Vaginal bleeding between periods

Bleeding between periods; Intermenstrual bleeding; Spotting; Metrorrhagia

Normal menstrual flow lasts about 5 days. It produces a total blood loss of 30 to 80 ml (about 2 to 8 tablespoons), and occurs normally every 21 to 35 days.

Vaginal bleeding that occurs between periods or after menopause can be caused by various problems. Most are benign and treatable. Sometimes vaginal bleeding may be due to cancer or pre-cancer. So any unusual bleeding should be evaluated promptly. The risk of cancer increases to about 10% in women with postmenopausal bleeding.

Make sure that bleeding is coming from the vagina and is not from the rectum or the urine. Inserting a tampon into the vagina will confirm the vagina, cervix, or uterus as the source of bleeding.

A careful exam by your health care provider is most often the best way to find the source of the bleeding. This exam can be done even while you are bleeding.

Causes may include:

• Uterine fibroids or cervical or uterine polyps
• Changes in hormone levels
• Inflammation or infection of the cervix (cervicitis)
• Injury or disease of the vaginal opening (caused by intercourse, trauma, infection, polyp, genital warts, ulcer, or varicose veins)
• IUD use (may cause occasional spotting)
• Ectopic pregnancy
• Miscarriage
• Other pregnancy complications
• Vaginal dryness due to lack of estrogen after menopause
• Stress
• Stopping and starting birth control pills or estrogens
• Underactive thyroid (low thyroid function)
• Use of blood thinners (anticoagulants)
• Cancer or pre-cancer of the cervix, uterus, or (very rarely) fallopian tube
• Cervical or endometrial biopsy or other procedures

Contact a provider right away if bleeding is very heavy.

Keep track of the number of pads or tampons used over time so that the amount of bleeding can be determined. Uterine blood loss can be estimated by keeping track of how frequently a pad or tampon is soaked and how often one needs to be changed.

Because aspirin may prolong bleeding, it should be avoided, if possible. However, NSAIDS such as ibuprofen can be used to minimize bleeding and cramping.

Call your health care provider if:

• You are pregnant
• There is any unexplained bleeding between periods
• There is any bleeding after menopause
• There is heavy bleeding with periods
• Abnormal bleeding is accompanied by other symptoms, such as pain, fatigue, dizziness

The provider will perform a physical exam and ask questions about your medical history. The physical exam with include an emphasis on the pelvic area.

Questions about the bleeding may include:

• When does the bleeding occur and how long does it last?
• How heavy is the bleeding?
• Do you have cramps too?
• Are there things that make the bleeding worse?
• Is there anything that prevents it or relieves it?
• Do you have any other symptoms such as abdominal pain, bruising, pain when urinating, or blood in urine or stools?

Tests that may be done include:

• Blood tests to check thyroid and ovarian function
• Cervical cultures to check for a sexually transmitted infection
• Colposcopy and cervical biopsy
• Endometrial (uterine) biopsy
• Pap smear
• Pelvic ultrasound
• Hysterosonogram
• Hysteroscopy
• Pregnancy test