Vaginal bleeding (not pregnant): documentation that holds up
Abnormal uterine bleeding is common, but two questions make the chart defensible: is she pregnant? and is she postmenopausal? The first reframes the entire workup; the second makes the bleeding endometrial cancer until proven otherwise. The note documents the pregnancy test, the hemodynamic assessment, and the referral.
01What's at stake
A "negative by history" pregnancy is still an ectopic until the test is run — pregnancy status is never assumed. Heavy bleeding can drop the hemoglobin faster than it looks, especially with a coagulopathy or anticoagulation. And any bleeding after menopause is endometrial carcinoma until tissue says otherwise — reassurance without referral is the indefensible move.
02Can't-miss issues
- Hemodynamically significant bleeding — tachycardia, hypotension, orthostasis, or a falling hemoglobin → resuscitate. → hemodynamics
- Unrecognized pregnancy — always test; an ectopic or miscarriage changes everything. → pregnancy test
- Postmenopausal bleeding — endometrial cancer until proven otherwise → gynecology for biopsy/ultrasound. → gyn referral
- Coagulopathy / anticoagulation — von Willebrand disease, platelet disorders, liver disease, warfarin/DOAC.
- Structural & ovulatory causes — fibroids, polyps, adenomyosis (the PALM-COEIN framework).
03Assessment
- Pregnancy test in every reproductive-age patient — the non-negotiable first step. → hCG
- Hemodynamics & blood loss — vitals, orthostatics, pad count/clots, hemoglobin; type-and-screen if significant. → hemodynamics
- Menopausal status and bleeding pattern; medication and bleeding-history (coagulopathy) review.
- Pelvic/speculum exam as indicated (source, trauma, mass, cervical lesion).
Skip the typing
Work the case in the Vaginal Bleeding Workup — it records the pregnancy test, the hemodynamic assessment, and the gynecology follow-up (including the postmenopausal-bleeding pathway), and assembles an MDM that documents the can't-miss causes were addressed.
04Management
- Resuscitate heavy/unstable bleeding — IV access, fluids/blood, reverse coagulopathy; acute heavy AUB may respond to IV/high-dose hormonal therapy or tranexamic acid, with gynecology for tamponade/D&C.
- Postmenopausal bleeding → gynecology referral for endometrial evaluation (transvaginal ultrasound/biopsy) — every time.
- Stable AUB → hormonal management (combined or progestin), tranexamic acid, iron, and outpatient gynecology follow-up.
- Treat the cause — coagulopathy, thyroid, structural lesions; admit the unstable or transfusion-requiring patient.
05What to document
06Where charts fail
- Not testing for pregnancy ("she says she can't be").
- Underestimating blood loss — no hemodynamic assessment or hemoglobin in heavy bleeding.
- Reassuring postmenopausal bleeding without gynecology referral for cancer workup.
- Missing a coagulopathy/anticoagulation contribution.
- No documented follow-up or return precautions.
07Sources
- Munro MG, Critchley HOD, Fraser IS, et al. The FIGO classification of causes of abnormal uterine bleeding (PALM-COEIN). Int J Gynaecol Obstet. 2018;143(3):393-408.
- American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. ACOG Committee Opinion No. 557. 2013 (reaffirmed).
- ACOG. The role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. ACOG Committee Opinion No. 734. 2018.
- Bradley LD, Gueye NA. The medical management of abnormal uterine bleeding in reproductive-aged women. Am J Obstet Gynecol. 2016;214(1):31-44.
© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from primary literature and guidelines. Synthetic examples. Not medical advice — apply local protocol and judgment.