A Patient Journey for Vaginal Bleeding

Menstruation, also known as your period, is a normal part of the lives of most women.  Learning what is normal for your body is important but it can be difficult to know what’s typical for you and what needs medical attention when it comes to your menstrual cycle.

Abnormal vaginal bleeding can include unusually heavy bleeding during your menstrual cycle (this is called menorrhagia), unusually prolonged bleeding, bleeding between periods, periods occurring irregularly or with unusual frequency, bleeding after sex, bleeding after going through the menopause and bleeding during pregnancy.

Abnormal bleeding may be a sign of a number of health conditions, so it’s essential to see a medical professional whenever you notice such symptoms.http://www.talkhealthpartnership.com/talkwomenshealth/patient_journey/images/middle_age_woman_back.jpg

Unusually Heavy Bleeding

On average, women will lose around 30 - 40 millilitres of blood during a period; 60 - 80 or more millilitres is considered heavy menstrual bleeding. It is rarely necessary to measure the amount of blood you have lost - instead using indicators such as; if you feel that you have needed to use an unusually high number of tampons or pads, if you notice an unusually large flow through to your clothes or bedding, or if you find yourself needing to use both tampons and pads together, that might be an sign that your period is heavier than usual and it may be worth making an appointment to see your doctor.

Unusually Prolonged Bleeding

On the normal menstrual cycle of most women, blood flow will occur for between 2 and 7 days with the average being five days. If blood flow continues for longer than you are used to, you should see a doctor. You should also see a doctor if your periods regularly include more than a week of blood flow and you’ve never discussed this with a medical professional.

Bleeding Between Periods

You should always see a doctor if you experience any bleeding between periods. Again, it is rare that bleeding is a result of any serious medical condition – common minor causes include being a new user of contraceptive medication, missing contraceptive medications, injury to the vagina as a result of sex or infection, stress, vaginal dryness, and benign (non-cancerous) changes occurring in the cervix. More serious causes, though, include some sexually transmitted infections (STIs) such as chlamydia, cervical cancer, and womb cancer – this is why it is important to see your doctor if you notice bleeding between your periods.

Periods Arriving Irregularly or Unusually Frequently

Most women’s menstrual cycles take somewhere between 24 and 35 days to complete a full cycle, with their periods coming fairly regular by adulthood. If your periods are slightly irregular, this is not usually any cause for concern, though you should see a doctor if you are worried. You should also see a doctor if your periods are arriving more than once a month.

Bleeding After Sex

Bleeding after sex (‘postcoital bleeding’) is quite common and usually has a harmless explanation. It is, however, worth seeing your doctor about, as it can be a symptom of some more serious conditions. This is particularly true of older (particularly post-menopausal) women, who should always see a doctor if they notice vaginal bleeding after sex.

There are various reasons for postcoital bleeding;

  • An infection such as Pelvic inflammatory disease (PID) or a sexually transmitted infection (STI) such as chlamydia.

  • It may also be caused by vaginal dryness (‘atrophic vaginitis’).

  • Damage to the vagina caused by childbirth or tears and friction which occur during sex.

  • Cervical or endometrial polyps ( benign or non-cancerous growths in the cervix or womb) 

  • Cervical ectropian (also known as cervical erosion) characterised by an inflamed area on the surface of the cervix.

In rare cases, it can be a sign of cervical or vaginal cancer.

Bleeding After Menopause

Any bleeding after the menopause - usually defined as any bleeding (even spotting) more than 12 months after your periods have stopped. Although it is considered a common problem it is not normal to bleed at any time post menopause and it is therefore crucial that you make an appointment to visit your doctor. One common cause is an inflammation of the lining of the womb, which is easily treated. Sometimes, bleeding can be a side-effect of Hormone Replacement Therapy (HRT). Another cause is cervical or womb polyps, growths on the womb or cervix that are usually benign (non-cancerous). About 10% of women who experience post-menopausal bleeding, though, have womb cancer, so it’s essential to visit your doctor as soon as you notice this symptom. Another cause is a thickening of the womb lining called endometrial atrophy, which can also lead to womb cancer if left untreated. Read more about the menopause.

Bleeding During Pregnancy

Around 20% of women experience some bleeding during the first 12 weeks of pregnancy. Usually, this is no cause for alarm; it is a common result of some of the normal processes of early pregnancy, such as the implantation of the fertilised egg into the uterus. Nonetheless, it is important to see your doctor or midwife if you notice bleeding during pregnancy, since it can in some cases be a sign of miscarriage or ectopic pregnancy (this is where the fertilised egg implants in the fallopian tube or some other place instead of the womb). Your doctor or midwife will talk to you about your bleeding and any other symptoms you are experiencing, may physically examine you, and will keep a close eye on you going forward.

Bleeding later on in pregnancy is less common and you should treat it more seriously. Make an appointment to speak with your doctor or midwife as soon as possible since it can be a sign of a more serious complication. Minor causes can include normal cervical changes that cause bleeding (particularly after sex), vaginal infections, and ‘shows’ – the dislodging of the plug of mucus that lies in the cervix during pregnancy which can occur a few days before contractions start. More serious conditions that may be indicated include placental abruption (the separation of the placental lining from the uterus prior to delivery - this is very serious and requires urgent medical treatment), low-lying placenta (or ‘placenta praevia’ - where the placenta is attached low down on the womb, near to the cervix), and vasa praevia (in which foetal blood vessels run across the entrance to the birth canal). It could also be a sign that labour will begin soon - if this happens before 37 weeks of pregnancy seek advice from your midwife immediately.

Seeing your Doctor

Your doctor will ask you about the nature of the bleeding (how long it has been going on for, whether there are activities which make it worse), your doctor will also ask whether you are experiencing any other symptoms, and about your medical history. He/she may also perform a physical examination such as a pelvic examination. During this examination your doctor may perform a visual examination of your vulva, an internal examination of the cervix and vagina using a speculum (similar to having a smear test, the speculum holds open the walls of the vagina so that the cervix can be clearly seen), during this time your doctor may decide to take a swab of the cervical tissue to test for any abnormalities. Your doctor may also conduct a bimanual examination (where he/she inserts two gloved lubricated fingers into the vagina while using the other hand to press on the outside of your abdomen). If cancer or another serious condition is suspected, you may be referred to a specialist for further testing.

In many cases, you will also be referred for specialist testing (either at a specialist clinic, or in some cases by your GP), including a vaginal ultrasound (the use of inaudible sound waves to produce an image of the vagina, uterus, ovaries, cervix, and fallopian tubes), an endometrial biopsy (the microscopic examination of tissue removed from the uterus), or a hysteroscopy (a procedure in which a narrow tube is inserted into the vagina in order to provide close-up images of the womb, it is conducted under a general or local anaesthetic so that you do not feel so much discomfort).

Further Treatment

Treatment will depend on what is causing your abnormal vaginal bleeding. Seeking advice from your doctor or specialist is crucial as well as being aware of your own body.  In the case of postmenopausal bleeding, for example, cervical polyps will usually need to be removed; endometrial atrophy can often be treated using creams; and if your bleeding is caused by HRT, your treatment plan may be altered. In the case of womb cancer, you will be assigned a multidisciplinary team (MDT) of specialists to decide upon the best course of treatment and care for you, which may include surgery, chemotherapy, radiotherapy, and hormone therapy.

You can receive support from the talkhealth community in the gynaecology section of the talkwomen's health forum. We also happily recommend the charity Women's Health Concern.

Sources used in writing this article are available on request.

Information written by the talkhealth team

Last revised: 20 October 2016