Differentials
Pregnancy-related bleeding
SIGNS / SYMPTOMS
A positive pregnancy test should alert attention towards problems associated with pregnancy, such as miscarriage and ectopic pregnancy.
INVESTIGATIONS
Positive pregnancy test (urine or blood pregnancy test). Sensitive urine pregnancy tests can detect pregnancies as early as a few days following a missed period.
Pregnancy should be excluded.
Menstrual-related migraine
SIGNS / SYMPTOMS
Menstrual-related migraine might be suspected in adolescent girls or women who report migraine headaches between 2 days before and 3 days after the onset of menstrual bleeding in at least two out of three consecutive menstrual cycles.
INVESTIGATIONS
Recording the frequency, duration, severity, and relationship of migraines with menstruation in a headache diary for at least two menstrual cycles can aid diagnosis.
Genital lesions
SIGNS / SYMPTOMS
It may be difficult to differentiate between uterine bleeding and bleeding coming from other parts of the genital tract. In some instances, further investigations may be needed to determine the source of bleeding (e.g., gastrointestinal tract, urinary tract, vulva, vagina, cervix, or uterus).
Traumatic injury during intercourse and physical abuse are important aetiologies that should always be kept in mind.
Careful history and physical examination is usually sufficient for diagnosis.
INVESTIGATIONS
Examination under anaesthesia may be required to diagnose the extent of genital injury.
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