Intermenstrual Bleeding

Intermenstrual bleeding is vaginal bleeding between regular periods, from spotting to heavy loss. Causes include ovulation related spotting, hormonal contraception, cervical ectropion, cervical or endometrial polyps, cervicitis (chlamydia, gonorrhoea), intrauterine device, endometrial hyperplasia, cervical and endometrial cancer, fibroids and pregnancy complications. It is common, and matters because persistent bleeding may signal infection or cancer.

• Risk factors: hormonal contraception, intrauterine device, sexually transmitted infection, age above 45 years, obesity, tamoxifen use, HPV infection, smoking.
• Spotting around ovulation is common and harmless.
• Persistent bleeding for 3 months or more needs examination and ultrasound.

Women have light or heavy bleeding between periods, with or without pain, discharge or bleeding after intercourse. The timing helps: midcycle suggests ovulation, and random bleeding suggests contraception or structural disease.

• Menstrual diary showing bleeding days outside periods.
• Cervical lesion, polyp or contact bleeding on speculum; tender uterus or cervical motion tenderness.
• Differential diagnosis: ovulation spotting, contraceptive breakthrough bleeding, cervical ectropion, cervical polyp, cervicitis, pelvic inflammatory disease, endometrial polyp, endometrial hyperplasia or cancer, cervical cancer, fibroids, adenomyosis, miscarriage or ectopic pregnancy, bleeding disorder.
• Complications: anaemia, delayed cancer diagnosis, pelvic infection and infertility, anxiety, missed contraception.

The approach is to exclude pregnancy and examine the cervix and uterus.

• Urine hCG; menstrual diary and contraceptive history; speculum and bimanual examination.
• Chlamydia, gonorrhoea and trichomonas tests, high vaginal swab, cervical screening (HPV test or Pap smear if due or if the cervix looks abnormal), colposcopy for a suspicious cervix.
• Full blood count; transvaginal ultrasound for polyps, fibroids and endometrial thickness.
• Hysteroscopy with biopsy or endometrial sampling if age is 45 years or above, or if bleeding persists beyond 3 months.

The principle is to treat the cause found, and to reassure when bleeding is normal ovulation spotting.

• Supportive: menstrual diary; reassurance for ovulation spotting; review of missed pills and drug interactions; partner treatment for infection; advice to use condoms.
• Pharmacological: chlamydia: doxycycline 100 mg oral 12-hourly for 7 days (or azithromycin 1 g oral as a single dose); gonorrhoea: ceftriaxone 1 g IM as a single dose; pelvic inflammatory disease: ceftriaxone 1 g IM once, then doxycycline 100 mg oral 12-hourly plus metronidazole 400 mg oral 12-hourly for 14 days; trichomonas: metronidazole 400 mg oral 12-hourly for 7 days; contraceptive breakthrough bleeding: combined oral contraceptive pill with ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms oral once daily for 21 days then 7 days free after a missed pill is excluded; tranexamic acid 1 g oral 8-hourly for 4 days for bothersome bleeding; mefenamic acid 500 mg oral 8-hourly with food for 5 days; ferrous sulphate 200 mg oral 12-hourly for 3 months for anaemia.
• Procedures: hysteroscopic polypectomy; removal of a cervical polyp in clinic; cryotherapy or silver nitrate cautery for symptomatic cervical ectropion; biopsy and treatment of precancerous or cancerous lesions; removal or replacement of a problematic intrauterine device.
• Special groups: women with positive pregnancy tests need ultrasound for miscarriage or ectopic pregnancy; women aged 45 years or above, or with risk factors, have endometrial sampling; women with HIV have yearly cervical screening and early colposcopy; women on tamoxifen have prompt endometrial assessment.
• Red flags: heavy bleeding, bleeding after intercourse, suspicious cervix, positive pregnancy test with pain, fever with pelvic pain, endometrial thickness above 12 mm, weight loss.
• Follow-up: review at 3 months with diary; repeat swabs after treatment; cervical screening as due; endometrial review if bleeding persists after treatment of the cause.