Abnormal vaginal bleeding

 

Many women will have experience some form of vaginal bleeding other than during their normal monthly menstruation.

The term commonly used for this is intermenstrual bleeding (in between ‘normal menstruation’). More often than not, this will cause a lot of anxiety and set off a whole list of possibilities and ‘what-ifs’?  It is sometimes difficult to differentiate between intermenstrual bleeding and irregular period.

Vaginal bleeding may occur at any age but should be investigated if it occurs in pre-pubertal girls or postmenopausal women.

So what are the possible causes of intermenstrual bleeding? As with most things in medicine, there is often a list of possibilities ranging from normal, benign to cancer.

 Bleeding after sex – When to Worry

  

Pregnancy?

First of all, the first thing that I would advise is to do a pregnancy test to rule out pregnancy as if you are pregnant then the whole management of this changes as commonly this signifies complications in the pregnancy – eg: miscarriage, ectopic pregnancy, molar pregnancy. To keep things simple, I will not be discussing on vaginal bleeding in pregnancy here. If you are bleeding and you are pregnant, please book an appointment with your doctor sooner rather than later.

 

Physiologic (mid cycle bleeding?)

Other common causes of intermenstrual bleeding could be due to physiologic causes, for instance ovulation causing mid cycle bleeding. This usually occurs in the form of vaginal spotting for a couple of days during the middle of your menstruation cycle. So ladies, ovulation spotting is a natural sign of fertility and entirely normal.  

Iatrogenic (Hormones – OCP/IUCD)

Other iatrogenic (usually as a result of a medical treatment) causes for intermenstrual bleeding could be related to hormonal stimulation or withdrawal – eg: starting, stopping or switching oral contraceptive pills, intrauterine contraceptive device. If you experience some form of vaginal bleeding after there has been some changes in terms of your hormone profile then do not panic; the body often needs time (usually 3-6 months) to readjust itself. However, if the vaginal bleeding does not settle or if it starts to give more significant symptoms (become heavier, making you feel tired, or changes in nature), then it will be wise to see a doctor as this could sometimes signify an underlying pathology.

 

Dysfunctional Uterine Bleeding (DUB)

The diagnosis of DUB is usually made after excluding any pelvic pathological causes (polyps/cancers, etc) or other general medical disease that could account for vaginal bleeding. It is commonly a diagnosis of exclusion and reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining. With DUB, the bleeding is unpredictable as it may be excessively heavy or light and may be prolonged, frequent, or random.  As DUB is a diagnosis of exclusion, other causes for hormonal imbalance including polycystic ovary syndrome (PCOS) must be considered.

 

Polyps (endometrial/cervical)

Endometrial or uterine polyps are growths that occur in the endometrium (the inner lining of the uterus) and are usually noncancerous (benign) but may cause problems with fertility or heavy or irregular vaginal bleeding.  Endometrial polyps usually occur in women who are between 40-50 years old and can also occur after menopause.

Cervical polyps are growths that occur on the cervix. They are common especially in women who have had children. Cervical polyps can cause heavy menstrual bleeding, intermenstrual bleeding or bleeding after sex (post coital bleeding).

Polyps are usually noncancerous (benign) although a minority of them can be cancerous or can eventually turn into cancer (precancerous polyps).

Uterine fibroids are a common cause of heavy menstrual bleeding, although they do not often cause abnormal intermenstrual bleeding.

Cancers

In a minority of abnormal vaginal bleeding, the reason could be due to a more sinister reason, like cancer. Cancers that can give rise to vaginal bleeding includes cervical, endometrial, vaginal and vulval cancers.

According to the latest data from the health promotion board, “Cervical cancer is the 9th most common cancer in Singaporean women. The best protection against cervical cancer is to go for regular Pap smear once every three years as it can be effectively treated if detected early.” Often-times prevention is better than cure and there are vaccines available (Cervarix & Gardasil) which could reduce the risk of contracting HPV, which is a known cause of cervical cancer.  

 

Conclusion

So ladies, there are a lot of causes for vaginal bleeding, most are not serious and may correct themselves. But there is a small but significant possibility that there may be a more sinister cause for the bleeding. If you are worried, unsure, or if your symptoms persist, it may be wise to our doctors early. Also one final tip; keeping a menstrual diary will be very helpful in monitoring the pattern of your bleeding (which will be unique to each patient) and may aid our doctors in getting a better overall picture of your symptoms.

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17 Comments

  1. Hi,
    I have not had my period for about 2-3 months, and am certain that im not pregnant. Should i visit the doctor to get checked?

    ps I never had a checkup on my vaginal health so im kinda scared.

    • Of course you should. Although pregnancy is the commonest cause of missed periods, there are many other possible causes. These range from medical problems like anemia or thyroid issues to psychological issues like stress. You should certainly see a doctor to figure it out.

  2. hi doctor, is it possible to remove endometrial polyps while on your menses? i scheduled an appointment that was supposed to be just after my menses but it seems like my menses is late and may coincide with the surgery..

  3. hi doctor, i’d like to know more about cervical polyps. what causes it, and how can i prevent it? is that the reason why i have been having very bad cramps during menstruation? also, what is the procedure for treating cervical polyps, and how long does it take to recover from it?

    thank you.

    • Cervical polyps are common. They appear in about 4% of women of reproductive age. Cause is unknown, although it is related to oestrogen hormone and previous infection that affects the cervix. Cervical polyps usually cause heavy menstruation. Your bad cramps may not be related to polyps.
      You should consult a doctor if you are concerned about bad cramps, and a gynaecologist about treatment of cervical polyps.

  4. hi doc last june 28 started spotting until i went to the doc obgyne he do pap smear test the result is class2 en he called imflamation then he give amoxicillin then its stop for few months last dec.is coming bck again then he test again the result is no bacteria growth i didnt take the medIcine that he give but now its start again last saturday only i went to the doc..im taking pills before but i stop already ..wat will i do im so worried ..tnx

    • You had a class 2 smear last year probably caused by a GBS infection and given amox. Now your spotting has started again. Sounds to me like you really need another PAP smear. In fact, preferably you should get a HPV test and ultrasound of your pelvis to rule out any other causes of bleeding.

  5. Hi, i’ve been experiencing a bit of vaginal bleeding after intercourse last month, and had a pap smear done and the results were normal. This month, some spotting occurred again after intercourse. Is this a big problem? Should i visit the doctor again?

    • Yes you absolutely should. Vaginal bleeding after intercourse is always a little bit worrying. It is good that your PAP smear is normal. At least we need not worry about Cervical cancer or pre-cancer. But there is also the possibility of womb cancer.

      • How is womb cancer tested? I’ve gone for a check up and the doctor did an ultrasound and said that everything seemed ok. Should I be worried??

        • Ultrasound scans of the pelvis are a very good way of detecting womb cancer. It will show up as a thickened endometrial lining. So if you USS was OK, you really should not be worried.

  6. Hi Doc,

    2 months back, my period was super heavy and last month period was reduce, this month even less to 2 days only.

    Will any STD cause this? Please advice.

    • You cannot tell if you have an STD or not based on period symptoms. The best thing for you to do is to see your doctor and get tested. As for your symptoms, it sounds like a hormonal aberration. Maybe you had a spontaneous abortion.

  7. Hello..i am saroj from Chennai,India..i was suffering from abnormal bleeding from last four years..my cycles r of 15 days.first 2 days spot..then 2 days nothing..then 3 days bleeding..then 3 days heavy stomach pain and clot in bleeding(as my haemoglobin is low around 9)..then 5 days normal and clot in bleeding..then clear for 20 days..then again same cycle..finally after showing to lot of doctors I hav operated and removed uterus and filipins tude..what I hav done Is correct or not and is there any side effect in future and will effect sex life..pls reply…thanx..

    • Since I do not know your diagnosis, I cannot comment on whether you received the ‘correct’ treatment. That is something you must check with your doctors. A hysterectomy (removal of womb and tubes) should not affect your sex life. Your ovaries and therefore hormones are still functional and your vagina is also normal. Of course having had the surgery means you cannot have any children in the future.

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