assessment of intermenstrual bleeding

Last edited 09/2018

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

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 ectropian and cancer (1)

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 (1)

Reference:

• (1) Lumsden MA, Gebbie A, Holland C. Managing unscheduled bleeding in non-pregnant premenopausal women. BMJ. 2013;346:f3251.