Most women with abnormal vaginal bleeding are not even aware they need medical intervention. But how does one know when their bleeding is not normal? “If you have soaked through a pad or tampon every hour for 2 to 3 hours (heavy bleeding), your bleeding lasts longer than 1 week (prolonged bleeding), you have vaginal bleeding while pregnant, you have bleeding or spotting between periods, you have bleeding after sex, or you have bleeding after reaching menopause then you have abnormal vaginal bleeding, and you need to see a doctor,” explains Dr Theo. 

Post-menopausal women who have vaginal bleeding are at an increased risk of having cervical, ovarian or endometrial cancer.

Zara’s story

Zara, a 31 year old lady had been bleeding heavily for two weeks and was changing six or seven pads every 24 hours. The bleeding was accompanied by large clots and she would occasionally bleed through a pad and stain her clothes. At times, she would feel the need to use double sanitary protection to control the menstrual flow. Sometimes she would wake up at night to change pads. She kept wondering why her periods were getting heavier and more prolonged during her last few cycles but had not yet sought any medical help. This was already restricting her daily activities and she was getting concerned as she often felt dizzy, tired, fatigued and short of breath.

One day, while leaving the house, she felt extremely dizzy and collapsed at home. She had to be rushed to hospital where she was admitted. Tests done revealed that she had low blood pressure, anaemia and uterine fibroids.  She was put on appropriate treatments. However, Zara’s case of excessive bleeding is not isolated.

What happens during a period?

The average menstrual cycle lasts 28 days. Cycles can be as short as 21 days or as long as 35 days. The lack of periods for 3–6 months (amenorrhea) is abnormal. Most periods last around 3 – 5 days, though 2 – 7 days is still normal for some women. Periods are considered heavy if they cause such things as flooding, the need for double sanitary protection, soaking of bedclothes or passing clots. Severe blood loss can lead to dizziness and fatigue due to anaemia. 

Causes of abnormal vaginal bleeding

Abnormal vaginal bleeding can relate to an issue with your reproductive system (a gynaecologic condition) or to other medical problems or medications. 

Gynaecologic causes 

These include: 

Endometriosis: This refers to the presence of uterine lining tissue in other locations outside of the uterus 

Adenomyosis: It refers to the presence of uterine lining tissue within the muscular wall of the uterus, cervical and endometrial polyps (tiny benign growths that protrude into the womb), 

Uterine Fibroids: They are benign (non-cancerous) growths in the uterus that can develop during a woman’s childbearing years.

Pelvic infections (STDs) such as Chlamydia and gonorrhoea, ovarian cysts. 

Others are hormone imbalances caused by hormone imbalances, miscarriage, Perimenopause, Polycystic ovary syndrome (PCOS), Stopping birth control pills or hormone replacement therapy (withdrawal bleeding). 

Cancerous causes include: ovarian cancer, endometrial cancer, cervical cancer. 

Normal ovulation is necessary for regular menstrual periods. Lack of ovulation (anovulation) causes hormone imbalance with excessive estrogen production. This stimulates the growth of the lining of the uterus. This can cause prolonged bleeding at irregular intervals after not having a menstrual period for several months. The thickened uterus can also lead to an increased risk of uterine pre-cancer or uterine cancer over many years. 

When hormones are the cause, doctors call the problem dysfunctional uterine bleeding (DUB). DUB is more common in teenagers or in women who are approaching menopause. It is not always clear what causes hormone changes that lead to DUB

Medical conditions that can cause abnormal bleeding 

These include thyroid problems, severe systemic disease, such as kidney or liver disease, and blood clotting and bleeding disorders. Medications such as anticoagulants that prevent blood from clotting may result in abnormal bleeding.

Trauma or injury, including injury through having sex/ sexual abuse may cause bleeding, as problems with a contraceptive coil or IUD or any foreign bodies can also cause bleeding. Medical procedures such as cervical or endometrial biopsy or other procedures

What causes abnormal vaginal bleeding during pregnancy?

Slight “Implantation bleeding” may occur as a result of the fertilised egg implanting in the uterine wall. More serious bleeding may be a sign of miscarriage, ectopic pregnancy, placenta previa or premature labour. 

What diagnostic tests are used to evaluate abnormal vaginal bleeding?

The doctor/ clinician will take a detailed medical history. He will then take a physical examination.

The following tests may be done: 

A Pap smear is also done to rule out cervical cancer. A speculum vaginal examination will check for any pelvic infection, and examine the cervix. 

A pregnancy test is done to rule out bleeding in pregnancy, 

A blood count may be done to rule out a low blood count (anaemia) resulting from excessive blood loss. 

Other tests include urine test, thyroid function, liver function, or kidney function. Hormone profile tests may be done to confirm hormone imbalance. These include: progesterone levels to verify that the woman ovulates or follicle-stimulating hormone (FSH) to check ovarian failure such as happens in menopause. Additional blood hormone tests are done if the doctor suspects polycystic ovary, or if excessive hair growth is present.

• A pelvic ultrasound is often performed based on the woman’s medical history and pelvic examination.