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Abnormal Vaginal Bleeding


Lunar and Menstrual Cycles

Abnormal vaginal bleeding can be out of turn or in turn but heavy, prolonged, infrequent or too frequent. Infrequent bleeding rarely has a sinister cause. Classification also depends on whether it happens before or after the menopause. English descriptive phrases such as heavy prolonged cyclical bleeding are preferred in my practice than Latin or Greek names at best are confusing.

Cyclical bleeding in a fertile woman is the usually, but not always, the end of an ovulatory cycle which is controlled by an interaction of hormones produced by a part of the brain and ovaries when fertilisation of the egg has not occurred. Teleologically, the process gives the female more chances of conceiving, as the desire for coitus in humans does not always coincide with ovulation.

The lining of the womb (endometrium) and a small amount of blood is shed every 28 days or so (most women off the pill do not have a 28 day cycle) as the cycle resets. Bleeding typically lasts 3-7 days and on average amounts to 80mls in total, a volume which most healthy women make up before the next period. When the loss is heavier than this over the 3-7 days or over a prolonged period, then anaemia may occur. The cycle is counted from day 1 of a period to day 1 of the next.

Bleeding out of turn is not uncommon in young people and can occur in between periods (inter-menstrual bleeding) or can be triggered by sex (coital bleeding). It can be caused by pathology in the birth canal (including the womb) or changes in the hormone status. Occasionally, bleeding from the rectum or bladder can be mistaken for being vaginal. Any persistent bleeding or bleeding associated with other symptoms such as pain may need investigating.

The menopause is defined elsewhere on this site. Any irregular bleeding around the time leading to the menopause or any bleeding occurring after the menopause (post menopausal bleeding) needs investigation as it could be sinister.

The doctor, or trained nurse, will take a detailed menstrual history followed by a general and internal examination. A smear and swabs may be taken at this time. Bedside tests such as pregnancy test or a vaginal ultrasound scan may also be carried out. Other specialised blood tests or investigations such as a hysteroscopy or biopsy may be arranged.

Pathology is not found in most cases and were it is, it can be benign or if malignant easy to treat. Most advanced cases of lower genital tract cancer are because the patient, or sadly sometime their health advisers ignored the symptoms, often dominated by bleeding.

Management is directed to the cause and may include reassurance, hormones or surgery.