Abnormal Vaginal Bleeding

The term abnormal vaginal bleeding can refer to abnormally heavy and/or prolonged periods, bleeding in between periods, bleeding after sex, bleeding after menopause, and irregularities in cyclical bleeding (either unusually frequent or infrequent menstrual cycles lasting less than 21 days or more than 35 days in length). While abnormal vaginal bleeding can affect women of any age, it is most common during the first years following the onset of menstruation and in the years leading up to menopause.

The cause of abnormal bleeding can be separated into two basic categories – anatomic and hormonal.

Anatomic causes of abnormal bleeding include any physical abnormalities of the vagina and uterus, such as:

  • Fibroids
  • Adenomyosis
  • Endometrial polyps
  • Endometrial hyperplasia (abnormal thickening of the uterine lining)
  • Cervical growths and polyps
  • Inflammation and/or infection of the vagina, cervix or uterus
  • Full-thickness vaginal endometriosis
  • Cancer of the vagina, cervix or uterus
  • Tubal pregnancy or miscarriage

Hormonal causes of abnormal bleeding include:

  • Ovulation problems
  • Metabolic imbalance
  • Insulin resistance
  • Polycystic ovarian syndrome (PCOS)
  • Cystic ovarian endometriosis (endometriomas)
  • Hypothyroidism
  • Excess androgen production (male hormones)
  • Perimenopause
  • Side-effects of hormone medications (such as birth control pills, Depo-Provera and the Mirena IUD)
  • Pregnancy

Blood clotting disorders can also cause abnormal vaginal bleeding

The first step in diagnosing the cause of abnormal vaginal bleeding is to obtain a comprehensive patient history, including information about your menstrual cycle. Keeping a diary of your prior menstrual cycle (regularity, duration, type of flow, and presence, timing and frequency of spotting or break-through bleeding) can be helpful. You will also undergo a physical exam and a sonogram (ultrasound) to look for fibroids, adenomyomas and adenomyosis, ovarian endometriomas (chocolate cysts), and to assess the thickness of the uterine lining. In some cases a sonohysterogram may be helpful. In this procedure, which is performed with the sonogram in the office, a small catheter is placed inside the uterus, which is filled with saline (salt water) to look at the inside of the uterus for polyps, etc. If indicated, a hysteroscopy may be performed as well to actually look inside of the uterus and to obtain biopsies of the uterine lining (endometrial biopsy). A vaginal swab and a cervical smear (PAP) test may also be performed. Blood tests can help identify any hormonal causes of abnormal bleeding, and rule out the possibility of pregnancy, if indicated.

The treatments for abnormal vaginal bleeding will vary depending on the cause(s) of the problem and include medical therapies and in some cases minimally invasive surgical procedures.

While abnormal vaginal bleeding can be very bothersome, in the majority of cases the underlying cause is benign and readily treatable. It is always important to monitor your cycle and, if you note any changes or abnormal bleeding, be sure to consult with your doctor. At Vital Health we routinely address this common yet worrying symptom that affects so many women at some time during their lives.

Further reading
Fibroids