Abnormal Vaginal Bleeding

You may assume that bleeding between periods, after sex or after menopause is simply another variation of menstruation. Abnormal vaginal bleeding has many non cancerous causes, but the timing in relation to pregnancy, sex, contraception and menopause determines how urgently it should be assessed.

Abnormal bleeding is bleeding outside the expected pattern This may include bleeding between periods, bleeding after sex, bleeding after menopause, unexpected bleeding on contraception or HRT, bleeding during pregnancy, bleeding after a gynaecological procedure, blood stained discharge, or bleeding from the vulva or vagina. Most causes are not cancer, but bleeding between periods or after sex should always be checked. First confirm where the blood came from Blood noticed in underwear or the toilet may come from the vagina, cervix, womb, vulval skin, urinary tract, or rectum. Tell the clinician whether blood appeared during urination, on wiping, mixed with stool, after sex, with vaginal discharge, or at an expected period time. You do not need to determine the source alone. Pregnancy must be considered If pregnancy is possible, take a pregnancy test. Bleeding in early pregnancy may occur with a continuing intrauterine pregnancy, miscarriage, ectopic pregnancy, cervical changes, infection, or other pregnancy related conditions. The colour or amount cannot reliably establish the cause. Any pregnancy bleeding should be discussed with the maternity or early pregnancy service according to local arrangements and symptom severity. Ectopic pregnancy may cause bleeding that is light, intermittent, dark brown, watery, or different from your usual period. Possible accompanying symptoms include one sided pelvic pain, shoulder tip pain, pain when opening your bowels, dizziness, faintness, or collapse. Call 999 for severe pain, shoulder tip pain, collapse or marked faintness. Miscarriage can cause light spotting, bleeding similar to a period, heavy bleeding, clots, cramping, or passage of tissue. Bleeding does not always mean miscarriage, and symptoms alone may not determine whether a pregnancy is continuing. Early pregnancy assessment may involve ultrasound and repeat pregnancy hormone tests. Bleeding after the first trimester can arise from cervical changes, infection, placental problems, labour, or other pregnancy complications. Contact maternity triage urgently for any bleeding later in pregnancy. Call 999 when bleeding is heavy or accompanied by severe pain, faintness, collapse or reduced consciousness. Bleeding between periods has several possible causes Possible causes include hormonal contraception, ovulation related spotting, pregnancy, cervical ectropion, cervical or uterine polyps, infection, fibroids, endometrial abnormalities, trauma, or cancer. The pattern, duration, pregnancy possibility and associated symptoms guide assessment. Bleeding after sex is called postcoital bleeding Possible causes include cervical ectropion, cervical polyp, vaginal dryness, infection, trauma, cervical cell changes, or cervical, vaginal or endometrial cancer. One episode may have a benign explanation, but assessment is advised because the source cannot be determined safely from symptoms alone. Cervical ectropion occurs when delicate glandular cells are present on the outer surface of the cervix, and may be associated with pregnancy, combined hormonal contraception, younger age, or increased hormonal exposure. These cells can bleed after contact. The diagnosis requires examination and should not be assumed before the cervix has been assessed. Cervical screening does not investigate symptoms A cervical screening test is designed to identify high risk HPV and prevent cervical cancer in people without symptoms. It is not a diagnostic test for bleeding after sex, bleeding between periods, pelvic pain, or abnormal discharge. Do not wait for a screening invitation when symptoms are present. You need a clinical assessment. A recent normal screening result does not exclude every cause of bleeding. Infection can cause bleeding Possible infections include chlamydia, gonorrhoea, trichomoniasis, cervicitis, or PID. Associated symptoms may include abnormal discharge, pelvic pain, pain during sex, urinary burning, or bleeding after sex. Testing should be confidential and non judgemental. Contraception commonly produces unscheduled bleeding Irregular bleeding may occur after starting or changing combined pills, progestogen only pills, implants, injections, or hormonal intrauterine systems. Other factors still require consideration: pregnancy, missed doses, drug interactions, infection, cervical disease, expulsion or displacement of an intrauterine device, or a new unrelated bleeding problem. Do not stop contraception without considering pregnancy prevention and obtaining advice. The copper intrauterine device can make periods heavier or more painful. Bleeding between periods, severe pain, fever or pregnancy symptoms may require examination of the device position and assessment for infection or pregnancy. HRT can cause unscheduled bleeding Bleeding patterns depend on the type of HRT. Sequential HRT is designed to produce a planned withdrawal bleed. Continuous combined HRT is intended to become bleed free after an adjustment period. Unscheduled bleeding can occur during the first six months after starting HRT, or within three months after changing the dose or preparation. When bleeding is light, there are no important endometrial cancer risk factors and adherence is correct, the initial response may include reviewing the regimen and adjusting the progestogen or preparation. Urgent transvaginal ultrasound, normally within six weeks, is recommended when bleeding first begins more than six months after starting HRT, more than three months after a change, is heavy or prolonged, or when risk factors increase concern. Some higher risk combinations require an urgent suspected cancer pathway rather than ultrasound alone. Bleeding that persists despite an appropriate period of HRT adjustment also requires investigation. Do not assume all bleeding on HRT is expected. Postmenopausal bleeding always needs assessment Postmenopausal bleeding means bleeding after you have gone 12 months without a natural period. It includes one spot, pink discharge, brown discharge, bleeding after sex, or light or heavy bleeding. Common causes include thinning of the vaginal or womb lining and polyps. Cancer is less common but must be excluded. GP assessment is advised even when the bleeding occurred once or you are unsure whether it was blood. Suspected cancer referral is recommended for unexplained postmenopausal bleeding not attributable to HRT in people aged 55 or over. For those under 55, the same referral pathway should be considered. Bleeding on HRT requires individual assessment using the bleeding pattern and specialist guidance. These pathways do not mean that cancer is likely or already diagnosed. They ensure timely investigation. Vaginal dryness, polyps and fibroids After menopause, during breastfeeding or with some hormonal treatments, vaginal tissues may become thin, dry and less elastic, causing soreness, burning, pain during sex, small tears, or light bleeding. The clinician should still assess the source before attributing bleeding to dryness. Polyps may cause bleeding between periods, bleeding after sex, heavy periods, or blood stained discharge. Fibroids more commonly cause heavy periods and pressure but can also contribute to irregular bleeding. Ultrasound or hysteroscopy may be offered according to the pattern. Cancer symptoms often overlap with benign conditions Cervical, endometrial, vaginal and vulval cancers can cause bleeding after sex, bleeding between periods, postmenopausal bleeding, blood stained discharge, pelvic pain, or a visible lesion or lump. Most people with these symptoms do not have cancer. The appropriate response is prompt assessment rather than either reassurance or assumption. Bleeding from the vulva requires examination. Possible causes include skin inflammation, trauma, infection, ulceration, a vulval skin condition, or cancer. Suspected cancer referral is advised for unexplained vulval lump, ulceration or bleeding. Medicines can worsen bleeding Possible contributors include anticoagulants, antiplatelet medicines, tamoxifen, or hormonal medicines. These medicines can increase bleeding but do not identify its source. Do not stop them without clinical advice. Assessment, examination and testing Your clinician may ask when bleeding happened, whether it was related to sex, whether you could be pregnant, when your last natural period was, which contraception or HRT you use, whether there is pain or discharge. Whether bleeding is heavy, whether you have missed medication doses, whether cervical screening is up to date, whether you take tamoxifen or anticoagulants, and whether you have recently given birth or had a procedure. Possible assessment includes checking pulse and blood pressure, abdominal examination, looking at the vulva, speculum examination of the vagina and cervix, internal pelvic examination, pregnancy testing, infection swabs, or blood tests. You should receive an explanation and give consent. Depending on the presentation, tests may include pelvic ultrasound, transvaginal ultrasound, hysteroscopy, endometrial biopsy, colposcopy, or cervical biopsy. Each test answers a different question. A normal cervical screening result does not replace these investigations.

Abnormal vaginal bleeding is classified by timing: bleeding during possible pregnancy, bleeding between periods, bleeding after sex, unscheduled bleeding while using hormones, bleeding after menopause, and bleeding following a procedure, injury or childbirth. This timing directs the safest investigation pathway.