CCFP 105 Topics: Vaginal Bleeding Part 2 - Non-pregnant Patients

Abnormal uterine bleeding in non-pregnant patients requires a structured diagnostic approach using the PALM-COEIN mnemonic to differentiate between structural causes—such as polyps, adenomyosis, leiomyomas, and malignancy—and medical disturbances like coagulopathies, ovulatory dysfunction, and iatrogenic factors. Clinical assessment involves a thorough history, physical examination, and targeted investigations, including CBC, TSH, and transvaginal ultrasound. Hemodynamically unstable patients necessitate immediate resuscitation, IV fluids, and potential surgical intervention, while stable patients benefit from hormonal or non-hormonal therapies like tranexamic acid or oral contraceptives. In postmenopausal patients, any new vaginal bleeding demands the exclusion of endometrial cancer, typically starting with a transvaginal ultrasound to assess endometrial thickness. If the lining exceeds four millimeters or symptoms persist, an endometrial biopsy is essential. Vulvovaginal atrophy remains a common, treatable cause of postmenopausal bleeding, effectively managed with topical estrogen.