This document discusses irregular vaginal bleeding, including definitions, causes, evaluation, and management. It provides information on what constitutes normal menstrual cycles and bleeding. Causes of irregular bleeding include hormonal contraceptives, endometrial polyps, fibroids, pregnancy-related issues, infections, and cancers. Evaluation involves history, examination, Pap smear, ultrasound, and sometimes hysteroscopy. Management depends on persistence and severity of bleeding, with referral indicated for persistent irregular bleeding after initial evaluation and treatment.

1. IRREGULAR
vaginal bleeding
Masoud Moghaddam
20/1/2015

2.  A normal menstrual pattern is taken to be a ‘monthly bleed’. The cycle length can
vary, with a generally accepted normal range of 21-35 days and a bleeding
duration of 4-7 days.
 Irregular bleeding can consist of intermenstrual bleeding with a flow similar to
that of a menstrual period. It can be ‘spotting’ that is noted as stains on the
underwear or after toileting.
 It also includes postcoital bleeding and postmenopausal bleeding.
 Amenorrhoea and menorrhagia may occur as part of the irregular menstrual
pattern
Background

3.  It is important to understand that menstrual patterns that do not conform to the
regular cycling discussed above can be a normal occurrence
 The age of the woman is a critical factor in assessing the need to investigate or
manage an irregular menstrual pattern.
 In both puberty and the perimenopause, these transitional phases anovulatory
cycles occur, leading to failure to establish a distinct ‘withdrawal’ menstrual
bleed.
Irregular bleeding — what can be
normal?

4.  In periovulatory bleeding, bleeding or spotting can occur at ovulation, about 14
days before the following menstrual period.
 If there is a luteal phase defect, spotting can occur premenstrually each month,
said to be due to a lack of progesterone.

5.  The incidence of irregular bleeding is low overall, and the incidence of significant
pathology is also low
 In a study of menstruation in 621 normal women over 20,672 cycles,
intermenstrual bleeding was reported in 100 cycles (39 women; 6.3% of the
women studied and 0.5% of cycles studied). These women were all investigated
and no pathology was found.
How common is irregular
vaginal bleeding?

6.  A study looking at referrals to a gynaecology department for postcoital bleeding
reviewed the records of 248 women referred over a five year period and found
that benign polyps (including endometrial polyps) were found in 20% of cases,
25% had a cervical ectropion, while cervical intraepithelial neoplasia was detected
in 6.8% of cases

7. General
 Contraceptives — hormonal contraceptive methods and intrauterine devices
 Menopausal hormone therapy, including with tibolone, in a woman with an
intact uterus
 Endometriosis — may cause pre- and postmenstrual spotting. Generally presents
with dysmenorrhoea, which worsens with time
Causes of irregular bleeding

8. Uterine
 Endometrial polyps
 Endometrial hyperplasia
 Fibroids — generally cause menorrhagia but can present with intermenstrual
bleeding
 Pregnancy — ectopic, early pregnancy loss
 Endometritis — postnatal and postsurgical
 Endometrial/myometrial malignancy

9. Lower genital tract
 Cervical ectropion
 Cervical polyps
 Cervicitis
 Cervical malignancy

10. Relation of age to common causes of
irregular bleeding

11.  This is the most common invasive gynaecological cancer in Australia, ranking
sixth in terms of incident cancers in women
 It results in about 1400 new cases and 260 deaths every year
 Risk increases with age. It is most commonly diagnosed in women aged 50-70
and is rare in those under 40.
 Risk factors include age >40, weight >90kg, prolonged exposure to endogenous
or exogenous unopposed oestrogen.
Endometrial hyperplasia and
carcinoma

12.  The incidence of cervical cancer in Australia has been dramatically reduced as a
result of the cervical screening program.
 Guidelines for Referral for Investigation of Intermenstrual and Postcoital
Bleeding, by the Royal Australian and New Zealand College of Obstetricians and
Gynaecologists (RANZCOG)
Cervical cancer

13.  IMB is vaginal bleeding at any time other than during normal menstruation or
following intercourse.
 IMB is common, especially in women using hormonal contraception or hormonal
therapies. It is impractical and unnecessary to refer every woman with a single
episode of IMB for immediate investigation. Women at risk of sexually
transmitted infection should have appropriate tests performed. Women with
persistent IMB should have a cervical Pap smear, a transvaginal ultrasound and
referral to a gynaecologist for further assessment.
IMB

14.  PCB is vaginal bleeding after intercourse
 PCB is regarded as a cardinal symptom of cervical cancer and the commonest
presenting symptom for Chlamydia. Therefore women complaining of PCB
should have tests to exclude this. It is commonly accepted that a single episode
of PCB in a woman who has a normal smear and cervical appearance does not
warrant immediate referral, but recurrence or persistence of this symptom
mandates colposcopic examination.
PCB

15.  The woman’s age and stage of reproductive life.
 History of bleeding (how often, what time of the month, postcoital, etc).
 Risk of pregnancy/recent delivery/recent gynaecological surgery or instrumentation.
 Use of hormonal therapy and contraceptive history.
 Previous abnormal Pap tests.
 Sexual history, including risk for sexually transmissible infections, and relevant partner
history.
 Previous history of STIs
History

16.  Ectropion and contact bleeding on the cervix
 Friability of tissue or ulceration of the cervix
 Presence of cervical polyps
 Other possible sites of bleeding
 Signs of vaginal discharge, foreign body or IUD tail
 If pregnant, whether the cervical os is open or closed
 Tenderness on rocking the cervix
 Size of the uterus
 Adnexal masses/tenderness
Examination

17.  If the patient has not had a Pap smear within the previous three months, take a
Pap smear using the speculum carefully so as not to provoke further bleeding.
 The occurrence of contact bleeding or abnormal bleeding in the case history
should be noted on the request form.
 Cervical swabs should be taken for Chlamydia trachomatis if appropriate
Investigations

18.  can be a useful additional test in investigating abnormal bleeding when an
endometrial cause is suspected.
 Focal thickening of the endometrium can be suggestive of polyps, and
submucosal fibroids may distort the endometrial stripe, while global thickening
of the endometrium can be indicative of hyperplasia, and gross myometrial
involvement is suggestive of malignancy.
 Saline infusion sonohysterography (SIS) can clarify the contours, symmetry and
thickness of the endometrium.
Ultrasound imaging

19.  The sensitivity of SIS can be similar to that of hysteroscopy. In experienced
hands it has been found to have a sensitivity of 80-100% and a specificity of 76-
96% for detecting intrauterine pathology.
 A more recent technique is hysterosalpingo-contrast sonography

20. Algorithm for investigating intermenstrual and
postcoital bleeding

21.  WOMEN with persistent bleeding — even if Pap smears and other tests are
normal and regardless of whether or not an ectropion is present — should be
referred for specialist opinion
 In general, a hysteroscopy/D&C by a specialist should be the primary procedure
in women with persistent intermenstrual bleeding, while colposcopy should be
the primary procedure with persistent postcoital bleeding or if a suspicious
lesion is present on the cervix. Both investigations may be required.
Management and referral

22.  If the patient has minor intermittent episodes of bleeding (ie, not ‘persistent’)
they should be referred for colposcopy even if the smear report suggests the
presence of CIN-1 (low-grade squamous intraepithelial lesion [LSIL]) or a higher
grade abnormality or the presence of any glandular abnormality.
 If bleeding is persistent, immediate referral is needed
 It is not possible to give a simple and all-encompassing definition of ‘persistent’
but, for example, several minor episodes over a three-month period, or two
episodes of heavy bleeding, should generally prompt referral

23.  Women with intermenstrual bleeding who are on the progestogen-only minipill
or in the first six months of Depo-Provera treatment (often called break-through
bleeding) should generally not be referred in the first instance unless bleeding is
excessively frequent or prolonged, and provided Pap smears are normal and up
to date.

24.  When a woman presents with a history of postmenopausal bleeding (more than
12 months since menopause), referral should be made for transvaginal
ultrasound. If the ultrasound reveals that the endometrial stripe is homogenous
and uniformly 5mm or less, no further evaluation is generally required. The
likelihood of missing a significant endometrial abnormality is very low (0.1% in
HRT users and 1% in non-users).

25.  Tamoxifen can increase the risk of endometrial cancer. When a woman taking
tamoxifen presents with postmenopausal bleeding, prompt referral should be
made for transvaginal ultrasound, as above.
 A postmenopausal woman with a normal transvaginal ultrasound report and
persistent bleeding should be further investigated by hysteroscopy/
D&C/endometrial biopsy.

26. A 22-YEAR-old woman presented to a gynaecologist with breakthrough bleeding while
using the combined OCP. A Pap test was done and reported as normal. Several times over
the following year the patient presented to a GP, with a history of intermittent
breakthrough bleeding and postcoital bleeding while taking the pill. A repeat Pap test
reported monilia and mild squamous atypia, possibly due to inflammation, with a
recommendation to repeat in 3-6 months. The patient continued to note variable
postcoital bleeding and presented to another GP. She was then referred to a
gynaecologist. The gynaecologist found an eroded and friable cervix with contact
bleeding. Biopsy confirmed malignancy. Review of the previous Pap test indicated
abnormal cells, including CIN 3. The patient went on to have a radical hysterectomy for
stage 1b carcinoma of the cervix. Despite further surgery, radiotherapy and
chemotherapy over several years, she died of metastatic disease.
Cervical cancer: a cautionary tale