Vaginal bleeding may be considered as abnormal under the following circumstances :
- Bleeding between periods in a woman with a regular menstrual cycle.
- Vaginal bleeding after sexual intercourse.
- Profuse, frequent or prolonged bleeding at the time of periods.
- Bleeding before the age of 10 years (vaginal bleeding in a child).
- Vaginal bleeding after menopause.
Changes in the normal menstrual cycle leading to a ‘heavy’ period should not be considered as an abnormal vaginal bleed if it occurs on one or two occasions. However if it is occurs recurrently, then it warrants further gynecological investigation to identify the cause of the abnormal bleed. A scanty menses or a ‘light’ period is also considered as an abnormal vaginal bleed and this should also be investigated.
A profuse or excessive bleed during the menses (‘heavy period’) is known as hypermenorrhea or menorrhagia. This may be assessed by the number of sanitary pads of tampons that has to be changed and used during the course of the period in comparison to the the regular usage.
Prolonged menses is referred to as menorrhagia which is the same term used for profuse bleeding during menses. A normal period lasts for 3 to 7 days and any period than is 8 to 10 days or more will be considered as menorrhagia.
Irregular bleeding between periods is known as metrorrhagia and this can vary from a full bleed similar to a period to a heavy period or light spotting. Light bleeding or spotting may also be referred to as breakthrough bleeding when it is related to the use of hormonal contraceptives. Metrorrhagia may also be referred to as intermenstrual bleed.
Another term related to both metrorrhagia and menorrhagia is menometrorrhagia where there is prolonged or excessive menstrual bleeding which occurs at irregular intervals but is more frequent than would be normally expected.
If the menses is too frequent, then it is known as polymenorrhea. A normal menstrual cycle is between 21 and 35 days and if you menstruate more than once in a 20 day period, then it can be considered as polymenorrhea.
Oligomenorrhea is the term for an abnormally ‘light’ or scanty menses and/or infrequent menstruation. Having less than 10 periods in a 12 month period (menstrual cycle longer than 35 days) may be considered as oligomenorrhea.
It is important to understand and identify the type of abnormal vaginal bleed related to menstruation to assist your doctor with a differential diagnosis.
Causes of an Abnormal Vaginal Bleed
Common causes include :
- Pregnancy related bleeding. In the first 12 weeks, the most common causes are an ectopic pregnancy or miscarriage. Bleeding after 12 weeks may be related to a case of placenta previa or abruptio placentae although other causes should also be considered.
- Implantation bleed is a sign of pregnancy which occurs when the embryo implants onto the wall of the uterus. It usually appears like a blood-stained discharge.
- Polycystic ovarian syndrome or other causes of anovulation.
- Ovulation may at times cause a mid-cycle bleed or mild spotting.
- Pelvic inflammatory disease which is an infection of the uterus, fallopian tubes and/or ovaries.
- Contraception including oral and injectable contraceptives or an intrauterine device (IUD).
Less common causes of vaginal bleeding include :
- Endocrine disorders like hyperprolactinemia, diabetes mellitus or thyroid disorders including hypothyroidism or hyperthyroidism.
- Infection, injury and/or inflammation of the cervix, vulva or vagina (example – bacterial vaginosis, vaginitis).
- Gynceological disorders including endometriosis, adenomyosis, cervical or endometrial polyps or uterine fibroids.
- Cancer of the vagina, cervix or uterus.
- Foreign objects within the vaginal including remnants of toilet paper or tampons.
- Allergic reactions which may be caused by foreign objects in the vagina, condom lubricants and spermicides or lubricants for vaginal dryness.
- Induced abortion, either a surgical abortion involving machine, manual vacuum aspiration or dilation and curettage (d&c), medical abortion or illegal (‘backstreet’) abortion.
- Sexually transmitted diseases.
- Violent or forceful sexual intercourse.
- Drugs including hormone replacement therapy (HRT), the abortion pills (mifepristone and misoprostol), hormone drugs for hormonally responsive breast cancers (letrozole and tamoxifen), anticoagulants (warfarin and dalteparin) and fertility drugs (like antagon and cetrotide). Other drugs may also at times cause abnormal vaginal bleeding as a side effect.
- Herbal supplements like ginseng (Panax ginseng), black cohosh (Cimicfuga racemosa), chaste tree berry (Vitex agnus castus) and St. John’s wort (Hypericum perforatum). Other herbs may also be responsible for abnormal vaginal bleeding but this cannot always be conclusively ascertained due to the lack of clinical trials for herbal supplements.
- Bleeding disorders may cause abnormal vaginal bleeding and this could be related to platelet or coagulation disorders.