A patient journey for vaginal bleeding

For many women, periods play a huge role in our lives. Disruptions to that bleeding cycle are often early signs that something is amiss or changing inside - whether that's pregnancy, the approach of the menopause or other kinds of hormonal shifts. 

As with so many other things, knowing what's normal for you is key. Some women bleed heavily while others don't; if you're someone who tends to have very light, regular periods and you suddenly start to experience heavy, unpredictable bleeds, it's worth getting checked out. 

Abnormal vaginal bleeding includes anything that's out of your usual pattern. It can include unusually heavy bleeding during your menstrual cycle (this is called menorrhagia), unusually prolonged bleeding, bleeding between periods, irregular or unusually frequent periods, bleeding after sex, bleeding after going through the menopause and bleeding during pregnancy.

While there can be very simple explanations for unusual bleeding, it can also be a symptom of underlying health conditions - which is why it's so important to see a medical professional. 

Unusually heavy bleeding

On average, women will lose around 30-40ml of blood during a period; 80ml+ is considered to be heavy menstrual bleeding. Most of us don't measure how much blood we lose because there are other, easier ways of quantifying heavy bleeding. Do you get through an unreasonably high number of tampons/pads? Do you have to empty your menstrual cup often? Do you regularly bleed onto your clothes or bedding? If so, it might be worth chatting to your GP or practice nurse about the velocity of your flow. 

Unusually prolonged bleeding

Most menstrual cycles last anywhere between three and seven days. If your period regularly lasts for longer than a week, make a GP appointment.

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 – random spotting might be caused by a change of contraception, missing contraceptive pills, vaginal dryness, injury or benign changes in the cervix. Saying that, however, bleeding can be a sign of STIs or certain types of gynecological cancers. Whatever you think might be the cause, get yourself checked out by your GP anyway!

Irregular or unusually frequent periods

Loads of women experience irregular periods. That's totally normal for many of us, while things like polycystic ovarian syndrome, stress, weight changes, contraception and travel can all impact on when we get our periods. However, if you're going months without a period or are bleeding more than once a month, it's worth talking to a medical professional. At the very least, they may be able to help make your life easier by helping you work towards more regular, predictable bleeding. 

Bleeding after sex

Bleeding after sex (postcoital bleeding) is quite common and usually has a harmless explanation. But it can also be a sign of something more serious which is why it's really important that you see your GP if you notice it happening. Causes can include pelvic inflammatory disease, STIs, vaginal dryness, damage caused by childbirth or tears caused during sex, polyps and in very rare cases, cervical or vaginal cancer.

Bleeding after menopause

While it's common to bleed more than 12 months after your periods have officially stopped, it's not normal or something that you should ignore. One common cause of postmenopausal bleeding 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). Cervical or womb polyps (non-cancerous growths) can also cause spotting. However, about 10% of women who experience postmenopausal bleeding have womb cancer - so it’s essential to visit your doctor as soon as you notice this symptom. Read more about the menopause.

Bleeding during pregnancy

Around 20% of women experience some bleeding during the first 12 weeks of pregnancy. Usually, this is no cause for alarm; it's a common side effect of early pregnancy. Despite that, it's still important to see your doctor or midwife if you notice bleeding because it can be a sign of miscarriage or ectopic pregnancy. Your healthcare professional will talk to you about your symptoms before potentially suggesting a physical examination.

Bleeding later on in pregnancy is less common and you should treat it more seriously. Make an appointment to speak with your doctor or midwife as soon as possible. In some cases, it may be due to 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), low-lying placenta (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). All of these need serious and urgent medical attention. And it could also be a sign that labour will begin soon; if this happens before 37 weeks of pregnancy seek advice from your midwife immediately.

Seeing your doctor

Your doctor will ask you about the nature of the bleeding (how long it has been going on for, whether there are activities which make it worse), what other symptoms you may be experiencing and a little about your medical history. They may also perform a physical examination, during which they might want to look at your vulva and do an internal examination of the cervix and vagina using a speculum (similar to having a smear test, the speculum holds open the walls of the vagina so that the cervix can be clearly seen). During this procedure, your doctor may decide to take a swab of the cervical tissue to test for any abnormalities. You may also be subject to a bimanual examination (where the HCP inserts two gloved and 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.

It's perfectly normal to be referred for specialist testing, whether that's for a vaginal ultrasound (where they scan for images of your reproductive organs), endometrial biopsy (bits of tissue are taken from the uterus for examination or hysteroscopy (a procedure in which a narrow tube is inserted into the vagina in order to provide close-up images of the womb). Being referred for these kinds of checks does not automatically mean that you have cancer or any other serious condition, so try to stay calm. 

Further treatment

Treatment will depend on what is causing your abnormal vaginal bleeding. Seeking advice from your doctor or specialist is crucial, as is knowing what's normal for you.  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 (MDT) 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 talkwomenshealth forum. We also recommend that you check out the charity Women's Health Concern.

_{Last revised: 20 October 2016}