Inter-menstrual, Irregular Bleeding (metrorrhagia), Post-Coital Bleeding

Postcoital bleeding is non-menstrual bleeding that occurs immediately after sexual intercourse. Intermenstrual bleeding refers to vaginal bleeding (other than postcoital) occurring at any time during the menstrual cycle other than during normal menstruation. It can sometimes be difficult to differentiate true intermenstrual bleeding from metrorrhagia, which is vaginal bleeding at irregular intervals, particularly between the expected menstrual periods. Polymenorrhea (too frequent periods): is the term used to describe a condition when women have periods at much shorter intervals, usually less than 21 days apart, and periods may not be regular or predictable either. Polymenorrhea is different from metrorrhagia. It is an actual menstrual period that occurs shortly after the last one.

Causes:

Women who are ovulating normally can experience light bleeding (sometimes referred to as mid – cycle or ovulation “spotting”) between menstrual periods. Oral contraceptive pills, minipills or patches, as well as some intra-uterine contraceptive devices (coils) may sometimes lead to light bleeding between periods. Psychological stress, certain medications such as anticoagulant drugs, and fluctuations in hormone levels may all be causes of light bleeding between periods. Also irregular menstrual cycles, may occur first, before the onset of true menopause. It is important to understand that these are not diagnoses, but symptoms, which need further investigation or assessment. For example, conditions of the cervix, such as cervical ectopy (commonly called cervical erosion), benign growths in the cervix, such as cervical polyps, infections of the uterus (endometritis) and or cervix (cervicitis), may also be associated with intermenstraul and or post-coital bleeding. Genital tract malignancies (cancer of the cervix, womb or vagina) are uncommon causes of post-coital and/or intermenstrual bleeding are rare causes in young women. (see below).

Other causes include those pregnancy-related ones, such as ectopic pregnancy, undiagnosed threatened miscarriage and molar pregnancy, progesterone-only pills, Emergency contraception, Tamoxifen, Following smear or treatment to the cervix, Drugs altering clotting parameters, e.g. anticoagulants, SSRIs, corticosteroids, Alternative remedies, e.g. ginseng, ginkgo, soy supplements, and St John’s wort, Vaginitis, Infection – chlamydia, gonorrhoea, cervical warts, Endometrial polyps, and oestrogen-secreting ovarian cancers.

Diagnosis: It is helpful if you have detailed information of your menstrual bleeding. Be prepared for questions, such as when was your last menstrual period and was the last period ‘normal’. Do you suffer from heavy periods? Are your periods regular and what is the length of your cycle? When is the timing of bleeding in the menstrual cycle? Are there associated symptoms, e.g. abdominal pain, fever, vaginal discharge or painful sex? Your doctor may also ask you about your previous pregnancies and deliveries, the type of contraceptive method you use, and your last cervical smear test information. Do not feel offended, if information is requested on your sexual activities, and your partners’ or if you have had sexually transmitted infection in the past. Information about other conditions for which you may or may not be taking medications, could also be relevant, such as; bleeding disorders.

Your doctor will perform general examination and that of the abdomen and vagina, a swab may be taken. It will be quite obvious if you have swelling in the abdomen, womb, and pelvis; or if you have any ulcers, erosion, polyps, discharge, cervical ectropion, cervicitis, and any special areas that are tender will be noted. Tests such as pregnancy test, vaginal swabs, blood count, thyroid function tests, and if necessary, hormonal profile, ultrasound scan of the pelvis and thickness of the linning of the womb, may be requested. Depending on whether you see a gynaecologist or your doctor, a biopsy of the lining of the womb, may also be done, so also is a hysteroscopy (telescope inspection of the inside of the womb.)

Treatment Options for Intermenstrual Bleeding

The most important step is to treat the underlying cause of the bleeding. It is helpful if you keep a menstrual chart, to monitor the improvement from cycle to cycle.

• Infection: Your doctor or gynaecologist will prescribe antibiotics that are most suitable initially, while waiting for the results of the vaginal swab test. If there is likelihood of sexually transmitted infection, it may be neceesary to also treat your partner, to avoid re-
• Bleeding from Hormonal Contraception: It is quite common to bleed at the begining of use of oral contraceptives, and Mirena intra-uterine system. If the bleeding persists for longer than three or six months depending of the hormonal contraception in use, or if the woman is older than 45 yrears, or is not up to date with her cervcial screening, appropriate steps will need to be taken. For contraceptive pills user, the options is to continure use for a slightly longer time, or to change the pill, or adjust the relative amount of the pill being taken. For progestogen – only implants, depots and IUS users, adding an oral combined oral contraceptive pill may help.
• Cervical ectropions / Cervicitis: The options for intermentriual bleeding caused by cervical ectopy is to withdraw the use of the combined pill or to treat it by freezing or cauterising the area involved with electro-cautery and diathermy, cryosurgery or laser. Electrocautery of secondarily infected Nabothian follicles is sometimes performed for chronic cervicitis.
• Cervical polyps: Polyps should be avulsed and sent for histology. It may still be necessary to perform an ultrasound, and possibly a hysteroscopy, to rule out the presence of associated endometrial polyp.