What is Intermenstrual bleeding?
This is unscheduled bleeding that can occur in between periods. There are many different causes of bleeding between periods but seek medical advice if you are experiencing this, even if it is for reassurance in many situations.
What is the nature of bleeding?
Bleeding that occurs randomly without any relation to your monthly period should not be ignored, unless the cause is known. The bleeding may be light blood, spotting, a bloody or dark brown vaginal loss or heavy bleeding mimicking a period.
Mid cycle pain and bleeding
Mittelschmerz is one-sided, lower abdominal pain associated with ovulation, about 14 days before your next menstrual period. In most cases, mittelschmerz does not require medical attention and may be associated with light vaginal bleeding for a day or so. It may not occur every month. If you are concerned, seek advice.
Spotting in the lead up to or at the end of the period
Usually, this just suggests that levels of progesterone fall slightly more slowly in some cycles and can lead to spotting seen in the lead up to the proper menstrual flow. This is usually not a concern. Spotting or a brown vaginal loss as the period finishes is also not abnormal, unless lasting for days or associated with other symptoms. (See information on a normal menstrual cycle under the leaflet on Irregular Periods)
What are the possible causes of bleeding between periods? (not an exhaustive list)
- Hormonal contraceptives, such as the combined or progesterone only pill, implant, injection, intrauterine system, patch, ring can all cause bleeding between cycles, especially in the first few months of starting them. Bleeding can also occur if you forget your medication, take antibiotics, are sick with vomiting or diarrhoea or if you have a problem with your patch, ring, or coil. If you have not bled before and suddenly start bleeding, seek medical advice or if you have any concerns.
- Taking the emergency contraceptive pill
- Termination of pregnancy or miscarriage (recent) – seek medical advice if you are bleeding heavily
- Sexually transmitted infections (STI) such as chlamydia and pelvic inflammatory disease (PID)
- Injury to the female genital tract – vulva, vagina, cervix, uterus from penetrative sex, sex toys etc
- Vaginal and vulval dryness (Perimenopause, Lichen Sclerosus, pregnancy, breast feeding, birth trauma etc)
- Irregular periods as seen in PCOS, endometriosis
- Cervical Ectropion
- Cervical or Endometrial Polyps
- Fibroids, especially submucous fibroids or fibroid polyps
- Cervical, vulval, vaginal, endometrial cancers can sometimes present with bleeding in between periods, bleeding after sex, heavy periods or post menopausal bleeding. Always ensure you are up to date with your cervical smear test but seek advice if concerned or unusual bleeding.
- Medications including hormone replacement can cause bleeding in between periods
- Stress can affect menstrual cycles
- Bleeding from the bladder or back passage can cause diagnostic confusion
- Blood clotting disorders, like von Willebrand disease
- Other health conditions, like hypothyroidism, liver disease, or chronic kidney disease
When should I seek medical help?
If you have bleeding in between your periods and you are concerned or if it has lasted for more than 3 months, then you should speak to your doctor.
Depending on your clinical history and situation, you may be recommended to have an internal pelvic examination and some tests such as:
- Speculum examination to examine the cervix (neck of the womb)
- STI screening test
- Urine pregnancy test
- Cervical HPV screening test (Ages 25 to 64 and not up to date)
- Pelvic ultrasound scan to check your womb and ovaries
Management will depend on the underlying cause, depending on the results.
Dr Nitu Bajekal FRCOG Dip IBLM
Consultant Gynaecologist and Women’s Health Expert
Lifestyle Medicine Physician
July 2020
