DRUG INDEX
Vaginal Bleeding Medical Author: Carolyn Janet Crandall, M.D.
Medical Editor: William C. Shiel Jr., MD, FACP, FACR
What is normal vaginal bleeding?
Normal vaginal bleeding is the periodic blood that flows as a discharge from the woman's uterus. Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.
The ovaries are the main source of female hormones, which control the development of female body characteristics such as the breasts, body shape, and body hair. The hormones also regulate the menstrual cycle. The ovary, or female gonad, is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a fallopian tube to the uterus. Unless pregnancy occurs, the cycle ends with the shedding of part of the inner lining of uterus, which is menstruation. Although it is actually the end of the physical cycle, the first day of menstrual bleeding is designated as "day 1" of the menstrual cycle in medical parlance.
The time of the cycle during which menstruation occurs is referred to as menses. The menses occurs at approximately 4 week intervals, representing the menstrual cycle.
Menarche is the time in a girl's life when menstruation first begins. Menopause is the time in a woman's life when the function of the ovaries ceases. The average age of menopause is 51 years old.
What is abnormal vaginal bleeding?
Abnormal vaginal bleeding is a flow of blood from the vagina that occurs either at the wrong time during the month or in inappropriate amounts. In order to determine whether bleeding is abnormal, and its cause, the doctor must answer 3 questions: Is the woman pregnant? What is the pattern of the bleeding? Is she ovulating?
Every woman who thinks she has an irregular menstrual bleeding pattern should think carefully about the specific characteristics of her vaginal bleeding in order to help her doctor evaluate her particular situation. Her doctor will require the details of her history. Each category of menstrual disturbance has a particular list of causes, necessary testing, and treatment. Each type of abnormality is discussed individually below.
1. Is the woman pregnant?
Much of the abnormal vaginal bleeding during pregnancy occurs so early in the pregnancy that the woman doesn't realize she is pregnant. Therefore, irregular bleeding that is new may be a sign of very early pregnancy, even before a woman is aware of her condition.
2. What is the pattern of the bleeding?
The duration, interval, and amount of vaginal bleeding can suggest an abnormal condition.
An abnormal duration of menstrual bleeding can be either bleeding for too long of a period (hypermenorrhea) or too short of a period. (hypomenorrhea).
The interval of the bleeding can be abnormal in several ways. A woman's menstrual periods can occur too frequently (polymenorrhea) or too seldom (oligomenorrhea). Additionally, the duration can vary excessively from cycle to cycle (metrorrhagia).
The amount (volume) of bleeding can also be abnormal. A woman can either have too much bleeding (menorrhagia) or too little volume (hypomenorrhea).
3. Is the woman ovulating?
Usually, the ovary releases an egg every month in a process called ovulation. Normal ovulation is necessary for regular menstrual periods. There are certain clues that a woman is ovulating normally including regular menstrual intervals, vaginal mucus discharge halfway between menstrual cycles, and monthly symptoms including breast tenderness, fluid retention, menstrual cramps , back pain, and mood changes. If necessary, doctors will order hormone blood tests (progesterone level), daily home body temperature testing, or rarely, a sampling of the lining of the uterus (endometrial sampling) to determine whether or not a woman is ovulating normally.
On the other hand, signs that a woman is not ovulating regularly include prolonged bleeding at irregular intervals after not having a menstrual period for several months, excessively low blood progesterone levels in the 2nd half of the menstrual cycle, and lack of the normal body temperature fluctuation during the time of expected ovulation. Sometimes, a doctor determines that a woman is not ovulating by sampling the lining of the uterus (endometrial sampling).
What conditions cause abnormal vaginal bleeding in women who are ovulating regularly?
Abnormal vaginal bleeding in women who are ovulating regularly most commonly involve excessive, frequent, irregular, or decreased bleeding. Some of the common conditions that produce each of these symptoms are discussed below:
Excessively Heavy Menstrual Bleeding (Menorrhagia)
Excessively heavy menstrual bleeding, called menorrhagia, is menstrual bleeding of greater than 5 tablespoons per month. This condition occurs in about 10% of women. The most common pattern of menorrhagia is excessive bleeding that occurs in regular menstrual cycles and with normal ovulation.
There are several important reasons that menorrhagia should be evaluated by a doctor. First, menorrhagia can cause a woman substantial emotional distress and physical symptoms, such as severe cramping. Second, the blood loss can be so severe that it causes a dangerously lowered blood count ( anemia ), which can lead to medical complications and symptoms, such as dizziness and fainting . Third, there can be dangerous causes of menorrhagia that require more urgent treatment.
Benign (noncancerous) causes of menorrhagia include uterine fibroids, endometrial polyps (tiny benign growths that protrude into the womb), adenomyosis , intrauterine devices (IUD's), underactive thyroid function ( hypothyroidism ), an autoimmune disorder called systemic lupus erythematosis, and blood clotting disorders.
Though not common, menorrhagia can be a sign of cancer . This situation is more frequent in women who are over the age of 40.
Although there are many causes of menorrhagia, in most women, the specific cause of menorrhagia is not found even after a full medical evaluation. These woman are said to have dysfunctional uterine bleeding. Although no specific cause is found in women with dysfunctional uterine bleeding, there are available treatments.
Sometimes, a woman has a condition that is well known to cause menorrhagia, but another condition may actually be the cause of her menorrhagia. For example, a woman with uterine fibroids may actually be experiencing menorrhagia because she has endometrial hyperplasia. Therefore, a woman should not assume that her heavy bleeding does not require further evaluation without consulting a doctor.
A woman with menorrhagia should visit a gynecologist in certain situations. As explained above, because more serious disorders are more common causes of menorrhagia in women who are over 40 as compared to those under age 40, women over age 40 are often referred to a gynecologist for further evaluation. If a woman persistently bleeds between her periods (intermenstrual bleeding) or medical treatment has not controlled the bleeding, she may then be referred to a gynecologist.
Menstrual Periods That Are Too Frequent (Polymenorrhea)
Menstrual periods that are abnormally frequent (polymenorrhea) can be caused by certain sexually transmitted infections (such as chlamydia or gonorrhea) that inflame the uterus. This condition is called pelvic inflammatory disease. Endometriosis is a condition of unknown cause that can lead to pelvic pain and polymenorrhea. Sometimes, the cause of polymenorrhea is unclear, in which case the woman is said to have dysfunctional uterine bleeding.
Menstrual Periods At Irregular Intervals (Metrorrhagia)
Irregular menstrual periods (metrorrhagia) can be due to benign growths in the cervix, such as cervical polyps. The cause of these growths is usually not known. Metrorrhagia can also be caused by infections of the uterus (endometritis) and birth control pills ( oral contraceptives ). Sometimes after an evaluation, a woman's doctor might determine that her metrorrhagia does not have an identifiable cause and that further evaluation is not necessary at that time.
Decreased Amount Or Duration Of Menstrual Flow (Hypomenorrhea)
An overactive thyroid function ( hyperthyroidism ) or kidney diseases can cause hypomenorrhea. Oral contraceptive pills can also cause hypomenorrhea. It is important for women to know that lighter, shorter, or even absent menstrual periods as a result of taking oral contraceptive pills does not indicate that the contraceptive effect of the oral contraceptive pills is inadequate. In fact, many women enjoy this "side effect" of oral contraceptives.
What conditions cause abnormal vaginal bleeding in women who are NOT ovulating regularly?
Many conditions can interfere with the proper function of female hormones that are necessary for ovulation. For example, if a woman has chronic medical illnesses or is under significant medical or emotional stress, she can begin to have a loss of her menstrual periods (oligomenorrhea). Malfunction of a particular part of the brain, called the hypothalamus, can cause oligomenorrhea. Anorexia nervosa is an eating disorder associated with excessive thinness that causes many serious medical consequences as well as oligomenorrhea.
Polycystic ovarian syndrome (PCO) is a condition of unknown cause in which there may be obesity , a male pattern of excessive hair growth, infertility, and abnormal hormonal disturbances that are detectable by blood tests. Not all of the characteristics of PCO need to be present in any single woman for the diagnosis to be made. It is being debated whether the obesity is the cause or the result of PCO. PCO can occur along with other important medical problems, such as hypertension or diabetes. Therefore, it is important that PCO be diagnosed in a timely fashion and properly treated.
The complete loss of ovulation is referred to as anovulation. Since ovulation allows the body to maintain an adequate supply of progesterone, anovulation is a condition in which a woman's hormonal balance is tipped toward too much estrogen and not enough progesterone. The excess estrogen is like a vitamin for the lining of the uterus. The result is that the lining of the uterus becomes too thick, which eventually leads to an increased risk of uterine pre-cancer or uterine cancer over many years. In order to replace progesterone and establish a proper hormonal balance, doctors will prescribe either progesterone to be taken at regular intervals, or an oral contraceptive that contains progesterone. Such treatment dramatically decreases the risk of uterine cancer in women who do not ovulate. Because uterine cancer results from many years of anovulation, any woman with prolonged anovulation needs to be treated to avoid developing uterine cancer.
What tests are used to evaluate abnormal vaginal bleeding?
A woman who has irregular menstrual periods requires a physical examination with a special emphasis on the thyroid, breast, and pelvic area. During the pelvic examination, the physician attempts to detect cervical polyps or any unusual masses in the uterus. A pap smear is also done to rule out cervix cancer . While the pap smear is being obtained, samples might be taken from the cervix for chlamydia or gonorrhea testing.
A pregnancy test is routine if the woman is premenopausal. A blood count may be done to rule out a low blood count (anemia) resulting from excessive blood loss. If something in the patient's (or her family's) medical background or physical examination raises a doctor's suspicion, tests for certain clotting disorders may be done. Sometimes, a blood sample will be tested for thyroid function, liver function, or kidney function abnormalities. A blood test for progesterone levels or daily body temperature charting may be recommended to verify that the woman ovulates. If the doctor suspects that the ovaries are failing, such as with menopause, blood levels of follicle-stimulating hormone (FSH) may be tested. Additional blood hormone tests are done if the doctor suspects PCO or if excessive hair growth is present.
A pelvic ultrasound is often performed based on the woman's medical history and pelvic examination. If a woman does not adequately respond to medical treatment, if she is over age 40, or if she has persistent bleeding between her periods, a sampling of the lining of her uterus (endometrial sampling) is analyzed. Endometrial sampling helps to rule out cancer or precancer in the uterus, or it can confirm a suspicion that a woman is not ovulating.
How is irregular vaginal bleeding treated?
Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is actually necessary. Sometimes, all that is needed is for dangerous causes to be ruled out and to determine that the irregular vaginal bleeding does not bother the woman enough to warrant medication or treatment. If thyroid, liver, kidney, or clotting problems are discovered, treatment is directed toward these conditions.
Medication treatment of irregular vaginal bleeding depends on the cause. Examples are described below:
If the cause of the bleeding is lack of ovulation (anovulation). For this condition, doctors prescribe either progesterone to be taken at regular intervals, or an oral contraceptive, which contains progesterone, to achieve a proper hormonal balance. Such treatment dramatically decreases the risk of uterine cancer in women who do not ovulate.
If the cause of irregular vaginal bleeding is precancer, progesterone medications may be used in an attempt to avoid surgery.
When a woman has been without menses for less than 6 months and is bleeding irregularly, the cause may be menopausal transition. During this transition, a woman is sometimes offered an oral contraceptive to establish a more regular bleeding pattern, to provide contraception until she completes menopause, and to relieve hot flashes. A woman who is found to be menopausal as the cause of her irregular bleeding should also receive menopause counseling. (For more information about menopause treatment, see the Menopause article.)
If the cause of irregular vaginal bleeding is polyps or other benign growths, these are sometimes removed surgically to control bleeding because they cannot be treated with medication.
If the cause of bleeding is infection, antibiotics are necessary. Bleeding during pregnancy requires urgent evaluation by an obstetrician. Endometriosis can be treated with medications and/or surgery (such as laparoscopy ). (For more information about the treatment of endometriosis, see the Endometriosis article.)
Sometimes, the cause of excessive bleeding is not apparent after completion of testing (dysfunctional uterine bleeding). In these cases, oral contraceptives can improve cycle control and lessen bleeding.
If bleeding is excessive and cannot be controlled by medication, a surgical procedure called dilation and curettage (D&C) may be necessary. In addition to alleviating the excessive bleeding, the D&C provides additional information that can rule out abnormalities of the lining of the uterus.
Occasionally, a hysterectomy is necessary when hormone medications cannot control excessive bleeding. However, unless the cause is pre-cancerous or cancerous, this surgery should only be an option after other solutions have been tried.
Many new procedures are being developed to treat certain types of irregular vaginal bleeding. For example, studies are underway to evaluate techniques that selectively block the blood vessels involved in the bleeding. These newer methods may be less complicated options for some patients and as they are further evaluated they will likely become more widely available. - Normal vaginal bleeding is the periodic blood that flows as a discharge from the woman's uterus. Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.
- In order to determine whether bleeding is abnormal, and its cause, the doctor must answer 3 questions: Is the woman pregnant? What is the pattern of the bleeding? Is she ovulating?
- Abnormal vaginal bleeding in women who are ovulating regularly most commonly involves excessive, frequent, irregular, or decreased bleeding.
- There are many causes of abnormal vaginal bleeding that are associated with irregular ovulation.
- A woman who has irregular menstrual periods requires a physical examination with a special emphasis on the thyroid, breast, and pelvic area.
- Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is actually necessary.
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