Vaginal Bleeding After Hysterectomy (Surgery)

A hysterectomy is the surgical removal of the uterus, with or without the fallopian tubes and ovaries. Post-operative vaginal bleeding after a hysterectomy can be a potentially serious complication which may require a blood transfusion and further surgery. The vaginal bleeding can occur immediately after or within a few days of surgery, or in some cases it may even occur a few weeks after the operation.

Spotting After Hysterectomy

Slight vaginal bleeding is often experienced by some women and this may take the form of spotting or a faint pink discharge in the first four to six weeks following a hysterectomy. The spotting may be considered to be normal in these circumstances. This small amount of bleeding may occur while the wound is healing and should not be a cause for concern in most cases as long as it seems to be decreasing gradually and there is no significant pain.

Post Hysterectomy Bleeding

However abnormal vaginal bleeding is a cause for concern and this may appear as :

• spotting continuing for over six weeks.
• distinct vaginal bleeding (not spotting or discharge) immediately after a hysterectomy operation.
• sudden bleeding occurring within a few days or weeks after surgery.

Along with vaginal bleeding other symptoms such as abdominal or vaginal pain, vaginal discharge or fainting may be present. This requires medical intervention and you should consult with your doctor immediately

Causes of Vaginal Bleeding after Hysterectomy

The incidence of vaginal bleeding is found to be slightly higher after a vaginal hysterectomy than that after an abdominal hysterectomy. Your doctor may consider other investigative techniques to identify the cause of the bleeding as this is important to initiate proper treatment. Some of the causes of vaginal bleeding after a hysterectomy include :

• Improperly ligated (tied) blood vessel or a slipped ligature is reported as the most common cause of immediate bleeding after a hysterectomy operation. The cut edge of the vaginal mucosa should be sutured carefully during the operation to prevent this type of bleeding. Care has to also be taken to ensure that no severed blood vessel is left unattended and all blood vessels are ligated properly. The suture may become loose or open up in an improperly tied blood vessel, leading to immediate bleeding or bleeding within a few hours of the operation. Early identification of the cause of bleeding is very important for treatment, which may necessitate a blood transfusion and re-suturing.

• Granulation tissue sloughing results in delayed bleeding. This occurs when the granulation tissue, which forms during wound healing, ‘falls’ off and exposes a blood vessel.

• Wound dehiscence is the re-opening of the wound after surgical closure which may occur due to infection, poor healing, injury or ineffective suture material. The wound may open up partially or completely and will need re-suturing after recognition of the problem. In addition, antibiotics and pain relievers may become necessary for treatment.

• Coagulation or bleeding disorders in patients with clotting defects or those on anticoagulant therapy may result in post-operative vaginal bleeding after a hysterectomy. Although this is a rare cause, the bleeding has the potential of becoming quite serious unless adequate steps are taken as soon as possible. Vitamin K supplementation, stopping anticoagulant therapy, blood transfusion, and ligation of bleeding vessels may be necessary. A generalized ooze is quite common in these patients and a vaginal pack is effective here.

• Non-effective suture material may cause bleeding by improper ligation of the blood vessels and by not effecting proper closure of the wound. Some patients have a reaction to certain suture materials, resulting in improper wound closure and healing.

• Vaginal injury may occur either during or after the operation. Vaginal douches, insertion of tampons or sexual activity soon after the operation may also be contributing factors.

• Other causes of vaginal bleeding that may occur any time after a hysterectomy , even years later, and may or may not be related to the operation. These causes  include :

1. Subtotal hysterectomy – where only a part of the uterus is removed during operation.
2. Cancer.
3. Polyps.
4. Fibroids.
5. Bladder infections.
6. Atrophic vaginitis as a result of low estrogen levels.
7. Vaginal endometriosis.

Treatment of Vaginal Bleeding after Hysterectomy

Treatment for post-operative vaginal bleeding includes a blood transfusion and control of bleeding by identifying the cause and site of bleeding. This will involve taking the patient to the operation theater and then identifying and  ligating (tying) the bleeding vessels under general anesthesia if the site can be isolated.

If the bleeding points cannot be seen, then the stitches on the vault of the vagina may need to be reopened. Vaginal packing is only done in case of clotting defects. Additional treatment may include antibiotics to control infection, pain relievers, and vitamin K for clotting defects. Discontinuation of anticoagulation therapy may be necessary.