Vaginal bleeding between periods

Bleeding or spotting between periods can be associated with the following signs and symptoms:

• Heavy periods (menorrhagia)
• Irregular periods
• Periods lasting more than 7 days
• Menstrual cycles longer than 35 days or shorter than 21 days
• Bleeding after intercourse
• Bleeding during pregnancy
• Bleeding after menopause

How are normal and abnormal vaginal bleeding different? Tap here to know.

Bleeding between periods can be caused by an array of factors. PALM-COEIN is an acronym provided by the International Federation of Obstetrics and Gynecology (FIGO) to classify the underlying causes of abnormal uterine bleeding.

• P: Polyp (small, abnormal growth)
• A: Adenomyosis (a condition where the tissue lining the uterus grows into the uterus)
• L: Leiomyoma (known as a fibroid, is a noncancerous growth of the uterus)
• M: Malignancy (cancer) and hyperplasia (excessive tissue growth)
• C: Coagulopathy (impaired blood clotting)
• O: Ovulatory dysfunction (a condition where the ovaries do not release eggs regularly)
• E: Endometrial disorders (medical conditions affecting the lining of the uterus)
• I: Iatrogenic (health problems caused accidentally by medical treatment)
• N: Not otherwise classified

A woman with one or more of these listed conditions can experience abnormal vaginal bleeding. The various risk factors associated with these conditions are described in detail in the next section.

1. Hormonal Changes

• Polycystic ovary syndrome (PCOS): A common cause of menstrual irregularities, including spotting between periods.
• Hypothyroidism: An underactive thyroid gland can disrupt regular menstrual cycles and increase the risk of abnormal vaginal bleeding.
• Hyperthyroidism: An overactive thyroid gland is a common risk factor for abnormal uterine bleeding among reproductive-age women.
• Use of Oral Contraceptive Pills: Spotting or bleeding between periods (breakthrough bleeding) is a common effect during the first few months of use.
• Being Underweight or Obese: Weight affects the body's hormonal balance; thus, being overweight, underweight, or experiencing sudden weight changes can trigger irregular bleeding.
• Hormone Replacement Therapy (HRT): Breakthrough bleeding and spotting are common during the initial stages of HRT or when the dose is adjusted.

2. Infections

• Vaginitis: Inflammation of the vagina that can result in discharge, itching, pain, and spotting between periods.
• Cervicitis: Irritation or infection of the cervix, with bleeding between periods as a common symptom.
• Pelvic Inflammatory Disease (PID): An infection of the upper reproductive organs, including the uterus, fallopian tubes, and ovaries, leading to irregular menstrual periods.
• Endometriosis: A condition where tissue that normally lines the uterus grows outside the uterine cavity, causing pain, heavy bleeding between periods, and infertility.
• Sexually Transmitted Infections (STIs): Infections like Gonorrhea and Chlamydia can cause bleeding between periods.

3. Pregnancy Complications

• Miscarriage: Loss of pregnancy before the 20th week can cause vaginal bleeding or spotting.
• Ectopic Pregnancy: A pregnancy occurring outside the uterus, with vaginal bleeding and pelvic pain as early warning signs.
• Placental Abruption: Separation of the placenta from the inner wall of the uterus before birth, causing light, intermittent vaginal bleeding.
• Placenta Previa: A condition where the placenta blocks all or part of the baby's exit from the vagina, with vaginal bleeding as a common symptom.
• Premature Labor: Labor starting before 37 weeks of pregnancy can cause abnormal vaginal bleeding.

4. Noncancerous Growths and Other Uterine Conditions

• Uterine Fibroids: Non-cancerous growths from the muscle tissue of the uterus that may stimulate blood vessel growth, contributing to spotting between periods.
• Uterine Polyps: Overgrowth of cells in the lining of the uterus, usually not cancerous, though some can develop into precancerous polyps.
• Adenomyosis: A condition where endometrial tissue grows into the muscular wall of the uterus.
• Cervical Polyps: Benign growths protruding from the surface of the cervical canal.

5. Cancers and Precancerous Conditions

• Cervical Cancer: Vaginal bleeding is often the first noticeable symptom, typically occurring after intercourse.
• Endometrial Hyperplasia: A precancerous condition causing irregular thickening of the uterine lining, leading to heavy or abnormal bleeding.
• Vaginal Cancer: May present with unusual vaginal bleeding after intercourse.
• Uterine Sarcoma: A cancer starting in the muscle and supporting tissues of the uterus, leading to unusual vaginal bleeding.

6. Medical Conditions

• Celiac Disease: A chronic digestive and immune disorder that can lead to spotting between periods.
• Von Willebrand Disease (VWD): A blood disorder where blood does not clot properly, commonly causing heavy menstrual bleeding and abnormal bleeding between periods.

7. Certain Medications

• Blood Thinners and Aspirin: Women taking these medications may experience irregular, infrequent bleeding between periods.
• Tamoxifen: A drug prescribed for breast cancer treatment that may cause side effects like bloody or unusual vaginal discharge.

8. Other Factors

• Vaginal Dryness: Friction and irritation in the vaginal tissue may lead to small tears and spotting between periods.
• Injury to the Vagina: Can occur during sexual activity or from certain products, damaging the delicate vaginal tissue and causing bleeding.
• Stress: Elevated cortisol levels from stress can impact sex hormone production, potentially causing spotting.

1. Medical history A comprehensive and detailed medical history, including menstrual, reproductive, sexual, associated symptoms, and social factors, is taken by the doctor to identify the cause of vaginal bleeding between periods.
2. Physical examination During a general examination, the doctor assesses vital signs, checks for signs of anemia, endocrine disorders, and clotting disorders, and conducts a pelvic examination to identify potential causes of abnormal uterine bleeding.
3. Lab tests
   • Complete Blood Count (CBC): Identifies low red blood cell count and potential underlying causes.
   • Blood pregnancy test (HCG Beta Total Maternal): Measures hCG levels in pregnant women's blood, helping identify hormonal changes and potential causes of bleeding, including miscarriage or early pregnancy-related issues.
   • Thyroid tests: Diagnose any imbalance in thyroid hormones, a potential cause for bleeding between periods.
   • Urine analysis: Checks for the presence of human chorionic gonadotropin hormone (HCG) in the urine, which can indicate early pregnancy.
   • Progesterone and Estrogen test: These hormones regulate the menstrual cycle, and their imbalance can cause irregular bleeding.
   • Coagulation panel: Measures the blood's ability to clot and the time it takes to clot, as problems with clotting can lead to vaginal bleeding between periods.
   • Pap smear: A procedure used to test for cervical cancer by collecting cells from the cervix, helping detect abnormal cells before they become cancerous and cause vaginal bleeding.
4. Imaging tests
   • Transvaginal ultrasound: Involves inserting a small ultrasound probe into the vagina to produce detailed images of the pelvic organs; it is the first-line imaging test for evaluating abnormal uterine bleeding.
   • Lower abdomen ultrasound: Uses sound waves to visualize the inside of the uterus to detect any fibroids or polyps.
   • Magnetic resonance imaging (MRI): A non-invasive imaging technology that produces three-dimensional detailed anatomical images of the uterus.
   • Hysteroscopy: A procedure used to examine the inside of the womb (uterus) with a hysteroscope, allowing for diagnosis and treatment of the causes of abnormal bleeding.
   • Saline infusion sonography: Saline is infused into the uterus for a clearer ultrasound image, enhancing the detection of small abnormalities.
5. Endometrial biopsy An endometrial biopsy is considered the first-line test in women with abnormal uterine bleeding who are 45 years or older. This test is usually performed on women who are at high risk for hyperplasia or malignancy.

Though all cases of bleeding between periods cannot be prevented, here are some preventive measures that can help:

• Regulate your hormones: Prevent hormonal imbalances by focusing on a balanced diet and maintaining a healthy weight. Replace processed, packaged junk food with nutritious options.
• Avoid heavy exercises: Intense workouts and heavy physical exercises can cause exertion in the pelvic area, which may result in spotting in some women.
• Include iron in the diet: Iron is essential for maintaining healthy blood cells and preventing excessive bleeding. A lack of iron can lead to conditions like anemia, increasing the risk of abnormal bleeding. Consume foods rich in iron, such as bananas, beans, and spinach. You may also consider iron supplements after consulting your doctor to cover any gaps in your diet.
• Manage stress effectively: Stress can result in spotting and other menstrual changes. Therefore, effective stress management is an important preventive measure for bleeding between periods.
• Practice safe sex: This can reduce the risk of certain sexually transmitted infections (STIs) that can cause vaginal bleeding between periods.

The treatment is based on what is causing the vaginal bleeding between periods. It includes:

1. Lifestyle modifications
   • Maintain a healthy weight through diet and exercise
   • Stay hydrated and eat a balanced diet
   • Incorporate iron-rich foods in your diet
   • Avoid consumption of alcohol and tobacco
   • Limit caffeine intake
   • Manage stress by practicing relaxation techniques
   • Follow a regular sleep schedule
   • Avoid excessive physical strain
2. Medications
   • Birth control pills: These are used to regulate hormonal imbalances causing irregular bleeding. Estrogen and progesterone (combination birth control pill) is the most commonly used drug.
   • Progesterone: It is effective in preventing or treating excessive bleeding, especially in women with irregular ovulation. Examples include:
     • Medroxyprogesterone acetate
     • Norethindrone acetate
   • Gonadotropin-releasing agonists: These are effective in the long-term treatment of women with abnormal uterine bleeding. A few examples of GnRH agonists are:
     • Goserelin
     • Leuprorelin
     • Leuprolide
   • Tranexamic acid: It is an effective treatment for irregular uterine bleeding as it prevents excessive bleeding, particularly in cases of hormonal imbalance or heavy menstrual flow.
   • Non-steroidal anti-inflammatory drugs: They are given to reduce blood loss and cramping. Commonly used drugs are:
     • Ibuprofen
     • Naproxen
3. Intrauterine device (IUD): Progestin-releasing IUDs are recommended for abnormal uterine bleeding. They reduce menstrual blood loss, alleviate pain, and may even stop periods altogether.
4. Surgery: It could be an option if vaginal bleeding between periods is due to some noncancerous uterine growth such as a polyp, fibroid, or thickening in the endometrium. It includes:
   • Dilation and curettage (D&C): It is a procedure to remove abnormal tissue from inside the uterus. The cervix is dilated (opened) so that the uterine lining (endometrium) can be scraped with a curette (spoon-shaped instrument).
   • Endometrial ablation: It is a procedure that destroys the lining of the uterus. This is recommended for bleeding between menstrual periods, having a heavy flow, or having periods that last a long time. Note: In several cases, the periods will return to normal. However, in a few cases, the period stops completely.
   • Myomectomy: It is a surgery to remove uterine fibroids. Myomectomy leaves the uterus intact, so people can still become pregnant after the procedure.
   • Hysterectomy: It is a surgical procedure that removes the uterus. A woman will no longer be able to get pregnant after a hysterectomy.
   • Uterine artery embolization (UAE): This procedure is used to stop vaginal spotting if it is due to underlying medical conditions like uterine fibroids, trauma, cancerous tumors, and childbirth.

There are certain home remedies that can help with vaginal bleeding between periods. However, always consult your doctor before trying anything as they can interfere with your medications. These include:

• Ginger (Adrak): Ginger has anti-inflammatory and blood-thinning properties, which can mitigate minor bleeding issues.
• How to use it? Mince one teaspoon of fresh ginger, boil it in water for about 10 minutes, and make it into tea. Read about more benefits of ginger.
• Jaggery (Gudh): Jaggery has numerous medicinal properties, and regular consumption may help regulate spotting between periods.
• How to use it? You can take a small piece as it is or mix it in milk or water for easy consumption.
• Cinnamon (Dalchini): Cinnamon helps regulate blood flow to the uterus and may treat irregular periods.
• How to use it? It can be added to your diet in various ways, such as sprinkling it on oatmeal or yogurt, or making cinnamon tea by boiling a cinnamon stick in water.

Complications of vaginal spotting between periods can be grouped into the following:

• Acute complications:
• Severe anemia: Vaginal bleeding between periods can lead to excessive blood loss and anemia by reducing the number of circulating red blood cells.
• Hypotension (low blood pressure): A heavy period or spotting between periods can result in low blood pressure. Low blood pressure may also be caused by underlying health conditions such as uterine fibroids.
• Chronic complications:
• Infertility: Irregular periods contribute to a significant percentage of infertility cases.
• Endometrial cancer: Long-term abnormal vaginal bleeding is associated with an increased risk of endometrial cancer.

Alternative therapies act as an adjunct to managing the condition or the symptoms. These include:

• Yoga
  Yoga is beneficial for balancing the mind and body. Various studies suggest that yoga helps reduce menstrual pain and emotional symptoms associated with menstruation and bleeding between periods, such as depression and anxiety. Yoga emphasizes the holistic improvement of the mind, body, and soul. Here are some of the health benefits of yoga!
• Acupuncture
  Acupuncture is a traditional Chinese therapy that involves inserting thin needles into specific points on the body to regulate energy flow. Some studies suggest it may help regulate menstrual cycles and potentially reduce spotting, but the evidence is limited, and individual responses vary.

Experiencing irregular bleeding between periods can lead to anxiety, stress, mood swings, and strain on relationships, impacting mental health and overall well-being.

1. Do not delay medical attention: If you experience irregular or heavy bleeding between periods, consult a doctor immediately. They can evaluate your condition and identify any underlying causes.
2. Maintain a menstrual calendar: A menstrual calendar can track the frequency, duration, and flow of bleeding episodes. This information can help your healthcare provider make an accurate diagnosis.
3. Be vigilant about other symptoms: Pay attention to accompanying symptoms like pain, cramping, or changes in vaginal discharge. These details can provide valuable insights into the cause of the bleeding.
4. Follow your doctor’s advice: Once your doctor diagnoses the underlying cause, follow their recommended treatment plan that may involve medication, lifestyle changes, or other interventions.
5. Take care of your overall health: A healthy lifestyle, including regular exercise and a balanced diet, can support your reproductive health.