What is abnormal vaginal bleeding?
The usual cause of vaginal bleeding is menstruation (the monthly period). However, any vaginal bleeding that is not normal menstrual bleeding or mid- cycle spotting (which often occurs during the first few months of taking the oral contraceptive pill) may be abnormal and must be investigated. This is because it may be a sign of a problem within the vagina, uterus (womb) or ovaries. This includes irregular or excessively heavy menstrual bleeding, and any vaginal bleeding in a woman who has passed the menopause.
In teenage girls, the first few periods can be irregular and of varying degrees of heaviness, and this is not abnormal. Around the time of the menopause, menstrual bleeding often becomes irregular, and again this is not abnormal.
HRT (hormone replacement therapy) may also cause harmless bleeding in postmenopausal women who have stopped having periods.
What causes abnormal vaginal bleeding and who is at risk? Abnormal vaginal bleeding may occur between the normal menstrual bleeds (intermenstrual bleeding) or it may take the form of unusually heavy menstrual bleeding (menorrhagia). In postmenopausal women, it may develop after a number of years without any vaginal bleeding. It can be caused by a number of things, including:
- hormone imbalances,
- injury to the vagina or vulva,
- sexual abuse,
- infection in the uterus,
- polyps and fibroids (benign growths) in the uterus,
- cancer of the cervix,
- cancer of the uterus,
- some cancers of the ovaries,
- complications of an early (possibly
- unknown) pregnancy, for example,
- ectopic pregnancy or threatened miscarriage.
Hormonal imbalances are by far the most common cause, and the problem usually occurs during the reproductive years.
How do doctors diagnose abnormal vaginal bleeding?
If you are concerned about irregular or excessively heavy bleeding, you must see your GP or gynaecologist and explain the problem. The doctor will carry out an internal examination, looking for any obvious points of bleeding. The doctor will usually also perform a speculum examination, in which a sterile device is inserted into the vagina in order to view the cervix. A cervical smear test (‘Pap’ smear) may be carried out at this point. Finally, the doctor will feel for any enlargement of the uterus and ovaries by simultaneously pressing on your stomach and palpating inside the vagina.
Blood tests may be undertaken to make sure that you are not anaemic and to check your hormone levels. If you have not yet passed through the menopause, the timing of these blood tests is important and the doctor will explain the best time in your monthly cycle to have them done. Your doctor may also suggest that a pregnancy test be performed.
Further tests, such as an ultrasound scan of the uterus, may be recommended. This is a simple test in which gel is placed on the lower abdomen and a special scanner is moved through the gel. If necessary, a vaginal ultrasound may occasionally be performed, in which the scanner is placed inside the vagina instead of on the abdomen. In this way, clearer and more accurate views of the uterus can be obtained.
A hysteroscopy may be indicated. This involves a long fine telescope, used to look at the lining of the uterus (the endometrium) from the inside, usually under general anaesthetic. It may be performed as a day case or it may involve an overnight stay in hospital. At the start of the procedure, the doctor dilates the cervix slightly, so that the telescope can be inserted through the cervix towards the inside of the uterus. With this technique, it is possible to take a biopsy (remove tissue for examination) from specific areas of the lining of the uterus.
What is the treatment for abnormal vaginal bleeding?
Self-care action plan If you notice unusual bleeding, you should check that it is genuinely coming from the vagina and is not from the rectum (as might occur, for example, with haemorrhoids, i. e. piles). It is important for any woman who is concerned about irregular or abnormally heavy vaginal bleeding to contact either her GP or gynaecologist as soon as possible. It is useful if you can keep a record of the dates of normal menstrual cycles and the times of abnormal bleeding, as well as a note of how heavy the periods have been (e. g. in terms of number of towels or tampons needed per day). This helps give the doctor an idea of how severe the bleeding is.
Medicines and surgery
The treatment depends on the cause. If infection is causing the bleeding, your doctor may prescribe antibiotics. Fibroids and polyps of the uterus can be easily removed surgically if necessary.
If cancer of the cervix or the uterus is identified by the gynaecologist, you will have further treatment, which may involve surgery, possibly followed by radiotherapy (cancer-killing X-rays) or chemotherapy (cancer-killing drugs). Your gynaecologist should provide advice and support.
If you have none of these causes for abnormal or heavy bleeding, it may be recommended that you try hormone treatment, often in the form of the contraceptive pill, to make your periods lighter or more regular. A hysterectomy (removal of the uterus with or without the ovaries; see separate Factsheet) may be suggested. One in five women in the UK have a hysterectomy before the age of 60 years. This may be advisable if you have cancer of the reproductive organs. It is important to discuss the pros and cons of this operation fully with your doctor, and whether it is really necessary. Alternatives should always be tried first, especially if you have not yet reached the menopause. For example, drugs such as ibuprofen are usually effective for heavy periods.
What is the outcome of having abnormal vaginal bleeding?
The outcome depends on the cause of the problem, but abnormal vaginal bleeding rarely results from a serious condition and can usually be treated successfully.