Abnormal vaginal bleeding
Many women will have experience some form of vaginal bleeding other than during their normal monthly menstruation.
The term commonly used for this is intermenstrual bleeding (in between ‘normal menstruation’). More often than not, this will cause a lot of anxiety and set off a whole list of possibilities and ‘what-ifs’? It is sometimes difficult to differentiate between intermenstrual bleeding and irregular period.
Vaginal bleeding may occur at any age but should be investigated if it occurs in pre-pubertal girls or postmenopausal women.
So what are the possible causes of intermenstrual bleeding? As with most things in medicine, there is often a list of possibilities ranging from normal, benign to cancer.
First of all, the first thing that I would advise is to do a pregnancy test to rule out pregnancy as if you are pregnant then the whole management of this changes as commonly this signifies complications in the pregnancy – eg: miscarriage, ectopic pregnancy, molar pregnancy. To keep things simple, I will not be discussing on vaginal bleeding in pregnancy here. If you are bleeding and you are pregnant, please book an appointment with your doctor sooner rather than later.
Physiologic (mid cycle bleeding?)
Other common causes of intermenstrual bleeding could be due to physiologic causes, for instance ovulation causing mid cycle bleeding. This usually occurs in the form of vaginal spotting for a couple of days during the middle of your menstruation cycle. So ladies, ovulation spotting is a natural sign of fertility and entirely normal.
Iatrogenic (Hormones – OCP/IUCD)
Other iatrogenic (usually as a result of a medical treatment) causes for intermenstrual bleeding could be related to hormonal stimulation or withdrawal – eg: starting, stopping or switching oral contraceptive pills, intrauterine contraceptive device. If you experience some form of vaginal bleeding after there has been some changes in terms of your hormone profile then do not panic; the body often needs time (usually 3-6 months) to readjust itself. However, if the vaginal bleeding does not settle or if it starts to give more significant symptoms (become heavier, making you feel tired, or changes in nature), then it will be wise to see a doctor as this could sometimes signify an underlying pathology.
Dysfunctional Uterine Bleeding (DUB)
The diagnosis of DUB is usually made after excluding any pelvic pathological causes (polyps/cancers, etc) or other general medical disease that could account for vaginal bleeding. It is commonly a diagnosis of exclusion and reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining. With DUB, the bleeding is unpredictable as it may be excessively heavy or light and may be prolonged, frequent, or random. As DUB is a diagnosis of exclusion, other causes for hormonal imbalance including polycystic ovary syndrome (PCOS) must be considered.
Endometrial or uterine polyps are growths that occur in the endometrium (the inner lining of the uterus) and are usually noncancerous (benign) but may cause problems with fertility or heavy or irregular vaginal bleeding. Endometrial polyps usually occur in women who are between 40-50 years old and can also occur after menopause.
Cervical polyps are growths that occur on the cervix. They are common especially in women who have had children. Cervical polyps can cause heavy menstrual bleeding, intermenstrual bleeding or bleeding after sex (post coital bleeding).
Polyps are usually noncancerous (benign) although a minority of them can be cancerous or can eventually turn into cancer (precancerous polyps).
Uterine fibroids are a common cause of heavy menstrual bleeding, although they do not often cause abnormal intermenstrual bleeding.
In a minority of abnormal vaginal bleeding, the reason could be due to a more sinister reason, like cancer. Cancers that can give rise to vaginal bleeding includes cervical, endometrial, vaginal and vulval cancers.
According to the latest data from the health promotion board, “Cervical cancer is the 9th most common cancer in Singaporean women. The best protection against cervical cancer is to go for regular Pap smear once every three years as it can be effectively treated if detected early.” Often-times prevention is better than cure and there are vaccines available (Cervarix & Gardasil) which could reduce the risk of contracting HPV, which is a known cause of cervical cancer.
So ladies, there are a lot of causes for vaginal bleeding, most are not serious and may correct themselves. But there is a small but significant possibility that there may be a more sinister cause for the bleeding. If you are worried, unsure, or if your symptoms persist, it may be wise to our doctors early. Also one final tip; keeping a menstrual diary will be very helpful in monitoring the pattern of your bleeding (which will be unique to each patient) and may aid our doctors in getting a better overall picture of your symptoms.Click here for our full range of Women’s Health Services
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