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Bleeding between periods - Intermenstrual Bleeding
Intermenstrual bleedingis vaginal bleeding (other than post-coital) at any time during the menstrual cycle other than during normal menstruation.
Bleeding between periods (intermenstrual bleeding) may be associated with sexual intercourse - bleeding during intercourse or post coital bleeding) or may occur spontaneously. It is a frequently encountered symptom - 17% per annum 0401
Bleeding between periods may be in the middle of the menstrual cycle - mid cycle bleeding or mid cycle spotting.
Bleeding between periods is one example of gynaecological abnormal bleeding.
Women on the pill may experience break through bleeding. This is not strictly intermenstrual bleeding because the monthly bleeding experienced by those women taking the pill is correctly called 'withdrawal bleeding' and is not spontaneous menstruation. Usually, mid cycle bleeding amounts to no more than a little mid cycle spotting. When mid cycle bleeding is accompanied by lower abdominal or pelvic pain it is known as "Mittelschmerz".
Intermenstrual bleeding may amount to no more than spotting between periods or it may be heavy.
Bleeding between periods may be misinterpreted as irregular menstruation (irregular periods).
When intermenstrual bleeding is reported, care should be taken to exclude pregnancy bleeding - threatened miscarriage or ectopic pregnancy.
What Causes Intermenstrual Bleeding?
Physiological (hormone fluctuations) - 1-2% spot around ovulation (mid-cycle)
Iatrogenic (Medically Induced):
Combined oral contraceptive pill
Contraceptive depot injections
Intrauterine systems - Mirena0701
Following smear or treatment to the cervix
Drugs altering clotting parameters e.g. anticoagulants, SSRIs, corticosteroids
Alternative remedies e.g. ginseng, ginkgo, and soy supplements, St Johns Wort0501
Vaginitis (bleeding uncommon before the menopause)
Infection - e.g chlamydia.
Cervical erosion - ectropion
Cervicitis (most commonly causes blood-tinged discharge)
Condylomata acuminata of the cervix
Cancer (but bleeding is most often post-coital)
Adenomyosis (usually only symptomatic in later reproductive years)
Endometrial adenocarcinoma -
Only 2% endometrial cancers occur before 40 years old. Risk factors include:
Polycystic ovary syndrome
Chronic anovulatory cycles
Use of tamoxifen for treatment of breast cancer.
Oestrogen-secreting ovarian cancers
How Is Intermenstrual Bleeding Investigated?
Although worrying for many women, bleeding between periods is relatively rarely associated with sinister conditions. However, as cervical cancer and endometrial cancers can present with intermenstrual bleeding, it is imperative that they be excluded.
Determine that the bleeding is from the vagina, not the rectum or in the urine. Any doubt can be eliminated by inserting a tampon which will confirm presence of blood in the vagina.
Pregnancy test if appropriate.
Abdominal examination noting the presence/absence of pelvic masses.
Vaginal examination (speculum and bimanual) looking for obvious genital tract pathology.
Other possible investigations include:
Transvaginal ultrasound - Ultrasound should ideally be done immediately postmenstrually as the endometrium at its thinnest and polyps and cystic areas tend to be more obvious. An endometrial thickness of 8 mm or less is significantly less likely to be associated with a malignant pathology.0602
Endometrial biopsy - Endometrial biopsy may be done as a surgery or clinic-based procedure using the Pipelle device or Vabra aspirator.
Hysteroscopy - Hysteroscopy with biopsy is the current gold-standard for investigating the uterine cavity, allowing direct visualisation and tissue diagnosis. In many centres, it can be done as a clinic procedure.
How Is Intermenstrual Bleeding Managed?
Management depends on the cause of the bleeding:
If gynaecological cancer is suspected, refer urgently for investigation. Do not wait on the results of a smear test or be deterred by a previous negative result where clinical suspicion is high.
Cervical erosion - ectropions:
May resolve if the COCP is stopped or following pregnancy
Can be treated conservatively
If treatment is desired, options include thermal cautery and diathermy, cryosurgery, laser or microwave therapy.
Avulse and send for histology
They are accompanied by endometrial polyps in about 25%,0701 - further investigation (ultrasound +/- hysteroscopy), particularly in older women, can be indicated.
Antibiotics dependent on organism involved
Contact tracing and treatment of sexual partners
Electrocautery of secondarily infected Nabothian follicles in chronic cervicitis
Dysfunctional uterine bleeding (DUB) is the most common cause of abnormal vaginal bleeding (usually heavy periods) during a woman's reproductive years. However, it is a diagnosis of exclusion and should only be diagnosed after pregnancy, iatrogenic and systemic causes and genital tract pathology have been excluded.1 It is most common at the extremes of reproductive life, in the pubertal and perimenopausal phases and is associated with anovulatory cycles in 70% of cases and, in these cases, is caused by endometrial hyperplasia.
I have had an issue for over a year now. An issue I never had before. I've had my thyriod checked, after DD I had postthyriodis but that all checked out.
I had a test done that checkes for inflamation can't recall the name, but it checks for autoimmune, cancer, like a gazillion things. I had an US. Checked for std's. On and off the pill this occurs, it is so weird. I am young but at my follow up I am going to have her test me for perimenopause, my mom started at 35 I am 34. So it is possible. Very annoying. I know I am have not been pregnant for 19 months lol.