A Patient Journey for Vaginal Bleeding

Menstruation is, of course, a normal part of the lives of most women. It can be difficult, though, to know what’s normal and what needs medical attention when it comes to your menstrual cycle. Abnormal vaginal bleeding can include unusually heavy bleeding during your menstrual cycle (this is called menorrhagia), unusually prolonged bleeding, bleeding between periods, periods occurring irregularly or with unusual frequency, bleeding after sex, bleeding after going through the menopause, and bleeding during pregnancy.

As a rule of thumb, any vaginal bleeding that strikes you as abnormal is worth seeing your doctor about. Abnormal bleeding may be a sign of a number of health conditions, so it’s essential to see a medical professional whenever you notice such symptoms.

Unusually Heavy Bleeding

On average, women will lose around 30 – 40 millilitres of blood during a period; 60 or more millilitres is considered heavy menstrual bleeding . It is not, however, usually practical or necessary to measure the amount of blood you have lost – if you feel that you have needed to use an unusually high number of tampons or pads, if you notice an unusually large flow through to your clothes or bedding, or if you find yourself needing to use both tampons and pads together, that might be an indication that your period is heavier than usual and worth seeing a doctor about.

Unusually Prolonged Bleeding

On the normal menstrual cycle of most women, blood flow will occur for around four days. Some women will usually experience blood flow for a shorter duration; some for longer. If blood flow continues for longer than you are used to, you should see a doctor. You should also see a doctor if your periods regularly include more than a week of blood flow and you’ve never discussed this with a medical professional.

Bleeding Between Periods

You should always see a doctor if you experience any bleeding between periods. Again, it is rare that bleeding is a result of any serious medical condition – common minor causes included being a new user of contraceptive medication, missing contraceptive medications, injury to the vagina as a result of sex or infection, stress, vaginal dryness, and benign changes occurring in the cervix. More serious causes, though, include some sexually transmitted infections (STIs) such as chlamydia, cervical cancer, and womb cancer – this is why it’s imperative to see your doctor if you notice bleeding between your periods.

Periods Arriving Irregularly or Unusually Frequently

Most women’s menstrual cycles take somewhere between 24 and 35 days to complete a full cycle , with their periods coming fairly regular by adulthood. If your periods are slightly irregular, this is not usually any cause for concern, though you should see a doctor if you are worried. You should also see a doctor if your periods are arriving more than once a month.

Bleeding After Sex

Bleeding after sex (‘postcoital bleeding’) is quite common and usually has a benign explanation. It is, however, worth seeing your doctor about, since it can be a symptom of some serious conditions. This is particularly true of older (particularly post-menopausal) women, who should always see a doctor if they notice vaginal bleeding, as below.

Postcoital bleeding might, for example, be caused by a sexually transmitted infection (STI) such as chlamydia, or another kind of infection such as pelvic inflammatory disease. It may also be caused by vaginal dryness (‘atrophic vaginitis’), damage to the vagina caused by childbirth or sex, polyps (usually benign growths) in the cervix or womb, or inflammation on the surface of the cervix. It can also be a sign of pregnancy. In rare cases, it can be a sign of cervical or vaginal cancer.

Bleeding After Menopause

Any bleeding after the menopause – usually defined as any bleeding more than 12 months after your periods have stopped – is quite common, but is always cause for visiting your doctor. One common cause is an inflammation of the lining of the womb, which is easily treated. Sometimes, bleeding can be a side-effect of Hormone Replacement Therapy (HRT). Another cause is cervical or womb polyps, growths on the womb or cervix that are usually benign. About 10% of women who experience post-menopausal bleeding, though, have womb cancer, so it’s essential to visit your doctor as soon as you notice this symptom. Another cause is a thickening of the womb lining called endometrial atrophy, which can also lead to womb cancer if left untreated.

Bleeding During Pregnancy

Around 20% of women experience some bleeding during the first few months of pregnancy . Usually, this is no cause for alarm; it is a common result of some of the normal processes of early pregnancy, such as the implantation of the fertilized egg into the uterus. Nonetheless, it is important to see your doctor or midwife if you notice bleeding during pregnancy, since it can in some cases be a sign of miscarriage or ectopic pregnancy (this is where the fertilised egg implants in the fallopian tube or some other place instead of the womb). Your doctor or midwife will talk to you about your bleeding and any other symptoms you are experiencing, may physically examine you, and will keep a close eye on you going forward.

Bleeding later on in pregnancy is also relatively common. Again, it usually has a benign explanation, but it’s always necessary to inform your doctor or midwife, since it can be a sign of a more serious complication. Minor causes can include normal cervical changes that cause bleeding (particularly after sex), vaginal infections, and ‘shows’ – the dislodging of the plug of mucus that lies in the cervix during pregnancy which can occur a few days before contractions start. More serious conditions that may be indicated include placental abruption (the separation of the placental lining from the uterus prior to delivery – this is very serious and requires urgent medical treatment), low-lying placenta (or ‘placenta praevia’ – where the placenta is attached low down on the womb, near to the cervix), and vasa praevia (in which foetal blood vessels run across the entrance to the birth canal).

Seeing your Doctor

Your doctor will ask you about the nature of the bleeding, whether you are experiencing any other symptoms, and about your medical history. Your doctor may also perform a physical examination such as a pelvic examination, in which the doctor may perform visual examination of your vulva, an internal examination of the cervix and vagina using a speculum, a pap test of your cervical tissue, and a bimanual examination, in which the doctor inserts two gloved lubricated fingers into the vagina while using the other hand to press on the outside of your abdomen). If cancer or another serious condition is suspected, you may be referred to a specialist for further testing.

In many cases, you will also be referred for specialist testing (either at a specialist clinic, or in some cases by your GP), including a vaginal ultrasound (the use of inaudible sound waves to produce an image of the vagina, uterus, ovaries, cervix, and fallopian tubes), an endometrial biopsy (the microscopic examination of tissue removed from the uterus), or a hysteroscopy (a procedure in which a narrow tube is inserted into the vagina in order to provide close-up images of the womb) .

Further Treatment

Treatment will be decided in accordance with the causes of bleeding, which will be established with the above tests. In the case of postmenopausal bleeding, for example, cervical polyps will usually need to be removed; endometrial atrophy can often be treated using creams; and if your bleeding is caused by HRT, your treatment plan may be altered. In the case of womb cancer, you will be assigned a multidisciplinary team of specialists to decide upon the best course of treatment and care for you, which may include surgery, chemotherapy, radiotherapy, and hormone therapy.

You can receive support from the talkhealth community in the gynaecology section of the talkwomen'shealth forum. We also happily recommend the charity Women's Health Concern.