Abnormal Menstrual Bleeding (not on hormonal contraceptives)

Frederick R. Jelovsek MD

• Period twice in one month
• Bleeding 5 weeks after delivery with pain
• Continuous bleeding in spite of BC pill therapy
• Endometrial ablation for heavy 8 day menses
• Can prolonged menses be due to stress?
• Light brown discharge 9-14 days into cycle
• Endometrial ablation for bleeding and PMS
• Will spotting with straining interfere with conception?
• Recent period 1 week early then another 2 weeks later
• Bleeding after intercourse and anovulatory problems
• Can heavy bleeding wash out sperm or prevent implantation?
• 47 y.o. with heavy clotting and pain each month (adenomyosis)

Period twice in one month

If a teenage girl gets her period twice in one month what does that mean? is it even possible?

If one of the bleeding episodes is extra bleeding rather than a menses. It may be due to ovulation. Also if something happens to the corpus luteum gland on the ovary in the second half of the cycle, this may induce extra bleeding. Usually if the extra bleeding does not occur more than two months in a row, You don't need to have it investigated.

Bleeding 5 weeks after delivery with pain

Five weeks ago I had my third baby. It was a normal vaginal delivery with an episiotomy and no tears. My lochia turned yellowish-white around 3 weeks postpartum. Around 4 weeks postpartum I felt real tired. At 4.5 weeks I had a pain on my left side and two day later I started to bleed a dark brownish- pinky color, not bright red, and I'm still bleeding. I want to know if this is normal or should I contact my physician?

This is not uncommon. As long as you do not have a fever and as long as the bleeding is not greater than a normal menses, the doctor will probably just have you wait to see what happens further.

Or, could this mean I'm too active?

Probably not although sometimes strenuous activity can start off some spotting.

Could it be my periods returning?

It probably is not a menses but it could represent your first ovulation if you are not breast feeding.

Also, the same day I had that pain I had sex (not supposed too, until check up). Could I have caused this by having sex?

Sexual relations can sometimes start up some bleeding postpartum for the first one or two times. If it happened more than that you might need to see the doctor for a checkup.

Now, my bleeding has changed it turned bright red with a few small clots. Could there still be a piece of the placenta left?

Could be but probably not. What tissue does come out sometime later is the decidua which is the tissue between the lining of the uterus and the placenta. It takes awhile to totally slough out.

Continuous bleeding in spite of BC pill therapy

I'm a 38 year old female and I have bleed almost constantly for past month. Originally, I went back on the "pill" because periods and cramps were so debilitating and I have been on just about every family of pill available but nothing is bringing me back to "normal" This month, I have had my period all month (lightly) and when the time came for my actual period, there was very little change if any. My doctors say it is breakthrough bleeding and that everything is normal.

Has it been only one month that there has been bleeding other than at normal menstrual time or is it many months? We need to know the full history on the bleeding.

It sounds as if the cramps have been going on quite awhile. Have you asked to be referred to a gynecologist?

I've been bleeding for 5-6 weeks and the gynecologist says to wait for three months to see if the pills straighten me out.

Anovulatory bleeding that is irregular often does take 3 months to straighten out on its own, but we don't wait 3 months to treat if it is continuous bleeding. If this is really continuous for 5-6 weeks you should get some hormonal treatment to try to stop it, cause a withdrawal bleed and hopefully get it straightened out. If a family doctor can't do that, insist on seeing a gynecologist soon.

I have been seeing a gynecologist and have been taking birth control pills for some time to straighten this thing out. I've been told that I am exhausting the different families of pills that I can take. Some of them cause me to blow up like a balloon and this last one did not even stop the bleeding. I just kept having my period all month long and the gynecologist said, "Let's give it a total of three months."

You have had reasonable trials of hormonal therapy. It is now time for a hysteroscopy and D&C to make sure there is no mechanical cause of bleeding inside the uterus such as polyps or fibroids.

Endometrial ablation for heavy 8 day menses

I'm 36, have two children ages 15 and 12. I am not having any more children. My periods are very regular, but last over 8 days. No bleeding between periods. The bleeding is so bad that I have to stay at home for 2 days during my period. Another question. If I do not have submucosal fibroids can an endometrial ablation still work?

Yes, ablation is targeted at women with heavy menstrual blood loss in the ABSENCE of organic pathology such as fibroids that have failed other medical or surgical management and who no longer wish to become pregnant. However, don't forget the numbers about success. In large studies, after ablation 25-60% had no subsequent periods, with most of the remainder having a decrease in the amount of menstrual flow. About 10% fail to improve and require another ablation or hysterectomy (about 2%).

Can prolonged menses be due to stress?

My period started on 10 days ago and it's still here. I am also very depressed these days because of some family problems. Can tension be a reason for this long time bleeding?

Tension and stress can affect ovulation which in turn affects menses. Your current bleeding however, if it is due to stress, is not due to the stress at this moment. Rather it is likely that the bleeding now represents stress in the month before this period started. The stress somehow causes a dysfunctional ovulation and then the menstrual bleeding after that is what is disturbed.

One more question..I am having pain in the lower abdomen at the left side. The pain is not severe but it is present there 24 hrs. and my bleeding got heavier for the last two days.I am concerned about the pain and heavy bleeding. Any comments?

When ovulation goes dysfunctional, there is often a follicular cyst or corpus luteum cyst on the ovary that can produce pain. There are other possibilities though such as infection, endometriosis, etc, so it would be a good idea to be checked if this pain persists.

Thanks! I am planning to see a doctor next week.

Light brown discharge 9-14 days into cycle

I'm 33 years old. I'm having a thin lightly-tinged brown discharge from my vagina. It happens about 9-14 days into my cycle. No pain or smell. I went to the gyn about 1 month ago and my pap and everything were normal. Could this be normal ovulation for me? Do you have any suggestions?

You can get ovulatory bleeding in the middle of the cycle and if it is very light, it just comes out as brown tinged as you describe. Usually it doesn't happen every month though.

Do you know that the Pap was normal or just that it was not abnormal? The reason I ask is sometimes inflammation shows up on the Pap but if you are not symptomatic with abnormal bleeding (in this case you are), then physicians usually don't notify you that the Pap shows this.

They said that the pap was "within normal limits." He told me not to worry about the light brown if it didn't continue more than a couple of days or if I didn't have pain. It doesn't happen every month. Every 2 or 3 months maybe. Sometimes only a touch, sometimes a little brown for a day or so.

That doesn't sound worrisome. If you start having bleeding more often or bleeding after sexual relations then you should return to see the doctor.

Endometrial ablation for bleeding and PMS

My doctor has recommended me to have endometrial ablation procedure done for my heavy bleeding and blood clots but my biggest concern is will this help my severe PMS. I have had all the tests done and they are normal but my periods are getting worse especially with the PMS and if this procedure does not help that what else can I do, I do not want to make this decision and it is not a right.

I don't know the answer to this. In one respect, all the factors associated with PMS -- ovulation, progesterone, pelvic blood vessel engorgement will still be present even though you have the ablation. The fact that the cramps and flow will decrease or be absent should play a role in decreasing some of the PMS symptoms. Basically I'm not sure whether ablation will decrease your PMS symptoms, but it is an out patient procedure which would not put you out of work or activity for more than 3-7 days.

Will spotting with straining interfere with conception?

It is time for my ovulation and I am trying to get pregnant, but I sometimes have a single, light spot of blood whenever I use the bathroom (a little heavier with a bowel movement) and usually only after straining. For most of the month it is normal for me and I never paid it much attention until now. Will it interfere with me conceiving?

No. The spotting should not interfere with conception.

Recent period 1 week early then another 2 weeks later

I am 32 with a 2 year old child. I have not been on any contraceptives for 5 months now and my period is every 30 days. The most recent period was only 21 days (1 week early) and two weeks later, I got what seems like another period. Before It seemed like a period, I called the doctor who ordered a pregnancy test which came out negative. Now I am puzzled. Any Thoughts?

Sometimes ovulation or menses gets out of synch for a cycle or two and we never know why. It can be due to medications, colds, things eaten, stress, etc. Usually the rule of thumb is that if the abnormal bleeding persists 3 cycles in a row, you need to see the doctor because it may not get better on its own. Your doctor ordered a pregnancy test because you are not on contraception and having bleeding could indicate an ectopic pregnancy or early miscarriage. With those ruled out by the negative test, it is generally safe to wait and see if the bleeding cyclicity will straighten out on its own.

Thanks for taking the time to answer my question. Since I have always had quite regular periods even prior to having a child I was a wreck for several days. Hopefully it was a one time thing....It is bad enough to have just one period a month!

Bleeding after intercourse and anovulatory problems

My question is, after intercourse I have spotting for about a day maybe two. This is a very recent thing, is it normal?

I do have a little background. I am 30 years old, and at age 18 my general practitioner put me on BC pills to cure abnormal bleeding. I stayed on the pill for 7 years until I had blood pressure problems. After being taken off my real problems began. I had no periods for 8 mos. then it was pill induced by Provera® for 2 mos. then I had a period that would last 30 days or more. After many tests my general practitioner sent me to an OB-GYN specialist. He continued the Provera®, did a hysterosalpingogram an found a blocked tube. Knowing that I wanted to start a family he began fertility treatment. After months of Provera®, Clomid®, and frustration I stopped all the madness and said forget it. My periods regulated to three weeks of bleeding and a period every two to three months for about three years.Then I had a heavy bleed that lasted 45 days so bad that I couldn't even get out of bed and became pale and hypovolemic. My Dr. sent me to a new OB-GYN. He explained what he thought was happening and again gave me Provera®, but this time it did not work. He proceeded with Lupron® shots and that did the trick. But my bleeding remained very heavy and lasted weeks for each period. He has done much blood work, many ultrasounds and another hysterosalpingogram to find both tubes unblocked. Again I had a round of bleeding that was just horrid and unstoppable. Because it was right before our vacation I was put on 10 days of Provera® followed by 5 days of Clomid®. In the middle of my vacation I had very painful mid cycle bleeding that brought me home and put me in the ER only days after stopping the Clomid®. They did an ultrasound and said that there was not much they could do to stop the bleeding, only the pain. That was about 8 weeks ago. the bleeding stopped a few days later, and now I have only had spotting after intercourse and nothing else. I feel like I am always calling the doctors office, but I know that this isn't normal. I feel like I am going crazy. I don't know if I should call with every little problem, or wait everything out. I have been without a period for 8 weeks now and I feel funny about calling since I was so anxious to get the bleeding to stop last time I called him. Not knowing where I am in my cycle makes it impossible to even calculate ovulation.

The bleeding (spotting) after intercourse is probably due to either direct irritation of the cervix or from starting up endometrial bleeding that is due to your basic problem of anovulation. Since you have had many blood studies done, your doctors must have some idea of what type of anovulation you have, i.e., hypothalamic amenorrhea, polycystic ovarian disease, hyperprolactinemia, etc. Clomid® may be used to induce ovulation in any of those so that is not helpful.

One of the main problems now it seems, is that the therapy is focusing on two goals, regulating the bleeding and inducing ovulation so as to get pregnant, that usually require almost the opposite therapy. One solution might be to just focus on the abnormal bleeding and get that straightened out, and then resume the fertility induction.

With so much abnormal bleeding, it is not safe to assume it only is dysfunctional, anovulatory bleeding even though you are young. Mechanical causes (polyps, fibroids) need to be ruled out with a hysteroscopy and D&C if that hasn't already been done. Also bleeding due to other unusual diseases such as coagulation problems (Von Willebrand's disease), thyroid problems (I'm sure this has already been checked), other medical diseases and medications need to be ruled out. When all of these have been done, the next step might be to regulate your periods with something like Premphase which is used in the perimenopausal/postmenopausal period to regulate bleeding and still produce a monthly menses.

Presuming the Premphase would regulate you so that there was no more abnormal bleeding for about 3 or 4 months, then you might consider retrying the Clomid® therapy to induce ovulation or whatever your doctor feels is needed.

At this point I would suggest making another visit to your doctor to discuss the bleeding after intercourse and let him examine you to make sure there are not local cervical factors, irritation etc., causing the bleeding. Then discuss the above plan as you and he think it applies. Agree on any plan or modification of the above so that you can have a systematic approach to getting over all of these problems. He will probably benefit from some regrouping in plan as much as you will.

Can heavy bleeding wash out sperm or prevent implantation?

I posted before about bleeding after a bowel movement and conceiving. I am now 3 days post ovulation and today after a bowel movement I began bleeding heavily with blobs of blood and cramping. It lasted about 3-4 hours and is now subsiding, but I'm still worried if it will affect conceiving. Am I just worrying too much?

If you are bleeding heavily such that it can "wash" sperm out of the cervix, then it will decrease the chance of getting pregnant. If it's just spotting, it shouldn't affect it.

Since I was 3 days after ovulation when the bleeding started, if I conceive this month, then conception had already happened before the bleeding started. So I guess what I'm really worried about is if the fertilized egg will be able to attach itself if I am steadily bleeding. As of today the bleeding has slowed but not stopped.

Implantation occurs about day 5-7 after fertilization. It implants in the uterus usually in the top or top-back on a very small area. I see why you are worried about the bleeding. If it continues heavy it could prevent implantation. It's still very possible, however, so just wait it out to see what happens.

47 y.o. with heavy clotting and pain each month (adenomyosis)

I am 47 years, and have had two children. I have always had pretty normal periods, although I was on the pill for 20 years. I have not been on the pill for about 6 years. Pap smears are normal.

For the last couple years, I have had really bad periods at least every third month. Then, last year, I started having heavy clotting, and pain every month. I went to a clinic and they said maybe I had endometriosis or cysts, or tumors...nothing specific....referred me to my ob/gyn. I never went, but it is really bad now.

Your age and with the above history, the most likely cause would be adenomyosis of the uterus. This is endometriosis interna or endometrial glands that go down into the muscle of the uterus. At the time of menses the endometrial tissue in those pockets cannot get out of the muscle and it gives pain. Unfortunately, adenomyosis is a diagnosis of exclusion. Other causes of the heavy bleeding and pain need to be ruled out.

Your gyn doctor would probably recommend a vaginal ultrasound ( to rule out uterine fibroids or any ovarian cysts) with a saline sonohysterogram (injection of fluid into the endometrial cavity at time of ultrasound to detect any endometrial polyps or submucous fibroids). If these are all normal, you could very strongly suspect adenomyosis as the main cause of your problems. Medical treatment for this at your age would be low dose birth control pills (if you are a non smoker) or Depoprovera injections to block your ovulation and menses until you become menopausal.

If any of the above studies suggest there is a mechanical cause of the bleeding or pain (polyps, fibroids, ovarian cysts) you will probably be recommended to have a D&C and hysteroscopy and possibly a diagnostic laparoscopy as outpatient surgery procedures.

Check out our menstruation forum to get more information about endometrial ablation.