Vaginal bleeding

Definition

Abnormal vaginal bleeding is any vaginal bleeding unrelated to normal menstruation. This type of bleeding may include spotting of small amounts of blood between periods — often seen on toilet tissue after wiping — or extremely heavy periods in which you soak a pad or tampon every one to two hours for two or more hours.

Normal vaginal bleeding, or menstruation, occurs every 21 to 35 days when the uterus sheds its lining, marking the start of a new reproductive cycle. A menstrual period may last for just a few days or up to a week. Your flow may be heavy or light and still considered normal. Menstrual cycles tend to be longer for teens and for women nearing menopause, and menstrual flow may also be heavier at those ages.

Causes

Abnormal vaginal bleeding can relate to an issue with your reproductive system (a gynecologic condition) or to other medical problems or certain medications. If you have reached menopause — defined as 12 consecutive months, give or take, without a menstrual period — subsequent vaginal bleeding may be a cause for concern and should be evaluated.

Possible causes of abnormal vaginal bleeding include:

Cancers and precancerous conditions

• Cervical cancer
• Endometrial cancer (uterine cancer)
• Endometrial hyperplasia
• Ovarian cancer
• Uterine sarcoma
• Vaginal cancer

Endocrine system factors

• Hyperthyroidism (overactive thyroid)
• Hypothyroidism (underactive thyroid)
• Polycystic ovary syndrome (PCOS)
• Stopping or changing birth control pills or menopausal hormone therapy (withdrawal bleeding)

Fertility and reproduction factors

• Ectopic pregnancy (in which the fertilized egg implants and grows outside of the uterus, such as in a fallopian tube)
• Fluctuating hormone levels
• Miscarriage (before the 20th week of pregnancy)
• Pregnancy
• Random ovulatory cycles
• Sexual intercourse
• Perimenopause (the transition time before menopause)
• Vaginal atrophy (genitourinary syndrome of menopause) 

Infections

• Cervicitis
• Chlamydia trachomatis
• Endometritis
• Gonorrhea
• Pelvic inflammatory disease (PID)
• Ureaplasma vaginitis
• Vaginitis

Medical conditions

• Celiac disease
• Severe systemic disease, such as kidney or liver disease
• Thrombocytopenia (low platelet count)
• Von Willebrand disease (and other blood clotting disorders)

Medications and devices

• Forgotten (retained) tampon
• Intrauterine device (IUD)
• Stopping or changing birth control pills or menopausal hormone therapy (withdrawal bleeding)
• Tamoxifen side effect

Noncancerous growths and other uterine conditions

• Adenomyosis
• Cervical polyps — noncancerous (benign) growths on your cervix
• Uterine fibroids
• Uterine polyps (endometrial polyps)

Trauma

• Blunt trauma or penetrating injury to the vagina or cervix
• Sexual abuse

When to see a doctor

If you're pregnant, contact your doctor immediately if you notice vaginal bleeding.

In general, anytime you experience unexpected vaginal bleeding, consult your doctor. Whether or not vaginal bleeding is normal depends on your age and the circumstances.

Contact your doctor in the following situations:

• Postmenopausal women not taking hormone therapy should see a doctor if they experience vaginal bleeding.
• Postmenopausal women taking cyclic hormone therapy may experience some vaginal bleeding. A cyclic hormone therapy regimen — oral estrogen daily plus oral progestin for 10 to 12 days a month — can lead to bleeding that resembles a period (withdrawal bleeding) for a few days out of the month. If you have bleeding other than expected withdrawal bleeding, contact your doctor.
• Postmenopausal women taking continuous hormone therapy — a low-dose combination of estrogen and progestin daily — may experience light, irregular bleeding for the first six months. If bleeding persists longer or heavy bleeding begins, see your doctor.
• Girls who don't have any other signs of puberty or are younger than age 8 should have any vaginal bleeding investigated.

The following situations are likely normal, but talk to your doctor if you're concerned:

• Newborn girls may have some vaginal bleeding during the first month of life. Bleeding that's excessive or lasts longer should be checked out.
• Adolescent girls who have just begun having periods may experience irregular cycles during the first few years. In addition, many girls and women have light spotting for a few days before menstruating.
• Women starting birth control pills may experience occasional spotting the first few months.
• Women nearing menopause (perimenopause) may experience increasingly heavy or irregular periods. Ask your doctor about possible treatments to minimize your symptoms.