Irregular or unscheduled bleeding

Overview

Many women struggle with both the heaviness, and the timing, of their bleeding. The ideal '28 day cycle' seems pretty elusive for some! There are a number of causes of irregular bleeding, and what investigations need to be done depend a bit on the age and fertility plans of the patient.

Causes

Common causes can include:

• Ectropion. Sometimes the cervix can be a little 'raw', and can become fragile and bleed after intercourse or occasionally at random times. Colposcopy is used to diagnose and treat this area.
• Endometriosis. The most common symptoms are painful periods, painful sex, pain before or during a bowel motion, and infertility. Sometimes the bladder, or very rarely other areas in the abdomen, can be affected. In some women, spotting leading up to the actual 'period' is a sign of endometriosis.
• Infection. Cervical or vaginal infection with chlamydia and other bacteria may cause bleeding, discharge and pain. In some cases the infection can spread to the womb and fallopian tubes, which can lead to severe illness (pelvic inflammatory disease) or infertility. It is very important that infection is ruled out in cases of irregular bleeding; in most cases this is already done by the GP before we see the patient.
• Instability of the lining of the womb – commonly due to fluctuations in hormone levels on the oral contraceptive pill, the contraceptive implant (Jadelle) or intrauterine devices (Mirena, Jaydess). This is sometimes called 'break-through' or 'unscheduled' bleeding. It is a common reason for stopping or changing contraception, but in most cases this will settle with time. There are various strategies that can be tried, such as adding extra estrogen hormone to balance the progesterone in the contraceptive, or an antibiotic (doxycycline) to help with repair of the lining.
• Ovarian cysts. Some types can cause irregular bleeding, including haemorrhagic cysts and functional cysts.
• Perimenopause. As women approach menopause, the number of healthy eggs in the ovaries is declining. Some cycles an egg won't mature and be released, leading to a missed period, while in others the higher hormone levels driving the ovaries leads to a shorter cycle. This unpredictability of the pattern, along with heavy and light cycles, can be very disruptive and many women seek advice at this stage to manage their bleeding. There are a range of options in this situation; see also the section on heavy periods.
• Polycystic ovarian syndrome (PCOS). This usually causes infrequent (4-5/year) and sometimes heavy periods. When the bleeding is so infrequent it tells us that the ovaries are not making an egg (ovulating) with any predictability. This makes getting pregnant very difficult, but luckily there are effective treatments. PCOS is associated with other medical issues, such as high blood pressure and diabetes, and so needs to be carefully managed throughout a woman's lifetime.
• Polyps. These are usually small (5-20mm) soft growths from the lining of the womb or the cervix. Sometimes the end can become ulcerated or break down and cause bleeding. It is rare for a polyp to be cancerous but it can occur and therefore if there are symptoms, if the polyp looks suspicious or you are around or after menopause we would suggest removal.
• Pregnancy. Early pregnancy needs to be ruled out as a cause in anyone who is sexually active and still having periods.