

›Bright red

›Dark brown

›Region/Radiation

›Pelvic pain location

›Back or flank radiation

›Severity

›Bleeding severity estimate

›Pain 0 to 10

›Timing

›Constant vs episodic

›Cyclic pattern

Gynecologic and obstetric context

›Reproductive history

›Last menstrual period date

›Typical cycle length and regularity

›Prior abnormal uterine bleeding episodes

›Prior pregnancy history

›Sexual history and STI risk

›New partners

›Barrier protection

›Prior STI history

›Contraception and devices

›Intrauterine device presence

›Hormonal contraception type

Associated symptoms

›Hemodynamic and anemia symptoms

›Lightheadedness or syncope

›Chest pain

›Dyspnea

›Fatigue

›Infection symptoms

›Fever

›Pelvic pain

›Vaginal discharge

›Endocrine and systemic symptoms

›Weight change

›Galactorrhea

›Hirsutism

Prior testing and procedures

›Screening history

›Last cervical cancer screening result

›Prior abnormal cytology

›Gynecologic procedures

›Prior endometrial biopsy

›Prior hysteroscopy

›Prior fibroid treatment

02Alarm Features/alarm33

First 5 minutes and escalation triggers

›Critical pathway

›Immediate escalation if

›Systolic blood pressure < 90 mmHg

›Heart rate > 120 per minute with symptoms

›Syncope

›Ongoing heavy bleeding

›Monitoring and access

›Cardiac monitor

›Two large bore IVs if unstable or heavy bleeding

›Immediate labs if unstable

›Type and screen

›Hemoglobin

›Immediate pregnancy exclusion

›Urine or serum beta hCG

›Treat as pregnant until excluded

High risk bleeding features

›Heavy bleeding indicators

›Soaking 1 pad per hour for 2 hours

›Large clots with ongoing brisk bleeding

›Bleeding causing presyncope or syncope

High risk etiologies

›Malignancy risk features

›Postmenopausal bleeding

›Persistent intermenstrual bleeding

›Postcoital bleeding with abnormal cervix

›Infection and sepsis risk features

›Fever with pelvic tenderness

›Purulent discharge

High risk exam findings

›Concerning pelvic findings

›Cervical mass

›Friable cervix

›Adnexal mass with pain

›Hemodynamic compromise

›Altered mental status

›Poor perfusion

03Medications/meds21

Bleeding and thrombosis relevant medications

›Anticoagulants and antiplatelets

›Warfarin

›Direct oral anticoagulants

›Heparin products

›Aspirin

›P2Y12 inhibitors

›Hormonal agents

›Combined oral contraceptives

›Progestin only pills

›Depot medroxyprogesterone

›Levonorgestrel IUD

›Other contributors

›NSAIDs

›SSRI and SNRI agents

›Herbal supplements affecting bleeding

Recent changes and adherence

›Recent medication changes

›New anticoagulant start

›Missed hormonal doses

›Adherence pattern

›Missed doses in last 7 days

›Variable dosing

04Diet/diet6

Intake and contributors

›Intake pattern

›Poor oral intake

›Dehydration indicators

›Substance exposure

›Alcohol use

›Caffeine and energy drinks

05Review of Systems/ros21

System review focused to bleeding etiologies

›General

›Fever

›Weight change

›Night sweats

›Cardiopulmonary

›Chest pain

›Dyspnea

›Palpitations

›Gastrointestinal

›Abdominal pain

›Hematochezia or melena

›Genitourinary

›Dysuria

›Vaginal discharge

›Pelvic pain

›Endocrine

›Heat or cold intolerance

›Galactorrhea

›Hematologic

›Easy bruising

›Gum bleeding

06Collateral History and Family History/chafh12

Collateral and reliability

›Additional sources

›Partner or caregiver report

›Prior records review

Family history relevant to bleeding and malignancy

›Inherited bleeding disorders

›von Willebrand disease

›Hemophilia carriers

›Gynecologic malignancy

›Endometrial cancer

›Ovarian cancer

›Thrombosis history

›Venous thromboembolism

›Known thrombophilia

07Risk Factors/rf21

Bleeding and coagulopathy risks

›Coagulopathy risks

›Known bleeding disorder

›Liver disease

›Thrombocytopenia history

›Medication risks

›Anticoagulant use

›Antiplatelet use

Structural and malignancy risks

›Endometrial hyperplasia and cancer risks

›Age 45 years or older

›Obesity

›Chronic anovulation

›Polycystic ovary syndrome (E28.2)

›Diabetes mellitus type 2 (E11.9)

›Tamoxifen exposure

›Cervical cancer risks

›Inadequate screening

›HPV history

Infection risks

›STI and PID risks

›New partner in last 3 months

›Prior PID

›Barrier nonuse

08Differential Diagnosis/ddx46

Life threatening

›Life threatening causes

›Pregnancy related bleeding despite history

›Ectopic pregnancy (O00.9)

›Miscarriage (O03.9)

›Severe hemorrhage with shock

›Acute blood loss anemia (D62)

›Coagulopathy associated bleeding (D68.9)

›Gynecologic malignancy with significant bleeding

›Endometrial carcinoma (C54.1)

›Cervical cancer (C53.9)

Common

›Common causes

›Abnormal uterine bleeding (N93.9)

›Ovulatory dysfunction (AUB O)

›Endometrial causes (AUB E)

›Leiomyoma fibroids (D25.9)

›Heavy menstrual bleeding

›Bulk related symptoms

›Endometrial polyp (N84.0)

›Intermenstrual bleeding

›Postcoital bleeding

›Iatrogenic bleeding

›Hormonal contraception breakthrough bleeding

›Anticoagulant associated bleeding

Less common

›Less common causes

›Adenomyosis (N80.0)

›Dysmenorrhea

›Enlarged tender uterus

›Cervicitis

›Chlamydia infection (A56.2)

›Gonorrhea infection (A54.01)

›Pelvic inflammatory disease (N73.9)

›Cervical motion tenderness

›Fever

›Ovulatory bleeding

›Mid cycle spotting

›Self limited

Key distinguishing clues

›Distinguishing features

›Postmenopausal bleeding

›Endometrial evaluation priority

›Malignancy exclusion priority

›Postcoital bleeding

›Cervical pathology evaluation

›Cervicitis evaluation

›Heavy prolonged menses

›Fibroids and adenomyosis likelihood

›Coagulopathy screen if lifelong pattern

09Past Medical History/pmh15

Relevant conditions and procedures

›Prior gynecologic history

›Prior fibroids

›Prior endometrial hyperplasia

›Prior cervical dysplasia

›Bleeding and hematologic history

›Known coagulopathy

›Prior transfusions

›Medical comorbidities

›Thyroid disease (E03.9)

›Chronic kidney disease (N18.9)

›Liver disease (K76.9)

›Surgeries and procedures

›Cesarean delivery

›Myomectomy

›Endometrial ablation

10Physical Exam/exam29

General and hemodynamics

›Clinical status

›Overall appearance

›Pallor

›Diaphoresis

›Vital signs pattern

›Orthostatic vitals if stable

›Fever pattern

›Perfusion assessment

›Capillary refill

›Peripheral pulses

Abdominal exam

›Abdominal findings

›Suprapubic tenderness

›Peritoneal signs

›Distension or mass

Pelvic exam

›External and speculum

›Active bleeding source

›Cervical lesions or mass

›Discharge

›Bimanual

›Uterine size and tenderness

›Adnexal mass or tenderness

›Cervical motion tenderness

Focused systems

›Cardiopulmonary

›Tachycardia

›Flow murmur

›Skin and mucosa

›Petechiae

›Ecchymoses

›Gum bleeding

11Lab Studies/labs27

Core labs for acute bleeding

›Initial labs

›Urine beta hCG

›CBC

›Hemoglobin trend if prior available

›Platelet count

›Type and screen

›Crossmatch if heavy bleeding or unstable

›Coagulation studies if indicated

›INR

›aPTT

›Metabolic and systemic labs when indicated

›Electrolytes

›Creatinine

›Liver enzymes

Etiology targeted testing

›Infection testing when indicated

›NAAT for chlamydia

›NAAT for gonorrhea

›Vaginal wet mount if discharge

›Endocrine testing when indicated

›TSH

›Prolactin

Interpretation pearls and pitfalls

›Key limitations

›Normal hemoglobin early in acute hemorrhage

›Coagulation tests may not reflect platelet dysfunction

›Thresholds impacting management

›Hemoglobin < 70 g/L

›Platelets < 50 x 10^9 per L with bleeding

12Imaging/img41

Scoring Systems

›PALM COEIN framework

›Structural causes

›Polyp

›Adenomyosis

›Leiomyoma

›Malignancy and hyperplasia

›Non structural causes

›Coagulopathy

›Ovulatory dysfunction

›Endometrial

›Iatrogenic

›Not otherwise classified

›Endometrial cancer risk prioritization

›Postmenopausal bleeding pathway

›Age 45 years or older with AUB

MRI

›Indications

›Problem solving after ultrasound

›Adenomyosis evaluation

›Complex fibroid mapping pre procedure

›Key considerations

›Gadolinium use local protocol dependent

›Contraindications

›Non MRI compatible implant

›Severe claustrophobia without support

›Indications

›Alternative abdominal source of bleeding concern

›Suspected malignancy staging discussion

›Key considerations

›Radiation exposure

›IV contrast risk

›Prior severe contrast reaction

›Significant kidney dysfunction

Ultrasound

›Transvaginal ultrasound

›First line for structural evaluation

›Endometrial thickness assessment in postmenopausal bleeding

›POCUS adjuncts

›Free fluid assessment if unstable

›Bladder volume if urinary retention symptoms

›Pitfalls

›Limited views with obesity

›Endometrial measurement unreliable with intracavitary blood

13Special Tests/spec13

Bedside and procedural diagnostics

›Speculum source identification

›Cervical bleeding vs uterine bleeding

›Vaginal laceration consideration

›Endometrial sampling indications

›Postmenopausal bleeding

›Age 45 years or older with AUB

›Persistent AUB with risk factors

›Cervical screening follow up

›Visible cervical lesion

›Overdue screening history

Hemostasis interventions when unstable

›Mechanical temporizing measures

›Vaginal packing local protocol dependent

›Foley catheter uterine tamponade local protocol dependent

14ECG/ecg8

Indications and high risk patterns

›ECG indications

›Chest pain

›Syncope

›Significant anemia symptoms

›High risk findings

›Ischemic ST changes

›New arrhythmia

›Prolonged QT with electrolyte issues

15Assessment/ax14

Problem representation and severity

›Vaginal bleeding severity

›Hemodynamically unstable vs stable

›Ongoing heavy bleeding vs controlled

›Working diagnosis categories

›Abnormal uterine bleeding (N93.9)

›Structural cause suspected

›Infection suspected

›Medication associated bleeding suspected

Complications and exclusions

›Cannot miss exclusions

›Pregnancy related bleeding excluded by beta hCG

›Malignancy risk stratified by age and pattern

›Anemia and end organ risk

›Symptomatic anemia

›Demand ischemia risk in older patients

16Plan/plan40

Stabilization and resuscitation

›Hemodynamic support

›IV crystalloid bolus if hypotension

›Massive transfusion protocol local protocol dependent

›Packed red blood cells if

›Hemodynamic instability with bleeding

›Hemoglobin < 70 g/L with symptoms

›Hemostatic medication options for heavy uterine bleeding

›Tranexamic acid IV 1 g over 10 minutes

›Repeat 1 g after 30 minutes if ongoing severe bleeding local protocol dependent

›Avoid if active arterial or venous thrombosis

›High dose combined oral contraceptive regimen local protocol dependent

›Avoid if migraine with aura

›Avoid if active thromboembolism

›High dose progestin regimen local protocol dependent

›Option if estrogen contraindicated

›Adherence critical

›Pain and nausea control

›Acetaminophen 1000 mg PO

›Ondansetron ODT 4 mg

Diagnostic sequencing

›Immediate diagnostics

›Beta hCG

›CBC

›Type and screen

›Targeted diagnostics

›STI NAAT if cervicitis or PID concern

›TSH if ovulatory dysfunction suspected

›Ultrasound if structural cause suspected or persistent bleeding

Etiology specific treatment

›Cervicitis and PID treatment local protocol dependent

›Ceftriaxone IM dosing local protocol dependent

›Doxycycline dosing local protocol dependent

›Anticoagulant associated bleeding

›Anticoagulant hold decision with prescribing indication context

›Reversal agents local protocol dependent

Reassessment loop

›Reassessment timing

›Repeat vitals every 15 to 30 minutes if moderate bleeding

›Repeat pelvic bleeding assessment after interventions

›Escalation triggers

›Worsening tachycardia

›New hypotension

›Ongoing pad soaking despite therapy

17Disposition/dispo19

Admission and higher level of care criteria

›ICU or resuscitation bay criteria

›Ongoing hemorrhagic shock

›Transfusion requirement with continued bleeding

›Inpatient admission criteria

›Hemoglobin < 80 g/L with ongoing bleeding

›Requires procedural intervention

›Suspected malignancy needing urgent workup

›PID with systemic illness

Observation and discharge criteria

›Observation pathway criteria

›Moderate bleeding requiring serial hemoglobin

›Uncertain trajectory after initial therapy

›Discharge criteria

›Hemodynamically stable

›Bleeding controlled or clearly improving

›Hemoglobin stable for clinical context

›Reliable follow up within 72 hours when needed

Follow up timing

›Outpatient follow up

›Gynecology within 1 to 2 weeks for persistent AUB

›Urgent within 72 hours for high risk features without admission

18Discharge Instructions/di18

Copy discharge instructions

›Vaginal bleeding evaluated and pregnancy test negative

›Bleeding may be from hormonal or uterine causes, but some causes need follow up testing

›Return to the emergency department now for

›Fainting or near fainting

›Chest pain

›Shortness of breath

›Fever

›Severe worsening pelvic pain

›Soaking 1 pad per hour for 2 hours

›Medications

›Take prescribed medications exactly as directed

›Avoid NSAIDs if on blood thinners unless told otherwise

›Activity

›Avoid intercourse until bleeding stops and infection ruled out if discharge or pelvic pain present

›Avoid heavy exertion if lightheaded

›Follow up

›Follow up with primary care or gynecology within recommended timeframe

›If age 45 years or older or postmenopausal, endometrial evaluation may be needed

19References/r15

Guidelines and key sources

›ACOG Practice Bulletin on abnormal uterine bleeding, evaluation and management, year varies local protocol dependent

›PALM COEIN framework

›Endometrial sampling indications

›ACOG guidance on management of acute abnormal uterine bleeding in nonpregnant reproductive aged patients, year varies local protocol dependent

›Medical therapy options

›Escalation to procedural management

›NICE guideline on heavy menstrual bleeding, year varies local protocol dependent

›First line investigations

›Treatment options and sequencing

›Society of Gynecologic Oncology and major society statements on postmenopausal bleeding and endometrial cancer evaluation, year varies local protocol dependent

›Ultrasound and endometrial thickness use

›Biopsy thresholds and follow up

›CDC STI Treatment Guidelines, cervicitis and PID management, year varies local protocol dependent

›Recommended regimens

›Follow up and partner management

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.