Bleeding between periods; Intermenstrual bleeding; Spotting; Metrorrhagia
Normal menstrual flow lasts about 4 days (plus or minus 2 - 3 days). It produces a total blood loss of 30 - 80 ml (about 2 - 8 tablespoons), and occurs normally every 28 days (plus or minus 7 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 precancer. 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 in 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 frequently the best way to sort out the source of the bleeding. This exam can be accomplished even while you are bleeding. Do not delay getting an exam just because you are currently bleeding.
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, infection, polyp, genital warts, ulcer, or varicose veins)
Vaginal dryness due to lack of estrogen after menopause
Stopping and starting birth control pills or estrogens
Underactive thyroid (low thyroid function)
Use of blood thinners (anticoagulants)
Cancer or precancer of the cervix, uterus, or (very rarely) fallopian tube
Cervical or endometrial biopsy or other procedures
Immediately contact a health care provider 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.
Call your health care provider if
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
What to expect at your health care provider's office
The doctor will perform a physical exam and ask questions about your medical history. The physical examination with include an emphasis on the pelvic area.
Questions may include:
When did this bleeding between periods begin?
Does it occur consistently, such as every month?
When (during the course of a menstrual cycle) does this bleeding begin?
How long does the in-between bleeding last?
Is the bleeding heavy?
How many tampons or pads are required?
Do cramps accompany the bleeding?
What makes it worse?
Does increased physical activity make the bleeding worse?
Does intercourse bring on the bleeding?
Is increased stress associated with the bleeding?
Does anything relieve or prevent it?
What other symptoms do you have?
Do you have abdominal pain or cramps?
Is there increased bruising elsewhere on the body?
Do you have any difficulty, pain, or burning with urination?
Bulun SE. The physiology and pathology of the female reproductive axis. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 12th ed. Philadelphia, Pa: Saunders Elsevier;2011:chap 17.
Linda J. Vorvick, MD, Medical Director and Director of Didactic Curriculum, MEDEX Northwest Division of Physician Assistant Studies, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington. Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Bellevue, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.