An Overview of Metrorrhagia

Metrorrhagia, commonly called intermenstrual bleeding, is vaginal bleeding that occurs at irregular intervals not associated with the menstrual cycle. While the blood comes from the uterus as it does during menstruation, the bleeding does not represent a normal period.

There are several causes of metrorrhagia, some of which are harmless. In other cases, metrorrhagia can be a sign of a more serious condition.

This article will explain the symptoms, causes, and treatment options for metrorrhagia.

Symptoms

Some women who menstruate regularly experience light bleeding or spotting at various times throughout their cycle, especially at ovulation. In these cases symptoms such as mild discomfort and spotting at mid-cycle may not be unusual.

Sometimes the bleeding seems to follow a pattern and it may feel like you're having “a second period” in between your usual periods. In other cases, the bleeding is entirely random and unpredictable.

It may be painless when the bleeding occurs, or you may experience cramps and other symptoms associated with your period, such as bloating.

Intermenstrual bleeding is often light but can also be quite heavy. In some cases, it may even be heavier than your regular period.

The color of the blood can range from dark brown to red to light pink. Some people may see clots or mucus in their underwear or when they wipe.

Tell your healthcare provider about the characteristics of the bleeding as well as its duration. This information can help them pinpoint a cause.

Causes

There are many potential causes of metrorrhagia, though hormone levels play a key role in most cases.

During a regular menstrual period, hormonal changes direct the lining of the uterus to build up in preparation to receive and nourish a fertilized egg. If this does not occur, the lining is shed and passes through the vagina.

With dysfunctional uterine bleeding, the lining is shed at another point in the cycle. Interruptions in the normal functioning of the hormones that direct the process can have various causes. Some, while inconvenient, are harmless, don’t last long, and can be easily treated.

Menarche and Menopause

When a woman first starts having a menstrual cycle (known as menarche), it is not unusual for cycles to be erratic. This can include spotting that occurs at various times throughout the cycle. Usually, this resolves as adolescence progresses and hormones stabilize.

This type of unpredictable, irregular bleeding may also occur at the other end of a woman's reproductive life when they begin to transition into menopause.

Stress

Interruptions to the menstrual cycle can occur during times of emotional and physical stress, such as after starting a new job or while traveling.

Birth Control and Medications

A person may also experience abnormal or unexpected bleeding if they start or stop using a form of hormonal birth control, such as the pill. Irregular use of hormonal contraception can also cause abnormal bleeding patterns, sometimes called "breakthrough bleeding," which will usually resolve once use becomes consistent or a person changes to another method of birth control that works better for them.

Other medications that can cause dysfunctional uterine bleeding include Depo-Provera shots, blood thinners like warfarin and aspirin, and supplements such as ginseng.

Malnourishment

Abnormal uterine bleeding and even the complete ceasing of the menstrual cycle can occur when a woman is malnourished and/or underweight. This can include restricting certain food groups, such as on the Atkins or Keto diet.

A person who is underweight may not be ovulating at midcycle. Anovulatory cycles are a common cause of irregular menstrual bleeding. These interruptions to normal ovulation can occur whenever the hormone balance in the body is interrupted, which can be caused by reasons other than weight or body fat percentage.

Fertility Treatments

Women who are undergoing fertility treatments often experience symptoms related to menstruation, including bleeding at unexpected times during their cycle, bleeding more or less than usual, or having premenstrual symptoms.

Underlying Health Conditions

Metrorrhagia can also be a sign of an underlying health condition. While some of the conditions are considered benign, others can have serious consequences if left untreated.

Metrorrhagia can occur in people with:

• Uterine inflammation (endometritis)
• Cervical inflammation (cervicitis)
• Pelvic inflammatory disease
• Sexually transmitted infections (STIs)
• Endometriosis
• Polycystic ovarian syndrome (PCOS)
• Adenomyosis
• Ovarian cysts
• Uterine fibroids or polyps
• Thyroid disease
• Conditions affecting the pituitary gland and/or adrenal glands
• Coagulation disorders such as Von Willebrand Disease
• Eating disorders
• Obesity

While many cancers of the reproductive system have few, if any, signs and symptoms in the early stages, abnormal uterine bleeding may be one. It is especially important to take note of abnormal vaginal bleeding if you are no longer having periods and have entered menopause.

The following cancers may cause metrorrhagia:

• Cervical cancer
• Vaginal cancer
• Primary fallopian tube cancer
• Ovarian cancer
• Endometrial cancer
• Uterine cancer

Diagnosis

If you are experiencing abnormal vaginal bleeding, your healthcare provider will start by asking you questions about your general health, particularly your menstrual cycle and sexual activity. They may also ask about the health of your family members, for example, if your mother or sister has ever been diagnosed with endometriosis, uterine fibroids, or reproductive cancer.

Your primary care doctor will most likely refer you to a reproductive healthcare provider, usually an obstetrician/gynecologist (OB/GYN), a doctor who specializes in reproductive health conditions.

An OB/GYN will talk to you more in-depth about your symptoms. They will likely ask you questions about the bleeding, such as:

• When the bleeding started
• How long it lasts
• Your sexual history
• If you have ever been pregnant and given birth

They may review any other medical conditions you have or have had in the past, as well as any medications and supplements you are taking.

Physical Exam

During a physical exam, you will be asked to change into a gown, position yourself on the exam table, and place your feet in stirrups. The healthcare provider may listen to your heart as well as your abdomen with a stethoscope. They may use their hands to palpate (push on lightly) your abdomen and pelvic region. If you experience any pain during this exam, let them know.

Your healthcare provider may also do a rectovaginal exam. Using a lubricated glove, they will place a finger inside your rectum and vagina. This helps them feel for any abnormalities.

A pelvic exam, in which a healthcare provider inserts a speculum into your vagina and spreads the vaginal walls, helps them see inside the vaginal canal up to your cervix, may also be done.

During a pelvic exam, your healthcare provider will most likely perform a Pap smear. A Pap smear is done by using a long swab to scrape some cells from the cervix. This sample will then be tested for any abnormalities.

While these exams can cause slight discomfort, they usually do not take long.

Labs and Tests

The healthcare provider may want to do some other types of tests to help determine the cause of metrorrhagia.

Tests your healthcare provider may order if you are experiencing metrorrhagia include:

• Blood tests to check for disorders that cause bleeding, nutritional deficiencies, infections, markers of inflammation, and other findings
• Tests to check your hormone levels and thyroid function
• Urine samples to check for pregnancy, infection, or STIs
• Ultrasounds of your abdomen and pelvis, including transvaginal ultrasounds
• CT scans or MRIs
• Tissue biopsies to check for certain types of cancer
• Surgery (laparoscopy or laparotomy)

Treatment

The treatment for menorrhagia will be specific to its cause, as well as the individual needs of the patient. Some treatments will be safer and more effective than others. For example, while hormonal contraception can be used to treat abnormal uterine bleeding, birth control pills may not be appropriate for a person with a history of blood clots.

Once your healthcare provider has figured out why you are experiencing menorrhagia, they can help you decide the best way to treat it.

Treatment options may include:

Lifestyle Changes

In some cases, the condition may be temporary and responsive to changes in your lifestyle. You may be able to treat discomfort with over-the-counter pain relievers (such as NSAIDs) while you work on reducing stress or getting yourself back on a routine after a vacation.

For example, if being underweight seems to be the cause of metrorrhagia, you may notice your symptoms improve when you regain the weight.

Hormonal Therapy

Certain types of hormonal therapy, especially those that include progestin, may be used to treat abnormal bleeding. These can include birth control pills, IUDs, estrogen patches, and other options.

Another form of therapy called Gonadotropin-releasing hormone (GnRH) agonists may also be prescribed. However, these medications can only be used short-term and can have many side effects.

If you are not sexually active or have never had sex, you can still use hormonal methods to treat problems with your menstrual cycle. Your healthcare provider will help you decide which one is best for you.

Dilation and Curettage

Procedures like dilation and curettage (D&C) may be recommended if you have heavy bleeding that is causing other problems, like anemia. A D&C involves removing some endometrial tissue with a special tool, a curette, inserted into the uterus through the vagina.

You don't necessarily need to go to the hospital for a D&C—the procedure can often be done in a healthcare provider's office or at a reproductive health clinic.

Although D&C is not surgery per se, it is typically performed while you are under anesthesia. While it can be useful for figuring out why you are bleeding abnormally, D&C procedures don't solve the problem indefinitely. They are also more invasive than other options and come with their own risks. Your healthcare provider will help you decide if it's the appropriate option for you.

Treating Underlying Health Conditions

If menorrhagia is being caused by another health condition, it’s important that it is properly diagnosed and treated.

Sexually-transmitted infections can often be treated with medication, such as antibiotics. If you are diagnosed with an STI, it is important that you notify any sexual partners you’ve had and practice safer sex.

For conditions that affect another part of your body, such as your thyroid or blood disorders, you will likely need to work with a specialist for treatment. Once you address the underlying disease that is causing your symptoms, menorrhagia will usually resolve.

If you are diagnosed with a more serious condition, you will need to work with a team of healthcare providers who will help you decide on treatment. Surgery may be required, especially for conditions such as endometriosis, fibroid tumors, and reproductive cancers which usually need specialized surgery. In some cases, your healthcare provider may recommend you have a partial or complete hysterectomy.

Summary

Metrorrhagia, also called intermenstrual bleeding, abnormal vaginal bleeding, or dysfunctional uterine bleeding is vaginal bleeding that happens outside of the normal menstrual cycle.

Sometimes the bleeding occurs due to lifestyle factors like stress, weight loss, or travel, but it can also be due to hormonal changes, medications, and certain health conditions.

This type of bleeding can have many causes, some of which are more serious than others. The type of treatment will depend on the cause and the specific needs of the person experiencing metrorrhagia.