Abnormal Vaginal and Uterine Bleeding

Many women and girls experience abnormal vaginal or uterine bleeding.  Normal menstrual cycles typically occur every 24 to 38 days, and bleeding lasts two to seven days.   In most cases, no more than 80 mL of blood is lost.  Any bleeding that occurs outside of the menstrual cycle is considered abnormal, and should be checked by a doctor.  Unusually heavy menstrual bleeding, “spotting” between periods, and menses that last longer than seven days all warrant evaluation.  After menses have stopped due to menopause, vaginal or uterine bleeding is often a sign of a problem.

Under age 20 and after 40, the risk for abnormal bleeding is higher due to hormonal imbalances at the beginning and end of your reproductive life.   Anovulatory menstrual cycles are the most common cause of this type of bleeding.  In these cases, no egg is released from an ovary due to insufficient hormone (LH and FSH) release from the pituitary.  As a result, high levels of estrogen cause the uterine lining to shed at random times.   This phenomenon is also associated with medical conditions such as obesity, hypothyroidism, anorexia, and polycystic ovary disease.  

Blood clotting disorders can cause excessively heavy menstrual bleeding.  Symptoms may begin at the onset of menses or during adolescence with associated nosebleeds or bruising on atypical locations of the body.  There is often a history of similar symptoms in other family members.

Certain infections may cause abnormal vaginal or uterine bleeding.  “Spotting” may occur in the presence of a yeast infection or an imbalance in the normal vaginal flora, known as bacterial vaginosis.  Bleeding may also be a symptom of a sexually transmitted disease such a chlamydia or gonorrhea.

Structural causes of abnormal uterine bleeding include:
• polyps
• fibroids
• tumors
• endometriosis

In teenagers and young women; pregnancy can cause abnormal bleeding.  Factors that can increase your risk of abnormal bleeding include:
• obesity
• excessive exercising
• stress

If bleeding occurs prior to 20 weeks, it could be a sign of an impending miscarriage.

When Should I See My Doctor?

See your doctor if you’re:
• passing blood clots the size of a golf ball or larger
• soaking a pad or tampon every hour, or using more than six in 24 hours
• feeling dizzy, weak, or lightheaded
• if you have severe abdominal pain
• your period doesn’t stop when expected

Be sure to tell your doctor if you could be pregnant.

How Will My Doctor Find Out What’s Wrong?

Your doctor will take a detailed medical history (your story of the problem and how long you have had it), and perform a physical exam.  She’ll want to know if your periods come every month, the dates of recent periods, how long your periods last, and the heaviness of the blood flow.  Your doctor will inquire about your pregnancy and childbirth history, and if  you’ve had an abortion or miscarriage.  She will ask about types of birth control used, and what medications you regularly take.  This  includes over-the-counter medicines, and the use of recreational drugs.

Your doctor will do a pelvic exam to assess vaginal problems such as trauma or an infection.  She may also do a Pap test of your cervix, the visible portion of your uterus.   If are over age 35, a biopsy may be taken during this part of the exam.  Using an instrument that is passed into the uterus via the cervix, a small piece of the uterine lining is removed for examination under a microscope.  Your ovaries and size of your uterus will be evaluated during a bimanual exam, possibly followed by an ultrasound or MRI.

Your doctor may also order the following tests:
• a complete blood cell count, clotting studies, and iron levels
•  thyroid function and other hormone level tests (blood sample)
• urine sample to check for infection
• a pregnancy test

What Can Be Done To Fix The Problem?

Your treatment options will depend on the cause of the bleeding.  For example, if you have developed anemia due to excessive blood loss and your blood pressure is normal, your doctor may recommend a birth control pill to balance your hormones and normalize your periods.  If you have high blood pressure or a clotting disorder that prohibits taking estrogen, your doctor may instead prescribe progesterone pills.  If your bleeding is very heavy, your blood count or blood pressure are very low, and you’re experiencing lightheadedness or heart palpitations, you may need to go to the emergency room.

If your doctor states that it is safe, you may take ibuprofen or naproxen for cramps associated with your periods.  Aspirin is not recommended because it can cause heavier bleeding.  

If medication is ineffective, you may need a hysteroscopy to examine the inside of your uterus.  If the hysteroscopy findings indicate it is appropriate, your doctor may perform an endometrial ablation.  This procedure involves inserting a device through your vagina, cervix, and into your uterus, then applying heat to destroy some of the lining of the uterus.   This procedure is only done if you don’t want to have more children.

A variety of medical and surgical techniques may be used for structural causes of uterine bleeding.  Small polyps and fibroids can be surgically removed while preserving the uterus depending on a woman’s childbearing plans.  Birth control pills and other hormone therapies are used to reduce bleeding caused by larger uterine fibroids.  Management of uterine, cervical or vaginal cancers may include local excision, progestin therapy, or radiation depending on the staging.  If all measures to control uterine bleeding are unsuccessful, surgical removal of the uterus may be considered, called a hysterectomy.

Leah Alexander, MD, FAAP
Leah Alexander, MD, FAAP

Dr. Alexander began her pediatric career at Elizabeth Pediatric Group of New Jersey in 2000, and has practiced at Pediatricare Associates of New Jersey since 2005. After graduating from Kalamazoo College and Michigan State University College of Human Medicine, she completed her pediatric training at Overlook and Morristown Memorial Hospitals. She is board certified in General Pediatrics. In addition to pediatrics, Dr. Alexander pursued her interest the culinary arts with study at the French Culinary
Institute. In 2007, she opened Global Palate, LLC, catering small group events for six years. Dr. Alexander has also been a professional writer and editor since 2018, engaging in a variety of medical editing and writing projects.