Intermenstrual Bleeding

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Last modified 22/04/2025

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Chapter 115 Intermenstrual Bleeding

INTRODUCTION

Description: Bleeding between otherwise normal menstrual cycles is called intermenstrual bleeding.
Prevalence: Ten percent to 15% of all gynecologic visits involve menstrual disturbances.
Predominant Age: Reproductive, greatest in adolescents and patients who are climacteric.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Uterine (pregnancy, endometrial polyps, endometrial hyperplasia, endometrial carcinoma, leiomyomata), cervical (polyps, cervicitis, cervical erosion, cervical dysplasia/neoplasia), vaginal (trauma, infection, atrophy), perineal (vulvar lesions, hemorrhoids).
Risk Factors: None known. (The purported relationship to surgical sterilization has been disproved.)

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Intermenstrual bleeding (painless)
• Bleeding after intercourse (common)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Pregnancy
• Climacteric changes
• Anovulation
• Endometrial polyps
• Uterine leiomyomata
• Cervical polyps, lesions, or cervicitis
• Endometrial cancer
• Endometriosis
• Nonuterine sources of bleeding (e.g., vaginal, vulvar, or perineal)
• Coagulopathy (congenital or acquired)
• Iatrogenic (intrauterine device use, medications)

Associated Conditions: Endometrial hyperplasia, endometrial cancer, endometrial polyps, endocervical polyps or carcinoma, uterine leiomyomata.

Workup and Evaluation

Laboratory: Testing should be chosen on the basis of diagnoses being considered.
Imaging: No imaging indicated.
Special Tests: A menstrual calendar helps to document the timing and character of the patient’s bleeding. Endometrial biopsy, curettage, or hysteroscopy may be indicated.
Diagnostic Procedures: History and physical examination often point to possible causes for further evaluation.

Pathologic Findings

Based on underlying pathologic conditions.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation.
Specific Measures: Focused on underlying causation, age of the patient, and contraceptive needs.
Diet: No specific dietary changes indicated.
Activity: No restriction.
Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP095 (Abnormal Uterine Bleeding), AP049 (Menstruation [Especially for Teens]), AP162 (Menopausal Bleeding), AP163 (Cancer of the Cervix).

Drug(s) of Choice

Based on cause. Hormonal agents that produce endometrial thinning (such as combination contraceptives or long-acting progestins) can be useful in selected patients when conception is not desired.

FOLLOW-UP

Patient Monitoring: Normal health maintenance.
Prevention/Avoidance: None.
Possible Complications: Anemia.
Expected Outcome: Return to normal menstrual pattern with correction of underlying pathologic condition or periodic progestin therapy.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy aside from that resulting from causative conditions.
ICD-9-CM Codes: 626.6, 626.7 (Postcoital bleeding).

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REFERENCES

Level II

Peterson HB, Jeng G, Folger SG, et alU.S. Collaborative Review of Sterilization Working Group. The risk of menstrual abnormalities after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med. 2000;343:1681.

Level III

American College of Obstetricians and Gynecologists. Management of anovulatory bleeding. ACOG Practice Bulletin 14. Washington, DC: ACOG, 2000.

American College of Obstetricians and Gynecologists. Noncontraceptive uses of the levonorgestrel intrauterine system. ACOG Committee Opinion 337. Obstet Gynecol. 2006;107:1479.

Bayer RL, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA. 1993;269:1823.

Cowan BD, Morrison JC. Management of abnormal genital bleeding in girls and women. N Engl J Med. 1991;324:1710.

Field CS. Dysfunctional uterine bleeding. Primary Care. 1988;15:561.

Neese RE. Managing abnormal vaginal bleeding. Postgrad Med. 1991;89:205.

Pitkin J. Dysfunctional uterine bleeding. BMJ. 2007;334:1110.

Smith RP. Gynecology in primary care. Baltimore: Williams & Wilkins, 1997;375.

Thorneycroft IH. Cycle control with oral contraceptives: a review of the literature. Am J Obstet Gynecol. 1999;180:280.

Wathen PI, Henderson MC, Witz CA. Abnormal uterine bleeding. Med Clin North Am. 1995;79:329.

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