Guidelines for Nurse Practitioners in Gynecologic Settings 2016
Care Plan – Abnormal Vaginal Bleeding
N93.9: Abnormal uterine and vaginal bleeding, unspecified
I. DEFINITION
any variation from a woman’s usual menstrual pattern; bleeding postmenopause
II. ETIOLOGY
a. systemic illnesses: thyroid disease, blood dyscrasias, adrenal imbalance, von Willebrand’s disease
B. submucous leiomyomata in uterus, polyps, uterine prolapse, liver disease, clotting disorders, kidney disease, leukemia
C. tumor in vagina, uterus
D. trauma to vagina, cervix; scar tissue
e. Cervical lesions
1. Polyps
2. Carcinoma
F. abnormal hormone secretion (with anovulatory bleeding)
G. Change in ovarian function (perimenopause)
H. endometrial polyps or leiomyomata in cervix, uterus
i. Pelvic malignancy—nodes, uterus, bladder, rectum, vagina, ovary
J. ectopic pregnancy
K. abortion
l. Placental accidents
M. Hyperplasia
n. stress, excessive exercise
o. Postmenopausal bleeding
P. Pharmacotherapeutics
Q. sexually transmitted infections (stis), pelvic inflammatory disease (PiD)
r. structural abnormalities within the endometrium, including synthesis of vasculature vasodilatory proteins
s. endometriosis/adenomyosis
t. an object in the vagina
u. urethral prolapse
III. HISTORY
a. What the patient may present with
1. Midcycle bleeding
2. spotting
3. Pain
4. sudden onset of heavy bleeding
5. Perimenopausal bleeding
6. Postmenopausal bleeding
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B. additional information to be considered:
1. is bleeding recent or since menarche?
2. onset of bleeding
3. amount of flow (pads or tampons per hour); clots and size of clots
4. normal bleeding pattern: How does this episode differ from normal menstruation?
5. Current or recent use of medication; complementary therapies (herbals, homeopathics)
6. last menstrual period, previous menstrual period
7. last sexual contact, if sexually active
8. Birth control method(s) (including recent insertion of intrauterine device [iuD], intrauterine contraceptive device [iuCD])
9. recent trauma to pelvic area or any other part of body (screen for abuse)
10. Characteristics of present bleeding: clots, tissue
11. any related pain
12. any fever
13. any dizziness, syncope
14. symptoms of changing ovarian function (perimenopause)
15. recent pelvic surgery, including tubal ligation, uterine ablation
IV. PHYSICAL EXAMINATION
a. Vital signs
1. Blood pressure
2. Pulse
3. temperature
B. skin: examine for evidence of bleeding disorder (e.g., petechiae or ecchymosis); pallor; fine, thinning hair
C. neck—thyroid: examine for enlargement, palpate nodes
D. Breasts
1. Development
2. Masses
3. tenderness; appearance of skin, nipples
4. Discharge
5. axillary nodes
e. abdomen
1. tenderness
2. Guarding
3. Bowel sounds
4. Distension
5. Hepatosplenomegaly
F. Genital examination
1. observe perineum for trauma
2. observe for presence of hemorrhoids
G. Vaginal examination (speculum)
1. observe vaginal walls for lesions or evidence of trauma
2. observe cervix for
a. Polyps
b. lesions (evidence of trauma)
c. erosion or ectropion
d. Whether os is closed or dilated; discharge in os
3. evaluate amount and type of bleeding
H. Bimanual examination
1. uterus: evaluate size, shape, position, any pain
2. adnexa: evaluate for possible mass, pain
3. rectovaginal exam
a. Fullness (fluid)
b. Pain
c. Bleeding
V. LABORATORY EXAMINATION
(Will depend on history and assessment of bleeding)
a. Complete blood count, differential with hematocrit or hemoglobin; platelet count; bleeding and clotting time if indicated; specific testing for von Willebrand’s disease, ideally at time of menstruation
B. serum pregnancy test
C. Gonococcal culture
D. Chlamydia smear
e. thyroid studies
F. Hormone levels—luteinizing hormone (lH), follicle-stimulating hormone (FsH), prolactin, gonadotropin-releasing hormone (GnrH), serum estradiol
G. urinalysis
H. sti screen, including HiV and human papillomavirus (HPV) status
i. Wet mount
VI. DIFFERENTIAL DIAGNOSIS
See Etiology, II.
VII. TREATMENT
a. For light flow/regular/irregular bleeding (e.g., midcycle)
1. lab work as history demands
2. May observe 2 to 3 months as indicated by history and physical findings; should be instructed to keep record of days that bleeding occurs
3. after two to three cycles, after normal physical exam and Pap smear as indicated with appropriate lab work, consider
a. Progestin preparation
b. Monophasic oral contraceptive (oC) for 1 to 3 months or 6 to 12 months
c. Meclofenamate (Meclomen) 100 mg every 8 hours up to 6 days
B. For heavy bleeding
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1. Consult/refer to physician after appropriate workup.
2. Consider nonhormonal management with tranexamic (lysteda).
C. For bleeding with iuD in place, see IUD in Chapter 7
D. For heavy bleeding with Depo-Provera,1 consider addition of lowdose contraceptive for three cycles or supplemental estrogen until bleeding stops
e. if bleeding persists with a positive human chorionic gonadotropin (hCG)
1. Physician consultation
2. referral as indicated
F. if bleeding postmenopausal, will need an endometrial biopsy (see Endometrial Biopsy section)
G. endometrial biopsy should be considered for a woman of any age if no cause is found.
VIII. COMPLICATIONS
a. severe hemorrhage
B. shock
C. of underlying systemic illnesses
IX. CONSULTATION/REFERRAL
a. after completion of all laboratory work and physical examination, nurse practitioner may
1. Consult with physician for possible Mirena insertion
2. refer to physician for treatment, that is, endometrial ablation or dilation and curettage (D&C)
3. refer to hematologist if clotting time abnormal
B. immediate referral to physician if excessive bleeding after laboratory work and workup by clinician
X. FOLLOW-UP
as indicated by diagnosis and treatment
See Bibliographies.
Websites: www.womenshealth.about.com/cs/menstrualdisorder/index.htm;www
.webmd.com/women/tc/abnormal-vaginal-bleeding-topic-overview