Clinical Review

Managing unscheduled bleeding in non-pregnant premenopausal women

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3251 (Published 04 June 2013) Cite this as: BMJ 2013;346:f3251
  1. Mary Ann Lumsden, professor of gynaecology and medical education, honorary consultant gynaecologist1,
  2. Ailsa Gebbie, consultant gynaecologist and clinical lead for family planning2,
  3. Cathrine Holland, consultant gynaecological surgeon and oncologist3
  1. 1Department of Reproductive and Maternal Medicine, University of Glasgow, Glasgow G4 0SF, UK
  2. 2NHS Lothian Sexual and Reproductive Health Service, Edinburgh, UK
  3. 3Department of Gynaecological Oncology, Central Manchester University Hospital Foundation Trust, Manchester, UK
  1. maryann.lumsden{at}glasgow.ac.uk

Summary points

  • Pregnancy must always be excluded in the presence of unscheduled vaginal bleeding

  • Unscheduled bleeding is often seen with hormonal contraceptives, particularly progestogen only ones, in the first six months of use

  • Unscheduled bleeding results in many women discontinuing an otherwise highly effective method of contraception

  • Bleeding can result from benign lesions such as endometrial or cervical polyps, uterine fibroids, or adenomyosis, but consider concurrent disease of the endometrium and cervix in those at high risk

  • Although uncommon, endometrial and cervical cancer may present with unscheduled bleeding

  • The most important intervention in general practice is a vaginal speculum examination to visualise the cervix; the presence of bleeding should not defer this

Unscheduled vaginal bleeding—bleeding that occurs outside the normal menstrual period or the regular withdrawal bleed associated with the combined oral contraceptive pill—is a common reason for women of reproductive age to attend primary care. It is also referred to as intermenstrual bleeding. As well as intermenstrual bleeding, unscheduled bleeding also includes postcoital bleeding; it can be difficult to distinguish between the two because they often occur together. Because postcoital bleeding may have different implications, the causes of both need to be considered in a woman with unscheduled bleeding. Irregular bleeding associated with hormonal contraception is generally called breakthrough bleeding.

In a study of women presenting to primary care with menstrual problems, 36% of women reported intermenstrual bleeding or postcoital bleeding in addition to heavy menstrual loss.1 Unscheduled bleeding causes anxiety and concern because it can be a presenting symptom for gynaecological cancer, particularly cervical and endometrial cancer. This symptom can also be associated with other menstrual disorders, such as heavy menstrual bleeding, particularly when caused by benign lesions such as fibroids or endometrial polyps, but also heavy menstrual bleeding of no known cause (formally called dysfunctional bleeding).

However, it …

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