Assessment of intermenstrual bleeding

A careful history will usually reveal possible causes of unscheduled bleeding and guide on the need for examination and further investigations (1,2,3).

History:

• age – causes tend to differ with age
• menstrual history
  • last menstrual period - to determine the likelihood of pregnancy
  • length of cycle - establish the probability of anovulation
  • frequency, heaviness, and duration of the irregular bleeding and its association with menses
  • associated symptoms – abdominal pain, fever
• sexual history
  • starting a relationship with a new partner or presence of vaginal discharge – may indicate an infection, such as Chlamydia
  • past history of STIs
• hormonal and contraceptive history
  • failure to adhere to the hormonal contraceptive regimen is most often the cause of bleeding, especially if started within the past three months
  • further evaluation is required in cases with bleeding of more than 3 months duration, particularly if heavy
  • use of an intrauterine contraceptive device (IUCD)
• medical history
  • bleeding disorders
• family history of cancers
• current medication

Examination:

• observe whether the patient is obese since anovulatory cycles are associated with obesity
• abdominal examination
  • a pelvic mass suggests fibroid, especially if the patient has heavy periods
• bimanual examination
  • can be used to support the diagnosis of a pelvic mass
• digital examination
  • may reveal cervical excitation (indicative of infection) or craggy irregular cervix (in cervical cancer)
• vaginal speculum examination
  • most important examination and can detect cervical ectropion and cancer

Investigation:

• investigations undertaken in the primary care
  • cervical smear – if indicated
  • endocervical or vaginal swab – if there is a risk of infection
  • blood tests (FBC, clotting studies, thyroid function tests) if indicated from history. FSH/LH if the patient is suspected to be perimenopausal.
  • pregnancy test should be considered
  • consider a pelvic ultrasound if there is suspicion of uterine fibroids
• investigations in the secondary care may include:
  • hysteroscopy and endometrial biopsy
  • MRI

References:

1. Whitaker L, Critchley HO. Abnormal uterine bleeding. Best Pract Res Clin Obstet Gynaecol. 2016 Jul;34:54-65.
2. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Jul 2012 [internet publication].
3. Lumsden MA, Gebbie A, Holland C. Managing unscheduled bleeding in non-pregnant premenopausal women. BMJ. 2013;346:f3251.