Browse categories and answer follow-up questions to refine your symptom profile.
History
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
Alarm Features
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
Medications
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
Diet
Intake and contributors
Intake pattern
Poor oral intake
Dehydration indicators
Substance exposure
Alcohol use
Caffeine and energy drinks
Review of Systems
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
Collateral History and Family History
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
Risk Factors
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
Differential Diagnosis
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
Past Medical History
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
Physical Exam
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
Lab Studies
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
Imaging
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
CT
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
Special Tests
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
ECG
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
Assessment
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
Plan
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
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.