Womens Health

Abnormal Menstrual Bleeding Without BCPs

Frederick R. Jelovsek MD

Bleeding treated with shot of estrogen

I am 250 lbs., at 5'6" and 39 years old. I started bleeding the first week of March. I had just started an aerobics tape and was using it every day in February. The first week bleeding in March was light to average, the second week it was spotting, then the 3rd and 4th was very heavy. My GP gave me a shot of estrogen to stop the bleeding so that we could get a pap since it had been awhile. It did stop for about 5 days but then started again before a pap was taken. He went on vacation and another doctor gave me progesterone to take. I took it for 3 weeks but nothing happened. The whole month of April, I bled average to heavy with 3 days of extreme heaviness in which I flooded the bed at night. I have HMO insurance so I have to wait for the doctors to refer me but I am demanding it be soon!! My feet have been swelling up a lot and I have been drinking more water. That has helped. Other than the bleeding, there has been no period.

The abnormal bleeding in March can be an ovulatory problem (lack of or premature corpus luteum dysfunction) or a mechanical cause such as a polyp or fibroid. Either can be brought on by exercise or can be spontaneous, we won't know.

The initial estrogen shot you received may temporarily stop bleeding, but it always needs to be followed up with progestin (e.g. Provera) otherwise you may resume bleeding again (as you did after 5 days). The Provera you were then given was appropriate. It may slow the bleeding but the bleeding doesn't usually resolve until it is discontinued and a withdrawal happens (sometimes called a medical curettage). You said the 3 weeks of Provera "didn't work", what did you mean by that?

Well, the doctor said the first week I would still bleed but not the second and third week. I bled the whole time I was on it. I completed the 3 week dosage on Monday. Since then I have had just light spotting. Do you think it's over?

No. You will probably start another period in 2 days to two weeks. This next period may or may not be normal but after it is over, your menses may be straightened out. One or two cycles of BC pills would be insurance to really straighten it out (if you can take pills). Then, if you have any bleeding after that, an office endometrial biopsy needs to be done.

If the cause of the bleeding was just mechanical, was it due to me being obese and trying to exercise?

If there is a "plush" endometrium (estrogen stimulated because of synthesis of estrogen in fat cells), exercise could cause the bleeding. Now, after the endometrium has sloughed due to the progesterone withdrawal (in next several days), exercise should no longer cause bleeding.

Should I lose weight first with walking and not aerobics until I have lost 50 lbs?

I don't think that will make a difference.

I will comment that my second doctor said after a failed attempt at a pap again: "Well, you have three options..progesterone, D&C or hysterectomy!!" I am so glad I took the progesterone! I thought this "options" thing was a bit premature!

Is the 2nd doctor a gynecologist? Nothing against GPs but sometimes they don't do the same volume of office endometrial biopsies as gynecologists so they may have more technical difficulty. I would be sure to see a gynecologist if the bleeding isn't straightened out after this cycle.

I was so hopeful. Today was the first day, in 2 1/2 months, of no bleeding! One or two cycles of BC pills? What is BC? Yes, the second doctor was a GP. We have HMO insurance and he wouldn't refer me to a GYN until a pap was taken. We have HMO because it's better for kids and preventive medicine, but not for choice of doctor. So when Jan 1, 1999 hits, we are switching back to the old insurance. I did demand on Tuesday a referral and finally got one. I have an appointment with a GYN on June 10th. I don't know what I will be doing by then..I could be in the middle of a bad period. But either way, eventually I do need a complete GYN physical. It has been 10 years for one.

BC stands for birth control. I'm sorry, I shouldn't use abbreviations. Sometimes you'll see OCPs standing for oral contraceptive pills which is the same as BCPs, birth control pills. Both these are different than HRT (hormone replacement therapy) or ERT (estrogen replacement therapy), although sometimes birth control pills are being used for "HRT" in the perimenopausal age ranges. Confusing isn't it. Glad you asked.

I am learning lots of abbreviations with this bleeding. I may be a rare case, but I have never used birth control pills. My husband takes care of that, he said he wants to make sure. Think there is a trust issue here? Anyway, thanks for all the advice.


Viagra and bleeding

We just got the new Viagra and it worked! But, now three days later I started spotting. Pinkish discharge when I go to the bathroom, no flow or anything at this time. I haven't had a period in about 6 months, I think I am pretty much into peri- menopause. I am 45 and diabetic also. Is it possible that this is just a friction thing. I have noticed I am very dry lately, too. Any advice appreciated.

Did you use Viagra or your husband? Are you referring to bleeding after sexual relations? More information is needed.

My husband takes the Viagra, not me. I think I just got a regular period because, after I sent this thing, it has just become a regular cycle. Normal flow, nothing weird. I guess the excitement and anticipation made me ovulate a couple of weeks of ago. Actually, I feel better since I have had it--I was kinda hormonal.---From what I've read, this type of pattern can go on for a few more years. I'm going to have the FSH level done when I go for my refills on my diabetic meds. Thanks, anyway for your following-up. Re:--bleeding started 3 days later, not directly after sex if this helps.

Since the bleeding started 3 days later, that is more consistent with a menses that was induced. Trauma to an atrophic vagina from increased intercourse would have started either right after relations or within 12-24 hours.


Menses after stopping the pill

I am 29 years old and have been on the pill for about 12 years. I decided to take a break and my first period occurred on day 36. It has been 50 days since the first day of my last period. Before I went on the pill I used to have 35 day cycles. I am not pregnant - can anybody explain. It seems this may be normal after going off the pill! Is it?

Birth control pills do not seem to change your body's ovulation timing no matter how long you are on them. They mask what your normal cycle would have done had you not been taking the pills. When you discontinue the pills, your body goes back to whatever its cycle would have been at this point in your life had you not taken the pills. This may take up to three cycles to get back to that pattern however.


Premenstrual spotting

For the last 3 months I've been spotting brown or black discharge for about 3 to 5 days then I have my regular period which lasts about 5 to 6 days. I have severe cramping and I've been having a period every 15 days. I am not taking BC pills. What can cause this?

Ovarian cysts can cause the bleeding you describe. Endometriosis is another possibility. Sometimes is is just inadequate corpus luteum function which may go away on its own.


Want to delay my period

Going to a nude beach over the holiday weekend! My period will start about 1 or 2 days into my vacation. I am not on the pill. Is there any safe way to postpone my menstrual start date with less than a month to go?

Not that I know of. You would have to start BC pills now in order to do what you want. If you were on a BC pill this entire cycle it might be possible by extending the active pills (i.e., using the three week active pills then taking another week of active pills and then discontinuing). If you are much more than a week or so into this cycle, it probably would not work.


Change in menstrual flow

I am 25 and only during the past 2 yrs have my periods been normal. But in the last 2 months my periods have been strange. They have started out light for the 1st 2 days and then normal. Then this month it was light for about 3 or 4 days and then it really started. I had my period for about 5 days. It really started on a Thursday and was over on a Monday. Then the following Saturday I got it again. Only I noticed I passed 2 blood clots with heavy bleeding then it went to a very light flow. It is still that way now. I think it is over because the pad is clean but there is blood when I go to the bathroom, but not in my urine. It is very light. This is the first time this has happened. My last pap smear was in January and it was normal as was my last exam. I am not a virgin but not sexually active for over 8 yrs and feeling no pain or discomfort.

As I understand, the character of the flow has changed the last two months with spotting and then normal flow and in addition, this month you are actually having extra bleeding that might be characterized as intermenstrual bleeding. These questions are actually some of the most difficult to answer because at this time, we are not sure if it is going to be a chronic, recurrent change or whether this is an isolated one or two cycles that just gets off kilter for reasons we'll never know.

The general rule-of-thumb is to just observe and do nothing unless the menstrual abnormality occurs three cycles in a row. That is because a situation such as you describe happens not infrequently to many women at some time, but does not usually continue as a long term problem. While we don't often know the causes, it is likely that something interfered with normal ovulation during the previous one or two cycles. Sometimes it can be stress or trauma or unusual physical exertion. It may be prescription or over-the-counter medicines taken. Any infections or illnesses could also affect this. If causes such as this don't continue, the menstrual problem will usually straighten out by the third cycle. If it doesn't, you should have an evaluation. Do you think any of these things might apply to your situation?

Yes, some of these may apply to me. During my first abnormal period, I had a cold and was taking Hall's cough drops-4 or 5 a day and Alka-Seltzer Cold Medicine. Then I had taken a sinus sudafed-like medicine from Walmart. The next day I began with the 2nd part to my period. Plus, I have been under stress with exams --3 last week-- and 2 weddings I am in this summer. Thank you for you help.


Eight months of irregular bleeding

I am 26 years old and in 8 months ago I went to my doctor because I had finished a regular period but in just over a week I began another one. I do not have a history of abnormal periods before this. At the time, I was not on any kind of birth control. The bleeding continued for over a week so I went to see the doctor expecting a cyst or tumor (my mother had a history of fibroid tumors). My exam was normal and my doctor suspected hormonal imbalance. She then prescribed birth control pills and I was to take a large dose at first (to stop the bleeding) that tapered down to the normal one per day. The very day after taking the first dose of pills the bleeding stopped. I then began to take the normal dosage of one per day. My doctor gave me three sample packets to start with, but by the time I reached the second pack I was once again starting bleeding while still on the "active" pills. One of the nurses informed me this was normal and it may take me three months to adjust. Well, three packs later it was still happening so they placed me on another kind of pill. Unfortunately I had a bad emotional reaction to those (I have a history of depression) and had to discontinue taking them. Anyway, I am now on my fourth kind of birth control pill and always start on average nine days too soon. It is driving me crazy! Since August I have been on my period more than off. The flow is much lighter than I experienced without the pills but all in all, I am VERY unhappy and have not found anyone with this same problem. Most everything I see are women who experience much shorter or no period at all. I am desperate! The latest pill I am taking is Lo/Ovral, it has made me mentally a wreck! I contacted my doctor's office who now want me to try something called Levelen. If anyone has experienced this or has a possible solution please contact me.

You've now had almost eight months of abnormal bleeding on pills. It is time to do some investigative work to see if there is a cause other than hormonal. Your doctor will probably want to check thyroid status, possibly a bleeding time (especially if you are an easy bleeder or bruise easily) and a pelvic ultrasound. If the endometrial lining is quite thin on ultrasound scan (one half centimeter or less) and the other studies are normal, you probably need to take a break from the pills or have supplemental estrogen. If the lining is thicker than one half centimeter, you may need to have a biopsy or saline sonohysterogram to make sure there is not a mechanical cause of the bleeding (polyps, fibroids) even though you are only 26 years old.


Bleeding after treatment for polyps

I am 30 years old. About a year ago I was diagnosed with endometrial polyps. I had them removed and my doctor said there were "billions". After surgery, my irregular bleeding problem stopped. Recently the problem started again. I experience clumpy bleeding mid cycle and while exercising. I am now trying to get pregnant and I wonder if the polyps will cause problems?

I don't think anyone knows for sure if polyps prevent pregnancy. I doubt that they do because infertility specialists don't see that problem in a higher proportion in their infertile patients. I suppose if there were a lot of polyps it would be possible. If you go more than 6 months of trying to get pregnant but don't, I think it would be time for another physician visit.


Spotting after menses

I am a teenager and have been menstruating for four years. Just recently I have noticed a very light flow of blood coming from me. After my period ended, it stopped for a day then came right back. I know I have no thyroid problems (as I found out from semi-recent blood work). I have no history of cysts or anything else like that, and it doesn't run in my family. I am sick and tired of the constant bleeding and I am quite scared of gynecologists, so I am looking for a home remedy. My email address is shared, so please don't provide a link or send anything to my address. Please just post this on the site and I'll check back every so often to see if anyone replied. Thanks.

Post menstrual spotting is a difficult diagnosis. It often occurs for unknown reasons. However, if it lasts more than 3 cycles in a row, it would be a good idea to see a gynecologist even if you don't really want to. The reason is that post menstrual spotting can often be due to a cervical inflammation (cervicitis) or vaginal irritation. Those are quite treatable if diagnosed correctly. I don't know of any home remedies that would even come close to treating this other than to just do nothing and see if it goes away.


Flooding periods

I am a 29 year-old female who has never had children. I am writing because I have a very regular but extremely short, heavy period with a lot of clotting. These periods are disruptive to my schedule, as I am often tired and light-headed to the point of missing days at work. Sometimes I will get a migraine headache right before the onset of my period. My pap smear is normal. I took the pill in order to regulate my period, but it did not work and made my general mood worse. I would just like to know what would cause such a heavy period to the point of what I jokingly refer to as "flooding". Any input would be appreciated.

It is hard to say what causes heavy periods. Sometimes it can be a "normal" (80ml or less than 3 oz) amount of endometrial tissue and blood that comes over a short time (1 or 2 days rather than 4-5 days) or larger amounts over 4 oz. (120 ml). Sometimes there is just plush but normal endometrium due to a healthy amount of estrogen from normal ovulation. Other times there can be excess estrogens (and thus excess endometrium) from disorders such as polycystic ovarian disease, adrenogenital syndrome or foods or medicines high in estrogens. There can also be mechanical or anatomical causes such as polyps or sub mucosal fibroids although they are not that common under age 30. Truthfully, most of the time the cause is unknown. If there is a lowering of your blood count (anemia) then it needs to be diagnosed and treated. Usually the doctor will check a complete blood count to see the hemoglobin level and what are called indices to see if your body is keeping up with the blood loss by forming new blood. If there is not an anemia, most of the time treatment is symptomatic to try to reduce the flow. Antiprostaglandins are used such as Ponstel in the U.S. Hormones can also be used but as you indicated there are often side effects to those too. There are surgical methods and office procedural methods to permanently decrease the flow but those are not usually used unless anemia is being caused by the blood loss and there has been an investigation that shows no anatomical causes such as polyps or fibroids.


Pain and vaginal bleeding after exercise

Today I was at the gym running on the treadmill, and I felt this sharp pain in my lower abdomen as I ran. When I got home and used the restroom, there was some blood in my underwear. My period didn't start. This isn't the first time I have felt that pain but I thought it was just a side stitch. I am having other problems with my menstrual cycle, like breakthrough bleeding, and some cramping. I have an appointment with my gyn, but I'm really starting to get concerned. Any ideas?

Vaginal bleeding brought on by exercise or trauma is usually related to either disruption of the corpus luteum of the ovary (gland that forms after egg is ovulated each month) or anatomic abnormality inside the uterus such as a polyp or fibroid. The sudden pain and then the bleeding would go along with a ruptured corpus luteum of the ovary or even mid cycle ovulation if it occurred 14 days or less from when the NEXT menses was supposed to occur. Bleeding from anatomical causes would be more likely at age greater than 35. There are other causes such as local cervical irritation, endometriosis, endocrine bleeding etc., so you are right to get an exam to put the total picture together with the other ovulatory problems you describe.


Heavy menses and polyps

I am 38 years old. I have three teenagers. Two were born by C- section and the third born naturally. My periods have always been normal other than a lot of cramping the first couple of days. My paps have always come back normal. Three years ago I was hospitalized for 5 days with a severe case of pneumonia. I had just started a period the day before being admitted. It lasted about 5 days which is normal. About a week later I started again and this time bled for 25 days: heavy the first week, then light to moderate the other. I was referred to an OB- GYN who did an endometrial biopsy. It came back clear. He did not pursue the cause -- just gave me options ranging from estrogen- therapy birth control pills to hysterectomy. Although I have never been able to handle birth control pills and he did not seem worried, I took that option anyway. I was off them in two months. My regular physician tried two lower doses of which I could handle neither. Nonetheless, my periods returned to normal. In December of '96 I was over two weeks late. Thinking I could be pregnant, I tried home tests. Negative. I went to the doctor. Started that day. Once again everything returned to normal. After a normal period in June '97, I did not start until August and then bled for about 22 days. Went back to regular doctor. He prescribed two hormones (he called it a "chemical D&C"). Normal in September and October. Started two weeks later in November and bled for 17 days. Started again on December 18 very heavy with lots of clotting. Due to being fed up with doctors treating symptoms and not causes, I waited until (yes, almost too late) 30 days of heavy bleeding. When I went to my regular doctor, my blood volume was at 26.2%. I was referred to a different OB-GYN. He did another endometrial biopsy and said it was probably hormone-related but was more worried about my blood count than what was causing the bleeding. He suggested we try Depo Provera injections for six months. I stopped about two weeks later. The biopsy was normal, however, the nurse said the was a polyp but they were not worried, they probably got it all and polyps are almost always benign. Three weeks later I started cramping like a period was about to start. He had told me I should not have a period except maybe a little slight bleeding. By late the afternoon I began cramping Feb 12, I was pain so severe it was worse than the labor pains with my last child. I called the specialist, but since it was almost time for him to go home the nurse told me to go the the ER. He had told me to call him if I had any problems. Just as we were about to leave, I felt something "drop" like about to deliver a baby. I sort of did, I guess. A mass of tissue (no form to it) that looked to be the size of mid-term fetus fell from my body. The pain eased to mild cramping but the bleeding was heavy. Stayed heavy for about a week, then was light. However, I have had some discolored discharge, then nothing, then some light bleeding for a couple of hours, back to nothing all in the same day. This is still the routine. I have not gone back to the doctor because it cost me over $500 to learn my blood count was dangerously low. I knew that at no charge. My husband and I have recently started our own business and have no insurance. Doctors here don't get very serious. In fact, most of the clinics in this area are "meat markets". Doctors have no time to have a discussion with their patients. I know, I made an appointment to do so and was rushed out in less than 5 minutes. I am still plagued that I had no problems until I was in the hospital. How can I find out the cause of my problem not just the correct treatment of the symptom?

You describe more and more frequent episodes of prolonged vaginal bleeding known as menorrhagia. While that can often have hormonal causes, you are getting in the age range where mechanical causes of bleeding may be more likely. You said one biopsy showed a polyp and it is likely that there may be more polyps there. It sounds as if you might have even passed a polyp or sub mucosal fibroid or perhaps just a large fibrin clot. See the article on our news site about saline infusion sonography about diagnosing mechanical causes of bleeding. It sounds as if it is time for you to have a D&C and hysteroscopy if this last episode doesn't resolve your heavy bleeding.


Fibroids and bleeding

I am a 39 yr old female. I was diagnosed 17 yrs ago with a pituitary tumor. For 13 years I did not have a period until I started taking Parlodel intravaginally. This month I have had what seems to be 2 periods which lasted 5 days and bleeding for 4 days between these "periods". I was sent for a pelvic ultrasound last Friday that showed fibroid tumors. My gyn wants to do a D&C because he "suspects" a fibroid is growing in a place it shouldn't be, causing the bleeding. My endocrinologist had me come for a Prolactin test. I got the results yesterday and for the very first time in 17 years it is at 24 - Normal is 0-25. It has been as high as 200. She said to continue the Parlodel and that this is not what is causing the bleeding. My question is - If the prolactin level is down and the pituitary seems to be able to generate estrogen now, could this irregular bleeding be caused from high estrogen level? I really do not want this D&C. I want to explore all my options first. How do I get my gyn to understand that part of my condition? Please anyone reply. I am scared!!

The bleeding sounds either to be on a functional (endocrine) level or a mechanical/anatomical cause such as fibroids, polyps, hyperplasia, or cancer (unlikely). At age 39 we tend to see the mechanical causes more frequently but fluctuating estrogen levels also may produce this. It sounds as if your doctor saw possible anatomical candidates (fibroids) on the ultrasound. Most of the time you can't see sub mucosal fibroids on a regular ultrasound. A saline sonohysterogram is an office procedure that can sometimes tell more definitely if there is an abnormal anatomical growth in the uterus that might be causing the bleeding. On the regular vaginal probe ultrasound, if the endometrial cavity is quite irregular, we usually recommend a hysteroscopy (looking into the uterus with a "scope") followed by a D&C, all done as outpatient or office surgery. When you say D&C, I am pretty sure your doctor means hysteroscopy and D&C.

On the other hand, the only serious cause would be a malignancy or pre malignancy of the endometrial cavity. That could be ruled out by an office endometrial biopsy. If that were negative, you could wait and see if the problem persists. An endometrial biopsy usually won't cure bleeding from a fibroid or polyp and you would eventually end up having the hysteroscopy and D&C.

To address the listening problem, asking your doctor if an endometrial biopsy would be sufficient for the time being and then the further work-up if the bleeding persists would be a tact to take. If the doctor is highly suspicious of an anatomical cause from the ultrasound already done, then still going ahead with the hysteroscopy and D&C is likely to be the primary recommendation. If it is not so certain that there is a anatomical cause, or there is someone in the community performing saline sonohysterograms, then temporizing with just the biopsy is likely to be an acceptable alternative.


Abnormal bleeding and family history of uterine cancer

I have had abnormal bleeding on/off for the past 3 yrs. I've mentioned it to my G.P., who brushed it off as stress ("If you were 40, I'd be concerned about uterine cancer"). I told her that my mom had it when she was 25. She just shook her head. Recently, it has been worse, mostly just spotting during the month. Besides my mom, her two sisters have also had uterine cancer, and just recently, my grandmother has been diagnosed (she is 65, hasn't had a pap in 25 yrs). I'm somewhat nervous (okay, scared), at facing the possibility that I could also be afflicted with this disease. I guess I just need a friend! :)

Three years is a long time to have abnormal uterine bleeding and not have a diagnosis or treatment. You are right to be concerned just on that basis. How abnormal is the bleeding? What is its pattern?

Uterine cancer can be endometrial (the lining of the uterus), cervical (abnormal paps etc.) or rarely the muscle of the uterus. Did everyone in the family have endometrial cancer that you know of? There are some genetic tendencies toward early endometrial cancer.

While usually endometrial biopsies or D&Cs are not done to rule out cancer at ages less than 35 or 40, that only applies to initial presentations of abnormal bleeding. If bleeding persists after attempts at hormonal therapy it still needs to be evaluated, including possibly an endometrial biopsy even at age 25.

There are very few drugs or medications known to prevent any cancer but birth control pills have definitely been shown to prevent endometrial cancer if taken over a long period of time.


Continuous bleeding for a month and a half

I have been having bleeding problems for the past month and a half or so. My periods haven't always been regular but over the past year, they have straightened out pretty well. My problem is that over the past 48 days, I have been moderately spotting every day and three days ago I began bleeding VERY heavily and have had HUGE clots, many, many clots. I am not cramping more than usual but I have been retaining water more than usual in the past two weeks. I can't afford to have a bunch of tests run or pay an exorbitant amount of doctors' fees; however, if that's what I have to do, I will. (I just needed some advice.) I have been very tired lately and have been feeling weak. I have also been fighting a headache off for about two weeks. I don't know if it's just sinuses or a migraine.

48 days is too long. Something needs to be done. Your tiredness may be from the stress of bleeding so long or actually from blood loss anemia. Your doctor will want to check your blood count.

How old are you? What the doctor will do next depends upon what age group you are in and any other signs and symptoms you may have. Are you on any hormonal medications or any other prescribed drugs or herbal supplements?

I am 23 years of age. There is no chance in the world that I could be pregnant -- I am completely celibate and have been forever. I am not taking any medication currently except for Benadryl (allergies) and Naprosyn (arthritis in knee).

The most likely cause of the bleeding is a lack of ovulation over one or two cycles followed by an irregular shedding of the previously estrogen primed endometrium. Quite often oral contraceptives are used over two or three cycles to try to stabilize the endometrium and slow or stop the irregular bleeding. The first month on the hormones you may not completely stop but by the second and certainly the third cycle you should straighten out. The pills do not allow you to ovulate either but after you stop them, hopefully your cycle will get back in synch.

An alternative is to just wait it out and see if the bleeding eventually stops and then you go back to cycling on your own. This may take awhile, however, so the pills are likely to regulate you the fastest. At your age the doctor will probably not need to do much testing other than to check your blood count. If you are an "easy bleeder or bruiser" or you have any family history of members who have bleeding problems, the doctor may want to get a bleeding time measurement to make sure you don't have a coagulation problem.


Differential Diagnosis of

Menstrual/bleeding abnormalities

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