Vaginal Bleeding

Normal vaginal bleeding or menorrhea occurs during menstrual periods. Bleeding from the vagina that occurs between periods is considered abnormal. Abnormal vaginal bleeding is also known as metrorrhagia, intermenstrual bleeding or spotting.

Vaginal bleeding is abnormal if the menstrual flow is very less or heavy than normal. Bleeding is abnormal if it occurs before the age of 9 years, after menopause, and if the woman is pregnant.

Abnormal bleeding from vagina needs medical check up as the cause may be serious. Immediate medical attention is warranted if other symptoms like pain, fever, fatigue, or dizziness are also seen along with bleeding.

Dysfunctional uterine bleeding is one of the most common causes of abnormal vaginal bleeding. Hormonal imbalance, particularly estrogen and progesterone, may lead to excessive bleeding from the vagina.

Non-sexually transmitted infections including bacterial vaginosis and thrush are also causes of abnormal vaginal bleeding. Bacterial vaginosis is caused by the overgrowth of bacteria in the vagina and often results in mild symptoms including bleeding from the vagina.

Thrush is the second most common cause of abnormal vaginal bleeding. It causes a thick, creamy white discharge from vagina along with abnormal bleeding. Sexually transmitted infections cause vaginal discharge, sore or ulcer, pain, and abnormal bleeding.

Polyps present in the neck of the cervix may cause abnormal discharge. More discharge may be produced when the neck of cervix becomes thickened and fragile. Cancer of womb may also cause abnormal bleeding.

Abnormality of the womb and hormonal imbalance may increase the flow during normal menstrual periods. Bleeding that occurs after sex and after menopause is also abnormal. Inflammation of cervix and chlamydial infection may lead to bleeding after sex.

Infections are also a common cause of spottings. Amenorrhea or cessation of periods may occur normally during pregnancy. Stress, losing weight, too much exercise, and hormonal problems may lead to stopped periods.

Physical examination, including evaluation of thyroid, breasts, and pelvic area is very important in identifying the cause of abnormal bleeding. Cervical polyps and abnormal growths in the uterus are checked during this physical examination.

Cancer of the cervix is diagnosed using Pap smear. A pregnancy test is also common in women, particularly if the woman is in the premenopausal stage. Blood count, thyroid function test, liver and kidney function tests are also suggested to identify the cause.

Hormonal levels and daily temperature levels are also monitored. Other tests and investigations are suggested based on the suspected cause of the condition. Pelvic ultrasound is used if the medical history of the person warrants pelvic examination. Endometrial biopsy is used to rule out cancer and any precancerous conditions.

Treatment of abnormal vaginal bleeding depends on the underlying cause of the condition. Specific treatment may be used to treat kidney, liver or thyroid abnormalities. Oral contraceptives or progesterone is recommended if abnormal bleeding is caused by lack of ovulation.

This will also help in preventing the progress of precancerous changes in the lining of the uterus. Surgical removal is suggested for polyps or other abnormal growths in the uterus. Dilation and curettage (D&C) is used to reduce bleeding when it is excessive and not controlled by medications.

In women who are ovulating regularly, abnormal vaginal bleeding may occur as heavy or scanty bleeding during normal menstrual periods.

Excessive loss of blood during menstruation may occur due to:

• Uterine fibroids – these are benign growths in the smooth muscles of uterus
• Endometrial polyps – polyps are small growths projecting into the womb
• Adenomyosis – uterine lining tissue within the muscular wall of uterus
• Intrauterine devices
• Hypothyroidism
• Autoimmune conditions
• Bleeding disorders
• Certain medications

It may also be a sign of endometrial cancer. Precancerous condition like endometrial hyperplasia also may lead to abnormal vaginal bleeding. Sexually transmitted diseases are implicated in menstrual periods that are frequent, leading to too much blood loss.

Chlamydia and gonorrhea infection causes inflammation of uterus that is a cause of frequent menstrual periods. Benign growths in the cervix like cervical polyps cause irregular menstrual periods.

Endometriosis and oral contraceptives also result in irregular menstrual periods or menorrhagia. Hyperthyroidism and kidney diseases decrease the amount of bleeding or duration of bleeding during menstruation.

Oral contraceptive pills and intrauterine devices increase the chances of spotting or intermenstrual bleeding. This may also be caused by stress, certain medications, and hormonal imbalance.

Many factors result in abnormal bleeding in women who are not ovulating regularly. The number of menstrual periods may be decreased by many medical conditions or hormonal changes.

Chronic medical conditions and significant stress are two common causes of reduced menstrual periods. Anorexia nervosa and polycystic ovary syndrome (PCOS) may also lead to oligomenorrhea.

Women who are in postmenopausal stage do not ovulate regularly and hence do experience vaginal bleeding. In these women, hormonal therapy may lead to spotting once in a while.

Endometrial cancer and hyperplasia are two rare, but serious causes of abnormal vaginal bleeding in postmenopausal women. Postmenopausal women who are taking cyclic hormone regimen may have vaginal bleeding similar to that of menstrual periods every month.

During pregnancy, some amount of vaginal bleeding is common. Reports show that up to 30% of women experience vaginal bleeding during pregnancy. It is more common in women with multiple pregnancies.

Miscarriage, abnormal location of placenta, ectopic pregnancy, cervical polyps, cervical infection, and premature labor cause abnormal vaginal bleeding in many pregnant women. During pregnancy, certain medications, and chronic illnesses may also cause abnormal bleeding from the vagina.

Vaginal bleeding after sexual intercourse is caused by several factors like:

• Injury to vaginal wall
• Sexually transmitted infections – chlamydia, gonorrhea, and yeast infections are all known to cause some amount of abnormal vaginal bleeding after sexual intercourse.
• Low levels of estrogen in perimenopausal and postmenopausal women – this is caused by the thinning of the vaginal wall which increases the chance of infection and inflammation and vaginal bleeding.
• Tumors and polyps on the wall of cervix and uterus – these lesions may cause abnormal bleeding during or after sexual intercourse

Inherited bleeding disorders is a not-so-common cause of abnormal vaginal bleeding. Von Willebrand disease and hemophilia may cause prolonged bleeding from the vagina.

Physical examination and review of medical history help in the diagnosis of abnormal vaginal bleeding. During the physical examination, thyroid, breast, and pelvic area are evaluated to detect abnormalities.

It helps to detect the presence of cervical polyps, and any other unusual masses in uterus or ovaries. Cervical cancer is diagnosed with the help of pap smear. During this test, samples may be obtained to test for the presence of other infections like chlamydia or gonorrhea.

For perimenopausal women, a pregnancy test is recommended. Excessive blood loss due to abnormal vaginal bleeding is checked using complete blood count. Blood clotting test is recommended if history indicates chances of a bleeding disorder.

Thyroid function test, liver test, and kidney test are suggested depending on the suspected cause of the condition. Ovulation is tested by checking for levels of progesterone and daily body temperature.

Follicle-stimulating hormone is a diagnostic test for menopause or failing ovaries. Additional tests for measuring the level of hormones are recommended if PCOS is suspected.

Imaging techniques like ultrasound are suggested based on the medical history of the person. Pelvic ultrasound helps to evaluate the health of pelvic organs. Endometrial biopsy is another not-so-commonly recommended diagnostic test.

It is generally suggested for patients above 40 years having persistent vaginal bleeding but do not respond to conventional treatment. Endometrial biopsy is used to detect cancer or precancerous conditions. It is also helpful in confirming whether ovulation is normal.

Treatment of abnormal vaginal bleeding depends on the underlying cause. In some cases, treatment may not be necessary, but periodic monitoring is suggested. This will help to avoid risky situations and to ensure that bleeding does not become excessive causing distress. Specific treatments are recommended if bleeding is caused by thyroid, kidney, or liver dysfunction.

Progesterone or oral contraceptives containing progesterone is suggested to treat lack of ovulation. This will help to retain hormonal balance and prevent abnormal vaginal bleeding. Progesterone medications are useful in reducing the progression of precancerous growth in the uterine lining.

This may help to avoid a surgical repair:

• To ensure regular menstrual period in women who are approaching menopause, oral contraceptives are suggested.
• Surgical removal is the treatment method for polyps and other benign growths in uterus, particularly when they cannot be treated with medications.
• Antibiotics helps to control infections that cause abnormal bleeding.
• Endometriosis is treated by laparoscopy or open surgery.
• When the actual cause is not identified, oral contraceptives are given to regularize the menstrual cycle. This will help to reduce bleeding.
• Dilation and curettage (D&C) is a surgical procedure used to control bleeding that cannot be controlled by medication.
• In some cases hysterectomy is considered as treatment, especially when bleeding cannot be contained by medications.

The prognosis of treatment for vaginal bleeding depends on the cause of the condition. Hormonal therapy helps to regularize menstrual cycles in women who have abnormal bleeding due to hormonal irregularities. But this treatment requires follow-up with medical personnel. More serious and life-threatening situations should be ruled out before the start of treatment.