Definition
Intermenstrual bleeding is bleeding from the uterus that occurs between menstrual periods.
Alternative Names
Bleeding between periods; Intermenstrual bleeding; Spotting; Metrorrhagia
Considerations
Normal menstrual flow lasts about 4 days, produces a total blood loss of 30 to 80 ml (about 2 to 8 tablespoons), and occurs normally every 28 days (plus or minus 7 days).
Vaginal bleeding may be something to worry about for women over age 50 (postmenopausal). The risk of malignancy increases with age.
Make sure that bleeding is coming from the vagina and is not from the rectum or in the urine. Inserting a tampon into the vagina will confirm the vagina, cervix, or uterus as the source of bleeding.
A careful exam by your health care provider is frequently the best way to sort out the source of the bleeding. This exam can be accomplished even while you are bleeding. Do not delay getting an exam just because you are currently bleeding.
Common Causes
Uterine fibroids or polyps
Injury or disease of the vaginal opening (caused by intercourse, infection, polyp, genital warts, ulcer, or varicose veins)
Vaginal injury from insertion of foreign objects, from malignancy, or from infection
Dry vaginal walls resulting from lack of estrogen after menopause
Pregnancy complicated by abortion (spontaneous or induced)
Ectopic pregnancy
Fluctuation in hormone levels
Stopping and starting birth control pills or estrogens
Low thyroid function
IUD use (may cause occasional spotting)
Drugs such as anticoagulants
Cervical conization or cauterization procedures
Stress
Home Care
Immediately contact a health care provider if bleeding is very heavy.
The number of pads or tampons used over time should be recorded (so that the amount of bleeding can be determined).
Because aspirin may prolong bleeding, it should be avoided if possible.
Call your health care provider if
You are pregnant
There is any unexplained bleeding between periods
There is any bleeding after menopause
Abnormal bleeding is accompanied by other symptoms
What to expect at your health care provider's office
The medical history will be obtained and a physical examination performed.
Medical history questions documenting vaginal bleeding between periods may include:
Time pattern
When did this bleeding between periods begin?
Does it occur consistently, such as every month?
When (during the course of a menstrual cycle) does this bleeding begin?
How long does the in-between bleeding last?
Quality
Is the bleeding heavy?
How many tampons or pads are required?
Do cramps accompany the bleeding?
Aggravating factors
What makes it worse?
Does increased physical activity make the bleeding worse?
Does intercourse bring on the bleeding?
Is increased stress associated with the bleeding?
Relieving factors
Does anything relieve or prevent it?
Other symptoms
What other symptoms are present?
Do you have abdominal pain or cramps?
Is there increased bruising elsewhere on the body?
Do you have any difficulty, pain or burning with urination?
Is there bloody urine or blood in the stools?
Other important information
Are you pregnant?
Have you had a miscarriage or abortion?
Have you had a D and C?
What medications are you taking?
Are you using tampons? What kind? What size?
At what age did your periods start?
Have there been normal periods without bleeding between in the past?
Are you sexually active?
Is there a history of sexually transmitted disease?
Are you using birth control? What kind?
Have there been any injuries?
Have there been any medical or surgical treatments?
A thorough menstrual history will be obtained and a physical examination performed with an emphasis on the pelvic area. Uterine blood loss can be estimated if the patient knows how many sanitary napkins or tampons were used during a period.
Diagnostic tests that may be performed include:
Urine pregnancy test
Cervical cultures for sexually transmitted diseases
Blood tests for thyroid and ovarian functions.
Pap smear (if not currently bleeding)
Endometrial biopsy
Pelvic ultrasound
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