• Normal vaginal bleeding is the periodic blood flow from the uterus.
• Normal vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.
• To determine whether bleeding is abnormal and its cause, the doctor, must answer three questions: Is the woman pregnant? What is the pattern of the bleeding? Is she ovulating?
• Abnormal vaginal bleeding in women who are ovulating regularly usually involves excessive, frequent, irregular, or decreased bleeding.
• May causes of abnormal vaginal bleeding are associated with irregular ovulation.
• A woman with irregular menstrual periods requires a physical examination with a particular emphasis on the thyroid, breast, and pelvic organs.
• Treatment for irregular vaginal bleeding depends on the underlying cause. After the cause is determined, the doctor decides if treatment is necessary.
Normal vaginal bleeding is the periodic blood that flows as a discharge from the woman’s uterus. Regular (menstrual) vaginal bleeding is also called menorrhea. The process by which menorrhea occurs is called menstruation.
Normal vaginal bleeding occurs because of cyclic hormonal changes. The ovaries are the primary source of female hormones, which control the development of female body characteristics such as breasts, body shape, and body hair. The hormones also regulate the menstrual cycle. The ovary, or female gonad, is one of a pair of reproductive glands in women. They are located in the pelvis, one on each side of the uterus. Each ovary is about the size and shape of an almond. The ovaries produce eggs (ova) and female hormones. During each monthly menstrual cycle, an egg is released from one ovary. The egg travels from the ovary through a Fallopian tube to the uterus.
Unless pregnancy occurs, the cycle ends with the shedding of part of the inner lining of the uterus, which results in menstruation. Although it is the end of the physical cycle, the first day of menstrual bleeding is designated as “day 1” of the menstrual cycle in medical jargon.
The time of the cycle during which menstruation occurs is referred to as menses. The menses occurs at approximately four-week intervals, representing the menstrual cycle.
Menarche is the time in a girl’s life when menstruation first begins. Menopause is the time in a woman’s life when the function of the ovaries ceases, and menstrual periods stop. Menopause is defined as the absence of menstrual periods for 12 consecutive months. The average age of menopause is 51 years old.
Abnormal vaginal bleeding is a flow of blood from the vagina that occurs either at the wrong time during the month or in inappropriate amounts. To determine whether bleeding is abnormal, and its cause, the doctor must consider three questions:
• Is the woman pregnant?
• What is the pattern of the bleeding?
• Is she ovulating?
Every woman who thinks she has an irregular menstrual bleeding pattern should think carefully about the specific characteristics of her vaginal bleeding to help her doctor evaluate her particular situation. Her doctor will require the details of her menstrual history. Each category of menstrual disturbance has a specific list of causes, necessary testing, and treatment. Each type of abnormality is discussed individually below.
Does the woman have abnormal vaginal bleeding during pregnancy?
Much of the abnormal vaginal bleeding during pregnancy occurs so early in the pregnancy that the woman doesn’t realize she is pregnant. Therefore, irregular bleeding that is new may be a sign of very early pregnancy, even before a woman is aware of her condition. Vaginal bleeding during pregnancy can also be associated with pregnancy complications, such as miscarriage or ectopic pregnancy.
What is the pattern of abnormal vaginal bleeding?
The duration, interval, and amount of vaginal bleeding may suggest what type of abnormality is responsible for the bleeding.
An abnormal duration of menstrual bleeding can be either bleeding for too long of a period (hypermenorrhea) or short of a period (hypomenorrhea).
The interval of the bleeding can be abnormal in several ways. A woman’s menstrual periods can occur too frequently (polymenorrhea) or too seldom (oligomenorrhea). Additionally, the duration can vary excessively from cycle to cycle (metrorrhagia).
The amount (volume) of bleeding can also be abnormal. A woman can either have too much bleeding (menorrhagia) or too little volume (hypomenorrhea). The combination of excessive bleeding combined with bleeding outside of the expected time of menstruation is referred to as menometrorrhagia.
Is the woman ovulating?
Usually, the ovary releases an egg every month in a process called ovulation. Normal ovulation is necessary for regular menstrual periods. There are certain clues that a woman is generally ovulating, including regular menstrual intervals, vaginal mucus discharge halfway between menstrual cycles, and monthly symptoms including breast tenderness, fluid retention, menstrual cramps, back pain, and mood changes. If necessary, doctors will order hormone blood tests (progesterone level), daily home body temperature testing, or rarely, a sampling of the lining of the uterus (endometrial biopsy) to determine whether or not a woman is ovulating regularly.
On the other hand, signs that a woman is not ovulating regularly include prolonged bleeding at irregular intervals after not having a menstrual period for several months. Excessively low blood progesterone levels in the second half of the menstrual cycle, and lack of the normal body temperature fluctuation during the time of expected ovulation. Sometimes, a doctor determines that a woman is not ovulating by using endometrial sampling with biopsy.
Vaginal bleeding may occur during or after sexual intercourse for many reasons, including:
• Injuries to the vaginal wall or introitus (opening to the vagina) during intercourse
• Infections (for example, gonorrhea, Chlamydia, yeast infections) can be a cause of vaginal bleeding after intercourse.
• Lowered estrogen levels in peri-menopausal or postmenopausal women may cause the lining of the vagina to become thinned and easily inflamed or infected. These changes can be associated with vaginal bleeding after intercourse.
• Anatomical lesions, such as tumors or polyps on the cervix or vaginal wall, may lead to vaginal bleeding during or after intercourse.
Women who experience vaginal bleeding during or following sexual intercourse should always visit their doctor to determine the cause of the bleeding.
Many women have some amount of vaginal bleeding during pregnancy. Some studies show that up to 20% to 30% of pregnant women will experience some degree of vaginal bleeding while pregnant. Vaginal bleeding during pregnancy is more familiar with twins and other multiple gestations than with singleton pregnancies (pregnancy with one fetus).
Sometimes women experience a very scant amount of bleeding in the first two weeks of pregnancy, usually around the time of the expected menstrual period. This slight bleeding is sometimes referred to as “implantation bleeding.” Doctors do not know for sure what causes this bleeding, but it may occur as a result of the fertilized egg implanting in the uterine wall.
The amount of bleeding, the stage of pregnancy, and any associated symptoms can help determine the cause of vaginal bleeding in pregnancy. While vaginal bleeding in pregnancy does not always signify a problem with the pregnancy, women who experience bleeding during pregnancy should be evaluated by a doctor.
Causes of vaginal bleeding in pregnancy include miscarriage, an abnormal location of the placenta, ectopic pregnancy, cervical infection or polyp, and premature labor. Chronic medical conditions and medication use can also be related to vaginal bleeding during pregnancy.
Excessively heavy menstrual bleeding, called menorrhagia, is menstrual bleeding of greater than about eight tablespoons per month (normal menstrual bleeding produces between two and eight tablespoons per cycle). The most common pattern of menorrhagia is excessive bleeding that occurs in regular menstrual cycles and with normal ovulation.
There are several important reasons that a doctor should evaluate menorrhagia. First, menorrhagia can cause a woman with substantial emotional distress and physical symptoms, such as severe cramping. Second, the blood loss can be so severe that it creates a dangerously lowered blood count (anemia), which can lead to medical complications and symptoms such as dizziness and fainting. Third, there can be dangerous causes of menorrhagia that require more urgent treatment.
Benign (noncancerous) causes of menorrhagia include:
• Uterine fibroids (benign tumors of smooth muscle; this type of tumor is known as a leiomyoma)
• Endometrial polyps (tiny benign growths that protrude into the womb)
• Adenomyosis (the presence of uterine lining tissue within the muscular wall of the uterus)
• Intrauterine devices (IUD’s)
• Underactive thyroid function (hypothyroidism)
• The autoimmune disorder systemic lupus erythematosus
• Blood clotting disorders such as inherited bleeding disorders
• Certain medications, especially those that interfere with blood clotting
Though not common, menorrhagia can be a sign of endometrial cancer. A potentially precancerous condition known as endometrial hyperplasia can also result in abnormal vaginal bleeding. This situation is more frequent in women who are over the age of 40.
Although there are many causes of menorrhagia, in most women, the specific cause of menorrhagia is not found even after a full medical evaluation. These women are said to have dysfunctional uterine bleeding. Although no specific cause of the abnormal vaginal bleeding is found in women with dysfunctional uterine bleeding, there are treatments available to reduce the severity of the condition.
Women who are ovulating regularly can experience light bleeding (sometimes referred to as “spotting”) between menstrual periods. Hormonal birth control methods (oral contraceptive pills or patches) and IUD use for contraception, may sometimes lead to light bleeding between periods. Psychological stress, certain medications such as anticoagulant drugs, and fluctuations in hormone levels may cause light bleeding between periods. Other conditions that cause abnormal menstrual bleeding or bleeding in women who are not ovulating regularly also can be the cause of intermenstrual bleeding.
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