Vaginal Bleeding: How Do I Differentiate Between Abnormal And Normal Vaginal Bleeding?

What is vaginal bleeding?

Vaginal bleeding is the flow of blood through the vagina from uterus, ovaries, cervix or fallopian tube.

Vaginal bleeding could either be Normal or Abnormal.

What is Abnormal vaginal bleeding?

Abnormal vaginal bleeding is any vaginal bleeding unrelated to normal menstruation. This type of bleeding may include spotting of small amounts of blood between periods, often seen on toilet tissue after wiping or extremely heavy periods in which you soak a pad or tampon every one to two hours for two or more hours.

In order to determine whether bleeding is abnormal, and its cause, the doctor must answer three questions: 

Is the woman ovulating?

Is the woman pregnant? 

What is the pattern of the bleeding?

Every woman who thinks she has an irregular menstrual bleeding pattern should think carefully about the specific characteristics of her vaginal bleeding in order 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 particular list of causes, necessary testing, and treatment. Each type of abnormality is discussed individually below.

1. 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 ovulating normally 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 normally.

2. Is the woman pregnant?

Much of the abnormal vaginal bleeding during pregnancy occurs so early in the pregnancy that the woman does not 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 complications of pregnancy, such as miscarriage or ectopic pregnancy.

Abnormal vaginal bleeding in women who are ovulating regularly most commonly involves excessive, frequent, irregular, or decreased bleeding.

Many causes of abnormal vaginal bleeding are associated with irregular ovulation.

A woman who has irregular menstrual periods requires a physical examination with a special emphasis on the thyroid, breast, and pelvic organs.

3. What is the pattern of 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 too 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.

What is normal vaginal bleeding?

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.

Menstruation is a normal vaginal bleeding that occurs every 21 to 35 days when the uterus sheds its lining, marking the start of a new reproductive cycle. A menstrual period may last for just a few days or up to a week. Your flow may be heavy or light and still considered normal. Menstrual cycles tend to be longer for teens and for women nearing menopause, and menstrual flow may also be heavier at those age.

Normal vaginal bleeding occurs because of cyclic hormonal changes. The ovaries are the main source of female hormones, which control the development of female body characteristics such as the 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 actually 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: This refers to the first mensturation in a girl's life.

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.

What causes abnormal vaginal bleeding

Let me continue with causes of vaginal bleeding. These causes are categorized as follow:

What causes Vaginal bleeding during and after sexual intercourse?

Vaginal bleeding may occur during or after sexual intercourse for a number of reasons including:

I. Low levels of estrogen hormone in peri-menopausal or postmenopausal women may cause the lining of the vagina to become thinned and easily inflamed or infected, and these changes can be associated with vaginal bleeding after intercourse.

II. Injuries to the vaginal wall or opening to the vagina during intercourse.

III. Anatomical lesions, such as tumors or polyps on the cervix or vaginal wall may lead to vaginal bleeding during or after intercourse.

IV. Infectious disease like chlamydia, gonorrhea, yeast infections can be a cause of vaginal bleeding after intercourse.

Women who experience vaginal bleeding during or following sexual intercourse should always visit their doctor to determine the cause of the bleeding.

What causes abnormal vaginal bleeding during pregnancy?

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 they are pregnant. Vaginal bleeding during pregnancy is more common with twins and other multiple gestations than pregnancy with one fetus (singleton pregnancies).

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 certain what causes this bleeding, but it may occur as a result of the fertilized egg implanting in the uterine wall.

The amount of the bleeding, the stage of pregnancy, and any associated symptoms can all 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.

What causes abnormal vaginal bleeding in women who are ovulating regularly?

Abnormal vaginal bleeding in women who are ovulating regularly, most commonly involve excessive, frequent, irregular, or decreased bleeding. Some of the common conditions that produce each of these symptoms are discussed below.

_Menorrhagia (Excessively heavy menstrual bleeding)

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 menorrhagia should be evaluated by a doctor. First, menorrhagia can cause a woman substantial emotional distress and physical symptoms, such as severe cramping. Second, the blood loss can be so severe that it causes 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.

Non cancerous (benign) causes of menorrhagia include:

Endometrial polyps (tiny benign growths that protrude into the womb)

Adenomyosis (the presence of uterine lining tissue within the muscular wall of the uterus)

Uterine fibroids (benign tumors of smooth muscle; this type of tumor is known as a leiomyoma)

Intrauterine devices (IUD's)

Hypothyroidism (underactive thyroid function)

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.

_Irregular vaginal bleeding; menstrual periods that are too frequent (polymenorrhea)

Menstrual periods that are abnormally frequent (polymenorrhea) can be caused by certain sexually transmitted diseases (STDs) (such as Chlamydia or gonorrhea) that cause inflammation in the uterus. This condition is called pelvic inflammatory disease(PID). 

Endometriosis is a condition of unknown cause that results in the presence of uterine lining tissue in other locations outside of the uterus. This can lead to pelvic pain and polymenorrhea. 

Sometimes, the cause of polymenorrhea is unclear, in which case the woman is said to have dysfunctional uterine bleeding.

_Metrorrhagia (menstrual periods at irregular interval)

Irregular menstrual periods (metrorrhagia) can be due to benign tumors in the cervix, such as cervical polyps. The cause of these growths is usually unknown. 

Metrorrhagia can also be caused by infections of the uterus (endometritis) and use of birth control pills (oral contraceptives). Sometimes after an evaluation, a woman's doctor might determine that her metrorrhagia does not have an identifiable cause and that further evaluation is not necessary at that time.

Perimenopause is the time period approaching or around menopause. It often is characterized by irregular menstrual cycles, including menstrual periods at irregular intervals and variations in the amount of blood flow. Menstrual irregularities may precede the onset of true menopause (defined as the absence of periods for one year) by several years.

_Hypomenorrhea (decreased amount or duration of menstrual flow)

An overactive thyroid function (hyperthyroidism) or certain kidney diseases can both cause hypomenorrhea. Oral contraceptive pills can also cause hypomenorrhea. It is important for women to know that lighter, shorter, or even absent menstrual periods as a result of taking oral contraceptive pills does not indicate that the contraceptive effect of the oral contraceptive pills is inadequate. In fact, many women appreciate this "side effect" of oral contraceptives.

_Intermenstrual  bleeding (bleeding between menstrual periods)

Women who are ovulating normally can experience light bleeding (sometimes referred to as "spotting") between menstrual periods. Hormonal birth control methods (oral contraceptive pills or patches) as well as 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 all be causes of 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.

How to diagnose (evaluate) abnormal vaginal bleeding?

To determine the cause of abnormal bleeding, your doctor will perform a physical exam, including a pelvic exam, and may perform one or more of the following:

A pregnancy test

Hormone test

Blood tests, including a blood clotting profile

Tests for sexually transmitted diseases

Thyroid function tests

Ultrasound of the pelvis to evaluate the uterus, cervix, ovaries, fallopian tubes and bladder.

A transvaginal ultrasound, in which a small hand-held device is inserted into the vagina, produces pictures of the endometrium, or the lining of the uterine cavity, and the walls of the uterus, called the myometrium, as well as the ovaries.

Sonohysterography, or ultrasound of the uterus, provides a more in-depth evaluation of the uterine cavity. In this minimally invasive procedure, a saline solution is injected into the uterine cavity to help visualize and measure the endometrium and to look for polyps or a mass of tissue. This exam may also involve an injection of air to help determine if the fallopian tubes are open.

Pelvic MRI is used after ultrasound to better visualize fibroids, cancer, or retained products of conception.

Endometrial biopsy is used to remove and examine a small sample of tissue from the endometrium under a microscope to diagnose cancer or other causes of abnormal bleeding. The procedure, which may be performed as an office procedure alone or in conjunction with hysteroscopy, involves a suction or cutting device that removes a small piece of tissue from the uterus.

Hysteroscopy involves inserting into the uterus a narrow lighted tube with an optical instrument or viewing device on the end to allow the physician to look for fibroids, polyps or other abnormalities.

How is abnormal vaginal bleeding treated?

Treatment for abnormal vaginal bleeding depends on the underlying cause, and may include:

  Medication

birth control pills or hormone-releasing intrauterine devices.

Uterine fibroid embolization (UFE). In this minimally invasive procedure guided by an x-ray camera called a fluoroscope, tiny particles are injected through a catheter into uterine arteries that are delivering blood to fibroids, blocking blood flow and causing the fibroids to shrink.

  Endometrial ablation. 

Guided by a narrow lighted tube with a viewing device on the end (called a hysteroscope), the lining of the uterus is destroyed using a laser or other specialized instruments that produce heat, freezing, microwave energy or electrical currents.

  Myomectomy, the surgical removal of fibroids.

  Dilation and curettage (D&C). 

A procedure in which endometrial tissue is gently scraped or suctioned from the uterus.

  Hysterectomy. 

A surgical procedure in which the uterus is removed.

How to prevent abnormal vaginal bleeding?

Maintain a healthy weight

Take your birth control pills as directed and at the same time every day

Take your hormone replacement therapy as directed and at the same time every month

Take a stress management class, listen to soothing music or learn some relaxation exercises — step back and smell the roses

Take a nonsteroidal anti-inflammatory drug such as naproxen or ibuprofen to help reduce menstrual bleeding (if you’re pregnant or have any questions about taking medication, call your doctor)

When to call your doctor

While abnormal vaginal bleeding may turn out to be nothing serious and easily treated, always contact your doctor if:

You’re pregnant

You have unexplained bleeding between periods

You have heavy bleeding during your periods

You bleed after menopause

You have additional symptoms such as dizziness, pain or fatigue.

Sources:

www.radiologyinfo.org

www.clevelandclinic.com

+3 other sources