ABNORMAL BLEEDING

Abnormal uterine bleeding or troublesome periods (including bleeding in pregnancy) Dr Greg Cario

Many women experience problems with their periods throughout their menstrual life particularly at either end of the reproductive years.  Most of these issues are well managed by your local general practitioner.  Some patients however will need to be referred on for a specialist evaluation in the following instances:

1. Amenorrhea or oligomenorrhea.  This condition is defined as the delayed onset of periods past the age of 16 (primary amenorrhea) or where there is a gap of at least 6 months in the menstrual cycle for no obvious reason (secondary amenorrhea). Infrequent bleeding or oligomenorrhoea may be a sign of Polycystic Ovary Syndrome or cycles where there is little or no regular ovulation. This is often associates with acne, hair growth and over activity of the male hormone testosterone.
2. Heavy periods.  It is very difficult for women to quantify how heavy their periods are in relation to their friends.  Generally speaking periods are referred to as heavy when they interfere with the patient’s lifestyle and their ability to carry on normal activities as well as school or work. This may mean that their Iron stores or even their blood count (Haemoglobin) may drop causing symptoms of anaemia like tiredness, lack of energy even shortness of breath.  The average period should last no longer than 7 days including spotting which may be present at the beginning or at the end of the period.  They should not be associated with large clots, which are jelly like condensations of blood larger than a 5 cent coin.  They should not also be associated with a flooding or soaking phenomenon where the blood can run freely into the toilet bowl or soaks through normal sanitary pads or tampons. Soak through accidents are a definite reason for referral and investigation. These periods may also be associated with significant pain and if they interfere with your lifestyle they should be investigated.
3. Irregular or erratic bleeding which can make planning your social life or even natural family planning difficult.
4. Bleeding between periods or spotting which can occur at any time in the cycle.  This is referred to as intermenstrual bleeding.
5. Post coital bleeding or bleeding following intercourse which may relate to a simple infection of the cervix.  It can also relate to pre-cancerous and even cancerous change in the cervix and the uterus.
6. Blood stained vaginal discharge.
7. Polymenorrhea or frequent periods occurring more than twice per month.
8. Pregnancy related bleeding is very common occurring in around 1 in 3 pregnancies. In most cases it is innocent with miscarriage occurring in 1 in 3 cases. In the first 12 weeks it is called a “threatened miscarriage”. Light spotting or a brown, sometimes mucoid discharge is usually innocent and can usually be followed up with your doctor at your next routine antenatal visit. If the bleeding is heavier than a period or persists for longer than 3 days or is associated with cramping period like pains or other severe pelvic pain it requires immediate investigation. This is usually with an ultrasound and blood tests and is very accurate. If the vaginal ultrasound detects a regular foetal heart beat it is associated with a 95% take home pregnancy rate.

If the bleeding is dark like “prune juice” and associated with severe pain and dizziness or fainting attacks it is more urgent as it sometimes indicates a pregnancy in the tube also called an ectopic pregnancy which can be a medical emergency and require presentation to the local emergency department or your doctor. Bleeding in the second and third trimester that is heavier than a period requires presentation to your booked labour ward for evaluation. Once again it is usually innocent.

9. Bleeding after the menopause or post-menopausal bleeding (PMB).  Bleeding after the menopause (the change of life where there has been no period for more than 6 months) is always abnormal.  There is a 15% risk of cancer of the uterus and this must be investigated as a matter of urgency.  It is never normal.