Vaginal bleeding in the non‑pregnant patient
Introduction
Vaginal bleeding in a non‑pregnant woman ranges from normal menstrual variation to acute, life‑threatening haemorrhage or a presentation requiring urgent cancer investigation. In the emergency department (ED) priorities are to: exclude pregnancy, identify and resuscitate the unstable patient, recognise red flags that require urgent gynaecology or 2‑week suspected‑cancer referral, and provide temporising medical therapy or safe outpatient follow‑up (NICE NG88; NG12; RCEM guidance).
Epidemiology and clinical impact
- Abnormal uterine bleeding (AUB) affects a substantial minority of women of reproductive age.
- Heavy menstrual bleeding (HMB) causes significant morbidity including iron‑deficiency anaemia, transfusion, missed work/school and psychosocial consequences.
- Postmenopausal bleeding (PMB) is a red flag: approximately 5-10% of women with PMB have endometrial cancer and PMB should prompt urgent investigation (NICE NG12).
Key definitions (practical ED use)
- Normal cycle: length 24-38 days; bleed 4-8 days; cycle‑to‑cycle variation 2-20 days.
- AUB: any deviation in volume, regularity, frequency or duration of uterine bleeding in a non‑pregnant woman.
- Chronic AUB: present for most days in the previous 6 months.
- Acute AUB: an episode of heavy bleeding requiring immediate action to prevent further blood loss or haemodynamic compromise.
- HMB: patient‑reported bleeding that adversely affects quality of life (QoL) (NICE NG88).
- IMB: intermenstrual bleeding (bleeding between menses, not post‑coital).