4 Vaginal bleeding

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Contents

• Objectives
• Normal menstruation
• Abnormal vaginal bleeding
• Irregular and postcoital bleeding
• Postmenopausal bleeding
• Amenorrhoea
• Dysmenorrhoea
• Premenstrual syndrome
• Case studies

Objectives

When you have completed this chapter you should be able to:

• Describe normal menstruation
• Understand the types of abnormal vaginal bleeding
• Manage a woman with heavy menstrual bleeding
• Manage women with post-menopausal bleeding
• Manage women with amenorrhoea
• Treat dysmenorrhea
• Manage women with premenstrual tension

Normal menstruation

4-1 When is vaginal bleeding normal?

It is normal for women of childbearing age to have regular vaginal bleeding. This is called menstruation. It is also normal to bleed after the delivery of an infant.

4-2 What is normal menstruation?

Menstruation (menstrual period) is the regular vaginal bleeding which occurs in women of reproductive age and is the commonest cause of vaginal bleeding. The bleeding is due to the shedding of the uterine lining (endometrium). Menstruation is part of the menstrual cycle which usually lasts 28 days (from the onset of one menstruation to the onset of the next). The length of the menstrual cycle may vary slightly from month to month but the variation should be less than 8 days.

4-3 What is menarche?

Menarche is the first menstruation in a young girl. It usually occurs between the ages of 10 and 16 years. Any vaginal bleeding before the start of puberty (growth spurt and development of pubic hair and breast buds) is always abnormal and must be investigated.

4-4 What is the menopause?

The menopause is the time when a woman reaches the end of her reproductive life and her periods stop permanently. It usually occurs between the ages of 45 and 55 years when a woman’s ovaries stop producing the hormones oestrogen and progesterone.

Menopause can only be diagnosed retrospectively once a woman has had no vaginal bleeding at all for 12 months. The post-menopause starts the day after the final period, but can also only be defined after 12 months of no vaginal bleeding. Therefore, a woman who has had 1 year of no vaginal bleeding is 1 year post-menopausal.

Commonly the term ‘menopause’, ‘change of life’ or ‘climacteric’ is used by lay people to describe the years around the menopause.

Older women who are on hormonal replacement therapy (HRT) may continue to menstruate as long as they are taking HRT.

Note

In women who do not have a uterus, or in women in whom the diagnosis of menopausal transition is unclear, serum follicle stimulating hormone (FSH) and luteinizing hormone (LH levels) can be measured to determine if the menopause has occurred.

4-5 What are the features of normal menstruation?

Menstrual periods may be irregular for the first few months after menarche but then the menstrual cycles should become regular. Menstruation typically starts every 28 days, but is still normal if it begins a few days earlier or later. Normal menstruation lasts for 3 to 6 days and should not be excessive.

Periods lasting more than 7 days or excessive blood loss are abnormal and should be investigated.

Abnormal vaginal bleeding

4-6 When is vaginal bleeding abnormal?

Vaginal bleeding is abnormal when:

• Menstrual bleeding is too heavy (excessive)
• It is irregular (bleeding between periods)
• It occurs after the menopause (post-menopausal bleeding)
• It occurs before puberty
• It happens after intercourse (post-coital bleeding)
• It is very painful
• Women do not menstruate at all, unless they are on medication which suppresses menstruation such as the 3-months birth control injection
• Infrequent menstrual bleeding

4-7 What is heavy menstrual bleeding?

Menstrual bleeding is too heavy (excessive) when the menstrual period lasts too long (more than 7 days) or when the blood loss is too much and the woman loses more than 80 ml of blood during her menstruation. Regular heavy menstrual bleeding is often called menorrhagia.

It is not practical to try and measure the total blood loss. Therefore it is important to take a careful menstrual history and listen to what the woman says. Symptoms of excess blood loss are having to change a tampon or pad every 1 or 2 hours, flooding or the presence of blood clots. Heavy menstrual bleeding can occur at any time, but is especially common in the first months after menarche and during the months before menopause.

Menorrhagia is regular but excessive menstruation.

4-8 Is there usually an obvious cause of heavy menstrual bleeding?

No. Often no obvious cause can be found. This pattern of excessive bleeding without any sign of disease or abnormality is called dysfunctional uterine bleeding. This is the commonest form of excessive vaginal bleeding in women of childbearing age, especially when approaching the menopause.

Note

Dysfunctional uterine bleeding is usually associated with a hormonal imbalance due to failure to ovulate (anovulation).

4-9 What are other common causes of heavy menstrual bleeding?

Other than dysfunctional uterine bleeding, the common causes of heavy menstrual bleeding include:

• Uterine fibroids
• Uterine polyps
• Adenomyosis (a condition where the normal endometrium grows into the body of the uterus and causes heavy, painful periods)

It is important to exclude these other causes before diagnosing dysfunctional uterine bleeding.

Note

Other rarer causes of heavy menstrual bleeding include thyroid disease and problems with coagulation.

4-10 Can pregnancy cause heavy menstrual bleeding?

No. Complications of pregnancy such as miscarriage or ectopic pregnancy often present with abnormal vaginal bleeding, but the bleeding is usually of sudden onset or is irregular.

4-11 What is the management of heavy menstrual bleeding?

1. Assess the woman’s vital signs to determine whether she is not shocked due to blood loss. Then measure her haemoglobin concentration. Refer all women with signs of shock (fast heart rate, cold hands and feet, low blood pressure) to hospital while women with a haemoglobin concentration below 10 g/dl but no shock should be referred to a gynaecology clinic.
2. Choose a medical form of treatment to reduce blood loss each month:
   • Combined oestrogen and progestogen oral contraceptive pill. This is the method of choice if contraception is also wanted.
   • Non-steroidal anti-inflammatory drugs during menstruation such as mefenamic acid (e.g. Ponstan) 250 to 500 mg 3 times daily or ibuprofen (e.g. Brufen) 200 to 400 mg 3 times daily.
   • Levonorgestrel-releasing intra-uterine device (also called the Mirena)
   • Progestogen-containing injections such as Depo Provera

   Medical treatment should reduce the blood loss by 30 to 50%.

   Note

   The Mirena is an intra-uterine device which releases progesterone and suppresses endometrial growth. It is the treatment of choice for abnormal uterine bleeding provided malignancy has been excluded. Unfortunately Mirena is expensive and not usually available in primary healthcare facilities or low-resource settings.

3. Check the woman’s haemoglobin and send a blood specimen for a full blood count if the haemoglobin is below 10g%. Supplement with iron tablets until the haemoglobin is 11g% or more or the excessive menstrual bleeding has been resolved.

Women over 35 years who smoke should not be offered the oral contraceptive pill because of the high risk of venous thrombosis.

Women who fail to respond to medical treatment and women where you suspect a cause other than dysfunctional uterine bleeding (such as fibroids) should be referred for further investigation as they may need surgery (a hysterectomy or endometrial ablation).

All women with heavy menstrual bleeding must have their haemoglobin assessed.

4-12 What is an important complication of excessive bleeding?

Heavy menstrual bleeding can interfere with a woman’s physical, mental and social wellbeing. Some women have to miss work or school during menstruation.

Excessive menstrual bleeding may cause iron-deficiency anaemia due to the increased blood loss. Women with iron-deficiency anaemia need treatment with daily oral iron for at least 3 months in addition to the treatment of the excessive vaginal bleeding.

If the bleeding has been severe, resuscitation with intravenous fluid or a blood transfusion may be needed. The patient should be referred immediately to hospital.

Heavy menstrual bleeding affects women’s quality of life and often causes iron-deficiency anaemia.

Irregular and postcoital bleeding

4-13 Is bleeding between periods normal?

No. These women should be referred for further investigation as irregular vaginal bleeding can be a sign of cancer or some other serious condition.

4-14 Why is bleeding after sexual intercourse important?

Because it indicates a local cause of bleeding such as cancer, a polyp or cervicitis. Sometimes it may be due to trauma during intercourse. Post-coital bleeding must be investigated.

4-15 Can contraception cause irregular bleeding?

Women who take their oral contraceptive pill regularly should not have irregular bleeding. However, women on the contraceptive pill may bleed because they have forgotten to take their pills regularly. They may also experience breakthrough bleeding, especially when they start on a low-dose pill, but this should soon settle.

Women who are on the 2- or 3- month injectable contraceptive may have some irregular bleeding during the first few months, but this should not continue. Menstruation may decrease or stop after being on injections for a long time.

Women who have irregular vaginal bleeding while on contraception should be referred to the local family planning clinic.

Postmenopausal bleeding

4-16 What is postmenopausal bleeding?

Vaginal bleeding 12 months or more after menstruation has stopped in older women.

4-17 Why is postmenopausal bleeding important?

Because it may be a sign of cancer of the cervix or uterus. Although there are many non-cancerous causes of postmenopausal bleeding, such as polyps in the uterus due to a thickened endometrium or vaginal and endometrial atrophy, all these women must be referred for investigation and management. It is very important that cancer of the uterus or cervix is diagnosed as early as possible.

All women with postmenopausal bleeding must be referred for further investigation for cancer.

Amenorrhoea

4-18 What is amenorrhoea?

Amenorrhoea means no menstrual bleeds. Amenorrhoea may be:

• Primary amenorrhoea when the woman has never menstruated. This means menarche has not taken place in a woman aged 16 years or older.
• Secondary amenorrhoea when a woman who previously menstruated no longer has menstrual bleeds. The diagnosis is usually made when a woman has not menstruated for 3 months.

4-19 What is the management of primary amenorrhoea?

Women and girls must be referred for investigation if;

• They are 16 years old and have not menstruated but have other signs of puberty (breast development and pubic and axillary hair)
• They are 14 years old and have not started menstruation and show no signs of puberty

4-20 What are the causes of secondary amenorrhoea?

• The most important cause is pregnancy. Therefore always perform a pregnancy test in any woman who presents with secondary amenorrhoea. Amenorrhoea may continue after pregnancy in women who exclusively breastfeed their infants.
• Menopause. This usually occurs in women over the age of 40 years and is associated with other symptoms of the menopause such as hot flushes.
• Women on the 2- or 3-month contraception injection often have secondary amenorrhoea. This is normal and these women should be reassured.
• Hormonal disturbances, which are often associated with severe weight loss, anorexia or excessive exercise, can cause secondary amenorrhoea.
• The polycystic ovary syndrome is a common cause of hormonal disturbance in women. It presents with menstrual irregularities (usually amenorrhoea, or oligomenorrhoea) acne and hirsutism (excess body hair). Many women with PCOS are obese.

Women with abnormal causes of secondary amenorrhoea should be referred for investigation and management.

Oligomenorrhoea (infrequent menstrual bleeding) may be normal during the year or 2 before menopause and also in women on injectable contraception. All other women with oligomenorrhoea should be referred for investigation.

Always exclude pregnancy in a woman with secondary amenorrhoea.

Dysmenorrhoea

4-21 What is dysmenorrhoea?

Dysmenorrhoea is abdominal pain or discomfort associated with menstrual bleeding which is so severe that it interferes with the woman’s daily activities. There are 2 forms of dysmenorrhea.

• Primary dysmenorrhoea is pain in the absence of any underlying cause. It commonly occurs in teenage girls soon after menarche when they start to ovulate. They have colicky lower abdominal cramps due to uterine contractions. The pain usually occurs just before or at the onset of menstruation. It lasts one to 2 days and stops by the third day of menstruation. They may also feeling bloated and suffer nausea and headaches. The pain may be so severe that they are unable to attend school or continue with normal daily activities.
• Secondary dysmenorrhea is menstrual pain that is caused by an underlying condition such as endometriosis, adenomyosis or fibroids. It usually occurs in older women.

Dysmenorrhoea is abdominal pain or discomfort associated with menstruation.

4-22 What is the management of women with primary dysmenorrhea?

Adolescents and adults who have not yet been sexually active must be treated without doing a gynaecological examination. A gynaecological examination must be done in women who were or are sexually active as secondary causes for dysmenorrhoea need to be ruled out.

Young women with primary dysmenorrhea usually respond to a low-dose combined oral contraceptive pill or a non-steroidal anti-inflammatory drug for pain. A careful explanation, reassurance and exercise are important. Advice of the importance of using a condom during sex must also be given.

Commonly used oral anti-inflammatory drugs are:

• Mefenamic acid 250 mg every 6 to 8 hours
• Ibuprofen 200 mg every 6 to 8 hours
• Naproxen 250 mg every 6 to 8 hours

4-23 What is the management of secondary dysmenorrhea?

Women with secondary dysmenorrhea should be referred for investigation of an underlying cause if they do not respond to oral anti-inflammatory drugs.

Premenstrual syndrome

4-24 What is premenstrual syndrome?

Premenstrual syndrome (PMS) or premenstrual tension (PMT) is a common condition which presents with a wide range of emotional symptoms and behavior changes that develop in the week or 2 before the start of menstruation and are completely relieved by the end of menstruation. The diagnosis is based on the cyclical nature of the condition which may become worse with age. The most frequent symptoms are:

• Irritability and tension
• Anxiety or depression
• Aggression and anger
• Mood swings
• Tiredness and lethargy
• A feeling of abdominal bloating and breast tenderness
• Poor concentration
• Premenstrual dysmenorrhoea

In about 5% of women the symptoms may be so bad that the woman is unable to manage her day-to-day life and social relationships. Some women become very depressed. The cause of premenstrual tension is unknown.

Premenstrual syndrome presents with irritability and other emotional and behaviour changes in the weeks before menstruation.

4-25 What is the management of premenstrual syndrome?

There is no generally agreed upon treatment. Sympathetic support and reassurance is important. Exercise, relaxation, healthy diet, stress reduction and learning coping skills may help. If the effects of premenstrual tension affects the quality of a woman’s life she should be referred to a specialist clinic.

Case study 1

A young woman who started her menstrual periods at 14 years of age visits her family doctor. She is worried that her periods are lasting 7 days and ask whether it is normal to feel tired and irritable for a few days before her period starts.

1. Is it normal to start menstruating at 14 years?

Yes. Menstruation normally starts between 10 and 16 years of age. Menarche is the first menstruation in a young girl.

2. Is a menstrual period of 7 days too long?

No. A normal menstrual period lasts between 3 and 7 days. The length of her periods are therefore at the upper end of normal.

3. Is it common to feel tired and irritable for a few days before a menstrual period?

Yes, this is very common.

4. How should this young woman be managed?

Measure her haemoglobin concentration and find out whether her periods are affecting her quality of life. If she is not anaemic reassure her. If she is anaemic or unhappy about her long periods, refer her.

Case study 2

A 48 year old woman visits her local clinic because she is having heavy menstrual periods. Previously this has not been a problem. On examination she appears pale and complains of a lack of energy.

1. How would you define heavy menstrual bleeding?

Menstrual bleeding that is too heavy and/or lasts too long so that the total menstrual blood loss is more than 80 ml.

2. What clinical history would suggest heavy bleeding?

Menstrual flooding (leaking past her sanitary protection), the presence of blood clots or having to change tampons or pads very often.

3. What is the probable cause of heavy bleeding in this patient?

Heavy menstrual periods are more common during the months before the menopause. At the age of 48 years she is probably approaching the menopause and is suffering from dysfunctional uterine bleeding.

4. What should be the management to reduce menstrual bleeding?

Because of her age, her best options are a non-steroidal anti-inflammatory drug. If she does not respond to treatment she must be referred for investigation and further management.

5. What common complication of heavy menstrual bleeding does this patient probably have?

Iron-deficiency anaemia as suggested by her pallor and history of lack of energy.

6. How would you treat this condition?

A haemoglobin measurement must be done and if below 10g% a full blood count requested. In the meantime she needs a course of oral iron in addition to treatment to reduce the excessive bleeding.

Case study 3

A 60 year old woman complains of occasional vaginal bleeding during the past 3 months, especially after sexual intercourse. She has had no menstrual periods for the past 10 years.

1. Is the woman postmenopausal?

Yes, she had no menstrual periods for 10 years.

2. What is the definition of postmenopausal bleeding?

Vaginal bleeding 12 months or more after menopause.

3. At what age does menstruation usually stop?

The last menstrual period (menopause) usually takes place between the ages of 45 and 55 years.

4. Is postmenopausal bleeding an important sign?

Yes. This is a very important sign because postmenopausal bleeding is abnormal and may indicate a serious condition such as cancer of the cervix or uterus.

5. Is bleeding after intercourse normal?

No. This also suggests a medical problem in the vagina, cervix or uterus.

6. How should this woman be managed?

She must be referred for further investigation that will include a gynaecological examination and appropriate additional investigations.

Case study 4

A teenager complains of severe cramping lower abdominal pains at the start of her menstrual periods. Sometimes it is so bad that she has to stay at home. She also says that she feels anxious and angry and cannot concentrate at school during the 2 weeks before her period. At times her mood swings get so bad that she fights with her mother and friends. She looks forward to the weeks after her period when she feels well and happy.

1. What is the likely cause of her abdominal pain?

Dysmenorrhoea. This presents as colicky lower abdominal pain or discomfort which occurs just before or at the start of menstruation. The pain usually stops soon after menstruation has begun. It is common in teenage girls.

2. How should you manage her abdominal pain?

Start by reassuring her and explain why she is getting the pain. Exercise may help. If the pain is severe she should try an oral anti-inflammatory drug, such as mefenamic acid, every 6 hours for a day or 2 to reduce the pain. If she is sexually active she should be given a low-dose combined oral contraceptive pill and be advised to only have sex if her partner wears a condom.

3. Why does she feel anxious and angry in the weeks before her menstrual period?

This is a common condition called premenstrual syndrome. It typically occurs in the weeks before but not the weeks after menstruation.

4. What is the cause of this condition?

The cause is unknown.

5. What is the treatment of this condition?

There is no generally agreed upon treatment other than explanation and sympathetic support. Exercise, a healthy diet and learning coping skills to reduce stress may help. If her symptoms do not improve or are so severe that they interfere with her daily activity she should be referred to a specialist clinic.