IRREGULAR vaginal bleeding

Masoud Moghaddam

20/1/2015

A normal menstrual pattern is taken to be a ‘monthly bleed’. The cycle length can

vary, with a generally accepted normal range of 21-35 days and a bleeding

duration of 4-7 days.

Irregular bleeding can consist of intermenstrual bleeding with a flow similar to

that of a menstrual period. It can be ‘spotting’ that is noted as stains on the

underwear or after toileting.

It also includes postcoital bleeding and postmenopausal bleeding.

Amenorrhoea and menorrhagia may occur as part of the irregular menstrual

pattern

Background

It is important to understand that menstrual patterns that do not conform to the

regular cycling discussed above can be a normal occurrence

The age of the woman is a critical factor in assessing the need to investigate or

manage an irregular menstrual pattern.

In both puberty and the perimenopause, these transitional phases anovulatory

cycles occur, leading to failure to establish a distinct ‘withdrawal’ menstrual

bleed.

Irregular bleeding — what can be normal?

In periovulatory bleeding, bleeding or spotting can occur at ovulation, about 14

days before the following menstrual period.

If there is a luteal phase defect, spotting can occur premenstrually each month,

said to be due to a lack of progesterone.

The incidence of irregular bleeding is low overall, and the incidence of significant

pathology is also low

In a study of menstruation in 621 normal women over 20,672 cycles,

intermenstrual bleeding was reported in 100 cycles (39 women; 6.3% of the

women studied and 0.5% of cycles studied). These women were all investigated

and no pathology was found.

How common is irregular vaginal bleeding?

A study looking at referrals to a gynaecology department for postcoital bleeding

reviewed the records of 248 women referred over a five year period and found

that benign polyps (including endometrial polyps) were found in 20% of cases,

25% had a cervical ectropion, while cervical intraepithelial neoplasia was detected

in 6.8% of cases

General

Contraceptives — hormonal contraceptive methods and intrauterine devices

Menopausal hormone therapy, including with tibolone, in a woman with an

intact uterus

Endometriosis — may cause pre- and postmenstrual spotting. Generally presents

with dysmenorrhoea, which worsens with time

Causes of irregular bleeding

Uterine

Endometrial polyps

Endometrial hyperplasia

Fibroids — generally cause menorrhagia but can present with intermenstrual

bleeding

Pregnancy — ectopic, early pregnancy loss

Endometritis — postnatal and postsurgical

Endometrial/myometrial malignancy

Lower genital tract

Cervical ectropion

Cervical polyps

Cervicitis

Cervical malignancy

Relation of age to common causes of irregular bleeding

This is the most common invasive gynaecological cancer in Australia, ranking

sixth in terms of incident cancers in women

It results in about 1400 new cases and 260 deaths every year

Risk increases with age. It is most commonly diagnosed in women aged 50-70

and is rare in those under 40.

Risk factors include age >40, weight >90kg, prolonged exposure to endogenous

or exogenous unopposed oestrogen.

Endometrial hyperplasia and carcinoma

The incidence of cervical cancer in Australia has been dramatically reduced as a

result of the cervical screening program.

Guidelines for Referral for Investigation of Intermenstrual and Postcoital

Bleeding, by the Royal Australian and New Zealand College of Obstetricians and

Gynaecologists (RANZCOG)

Cervical cancer

IMB is vaginal bleeding at any time other than during normal menstruation or

following intercourse.

IMB is common, especially in women using hormonal contraception or hormonal

therapies. It is impractical and unnecessary to refer every woman with a single

episode of IMB for immediate investigation. Women at risk of sexually

transmitted infection should have appropriate tests performed. Women with

persistent IMB should have a cervical Pap smear, a transvaginal ultrasound and

referral to a gynaecologist for further assessment.

IMB

PCB is vaginal bleeding after intercourse

PCB is regarded as a cardinal symptom of cervical cancer and the commonest

presenting symptom for Chlamydia. Therefore women complaining of PCB

should have tests to exclude this. It is commonly accepted that a single episode

of PCB in a woman who has a normal smear and cervical appearance does not

warrant immediate referral, but recurrence or persistence of this symptom

mandates colposcopic examination.

PCB

The woman’s age and stage of reproductive life.

History of bleeding (how often, what time of the month, postcoital, etc).

Risk of pregnancy/recent delivery/recent gynaecological surgery or instrumentation.

Use of hormonal therapy and contraceptive history.

Previous abnormal Pap tests.

Sexual history, including risk for sexually transmissible infections, and relevant partner

history.

Previous history of STIs

History

Ectropion and contact bleeding on the cervix

Friability of tissue or ulceration of the cervix

Presence of cervical polyps

Other possible sites of bleeding

Signs of vaginal discharge, foreign body or IUD tail

If pregnant, whether the cervical os is open or closed

Tenderness on rocking the cervix

Size of the uterus

Adnexal masses/tenderness

Examination

If the patient has not had a Pap smear within the previous three months, take a

Pap smear using the speculum carefully so as not to provoke further bleeding.

The occurrence of contact bleeding or abnormal bleeding in the case history

should be noted on the request form.

Cervical swabs should be taken for Chlamydia trachomatis if appropriate

Investigations

can be a useful additional test in investigating abnormal bleeding when an

endometrial cause is suspected.

Focal thickening of the endometrium can be suggestive of polyps, and

submucosal fibroids may distort the endometrial stripe, while global thickening

of the endometrium can be indicative of hyperplasia, and gross myometrial

involvement is suggestive of malignancy.

Saline infusion sonohysterography (SIS) can clarify the contours, symmetry and

thickness of the endometrium.

Ultrasound imaging

The sensitivity of SIS can be similar to that of hysteroscopy. In experienced

hands it has been found to have a sensitivity of 80-100% and a specificity of 76-

96% for detecting intrauterine pathology.

A more recent technique is hysterosalpingo-contrast sonography

Algorithm for investigating intermenstrual and postcoital bleeding

WOMEN with persistent bleeding — even if Pap smears and other tests are

normal and regardless of whether or not an ectropion is present — should be

referred for specialist opinion

In general, a hysteroscopy/D&C by a specialist should be the primary procedure

in women with persistent intermenstrual bleeding, while colposcopy should be

the primary procedure with persistent postcoital bleeding or if a suspicious

lesion is present on the cervix. Both investigations may be required.

Management and referral

If the patient has minor intermittent episodes of bleeding (ie, not ‘persistent’)

they should be referred for colposcopy even if the smear report suggests the

presence of CIN-1 (low-grade squamous intraepithelial lesion [LSIL]) or a higher

grade abnormality or the presence of any glandular abnormality.

If bleeding is persistent, immediate referral is needed

It is not possible to give a simple and all-encompassing definition of ‘persistent’

but, for example, several minor episodes over a three-month period, or two

episodes of heavy bleeding, should generally prompt referral

Women with intermenstrual bleeding who are on the progestogen-only minipill

or in the first six months of Depo-Provera treatment (often called break-through

bleeding) should generally not be referred in the first instance unless bleeding is

excessively frequent or prolonged, and provided Pap smears are normal and up

to date.

When a woman presents with a history of postmenopausal bleeding (more than

12 months since menopause), referral should be made for transvaginal

ultrasound. If the ultrasound reveals that the endometrial stripe is homogenous

and uniformly 5mm or less, no further evaluation is generally required. The

likelihood of missing a significant endometrial abnormality is very low (0.1% in

HRT users and 1% in non-users).

Tamoxifen can increase the risk of endometrial cancer. When a woman taking

tamoxifen presents with postmenopausal bleeding, prompt referral should be

made for transvaginal ultrasound, as above.

A postmenopausal woman with a normal transvaginal ultrasound report and

persistent bleeding should be further investigated by hysteroscopy/

D&C/endometrial biopsy.

A 22-YEAR-old woman presented to a gynaecologist with breakthrough bleeding while

using the combined OCP. A Pap test was done and reported as normal. Several times over

the following year the patient presented to a GP, with a history of intermittent

breakthrough bleeding and postcoital bleeding while taking the pill. A repeat Pap test

reported monilia and mild squamous atypia, possibly due to inflammation, with a

recommendation to repeat in 3-6 months. The patient continued to note variable

postcoital bleeding and presented to another GP. She was then referred to a

gynaecologist. The gynaecologist found an eroded and friable cervix with contact

bleeding. Biopsy confirmed malignancy. Review of the previous Pap test indicated

abnormal cells, including CIN 3. The patient went on to have a radical hysterectomy for

stage 1b carcinoma of the cervix. Despite further surgery, radiotherapy and

chemotherapy over several years, she died of metastatic disease.

Cervical cancer: a cautionary tale