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.
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.
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. Most of the time it is simply referred to as heavy periods. 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 Abnormal Vaginal Bleed
- 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
- 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.
Brown Vaginal Bleeding
The color of vaginal blood is usually expected to be a bright to dark red and a brown vaginal bleed may be concerning since it is not the norm. Brown vaginal blood, either light or dark in color, usually indicates that the blood is not fresh and has been contained in the vagina or uterus for a period of time before being expelled. It is important to identify any vaginal secretion because brown vaginal discharge is often mistaken for brown vaginal bleeding.
Causes of Brown Vaginal Blood
Brown vaginal secretions may at times be a vaginal discharge streaked with ‘old blood’ – blood that is breaking down and has taken a period of time before it exits through the vagina. At other times, a brown vaginal discharge may occur on its own with no signs of bleeding and this may seen in vaginal infections or pelvic inflammatory disease. Any of the causes of abnormal vaginal bleeding may appear as brown vaginal blood if the bleeding occurs slowly thereby allowing the blood to degrade over time. Some of the causes of brown vaginal bleeding include :
- Retained menses. The sloughing of the inner wall of the uterus (endometrium) is usually expelled during menstruation but at times a small portion of the uterine contents may be retained. If expelled after a couple of days or more, it may appear as brown vaginal bleeding. In the case of retained menses, this is usually a small amount that may occur a few days after you finish your period.
- Induced abortion. Using the abortion pill or having an illegal abortion may result in some of the uterine contents being expelled for days and weeks after the abortion. This may appear as brown vaginal bleeding with clots that are dark brown to black in color. In legal abortions, a D&C (dilation and curettage) is conducted and due to manual aspiration, most, if not all of the uterine contents are removed at the time of the abortion. This makes any late brown vaginal bleeding less likely.
- Miscarriage. Depending on the stage of your pregnancy when you miscarried, remnants of the fetus, placenta or parts of the inner lining of the uterus (endometrium) may be expelled over days or even weeks after the incident. It is important for women who have miscarried to consult with their doctor and verify if a D&C (dilation and curettage) is necessary.
- Infections of the vagina, uterus or fallopian tubes may cause slight bleeding that degrades before it exits the vagina. If it is a slight bleed and the infection is limited, a brown vaginal bleed may be noticed for a short period of time. Other symptoms like pain and a fever may also be present. Sexually transmitted diseases (STD’s) may also be responsible for brown vaginal bleeding with/without a discharge and this may occur over a long period of time.
- Cancer, especially in cases of cervical cancer where there is slight bleeding and ulceration of the cervix, a brown vaginal bleed may be noticed occasionally. In this case, the abnormal vaginal bleeding may occur over a duration of time and increase in severity at the malignancy progresses.
First Trimester Pregnancy Bleeding
Any vaginal bleeding during the first trimester (first 12 weeks) of pregnancy can be an indication of a serious problem such as a miscarriage or ectopic pregnancy and needs immediate medical attention. After proper evaluation, the treatment and management of the vaginal bleeding will be guided by the cause of bleeding.
Bleeding during the first trimester can vary from a dot or pinhead sized spot of blood to bleeding equivalent to a light or even heavy period. Any sign of blood from the vagina during pregnancy should be taken seriously. If there are other signs and symptoms like severe abdominal pain, fever or dizziness, immediate medical attention should be sought.
While spontaneous abortion or miscarriage (which includes threatened, incomplete, inevitable, complete, septic or missed) is the most common cause of vaginal bleeding in the first trimester of pregnancy, a ruptured ectopic pregnancy is the most dangerous one. There are other less serious causes which will not pose any threat to the pregnancy, however, this should be assessed by a medical professional.
- Implantation bleeding
- Implantation of the fertilized ovum into the uterine wall may cause a small amount of bleeding.
- This may occur around the time of the expected period.
- It is considered normal and does not require any treatment.
- Threatened abortion
- In this instance, the fetus may be under threat and a healthy pregnancy may not be possible.
- This could be due to improper implantation of the placenta, may be associated with the use of drugs and alcohol, trauma and other underlying diseases.
- Although the vaginal bleeding may end in a miscarriage, there is a chance of averting the danger so that pregnancy may continue to full term.
- Incomplete abortion
- Some of the products of conception (the fetus, placenta and membranes) have already been expelled from the uterus.
- Pregnancy cannot continue in this case.
- Complete abortion
- All the products of conception have been expelled by the uterus.
- Inevitable abortion
- The signs and symptoms indicate that it will not be possible to save the pregnancy.
- Missed abortion
- In some cases, although the fetus is dead, the products of conception are still retained within the placenta.
- Infected (septic) abortion
- There is infection of the uterus and products of conception after abortion.
- Ectopic pregnancy
- The fertilized ovum is implanted in some other site (usually the fallopian tube) instead of the uterus.
- Can pose a risk to the health of the mother.
- Molar pregnancy
- Instead of a fetus, a grape-like cluster of abnormal tissues grow in the uterus.
- Post-coital bleeding
- Bleeding after intercourse may be normal during pregnancy.
- Trauma or injury to vaginal wall
- May follow domestic violence or an amniocentesis or chorionic villus sampling procedure.
- Ruptured corpus luteum cyst
- Vaginal or cervical infection
- Cervical cancer
- Cervical polyps