Normal menstrual flow lasts about 4 days, produces a total blood loss of 30 to 80 ml (about 2 to 8 tablespoons), and occurs normally every 28 days (plus or minus 7 days).

Vaginal bleeding that occurs between periods or after menopause sometimes may be due to cancer or precancer, and should be evaluated promptly. The risk of cancer increases with age.

Make sure that bleeding is coming from the vagina and is not from the rectum or in the urine. Inserting a tampon into the vagina will confirm the vagina, cervix, or uterus as the source of bleeding.

A careful exam by your health care provider is frequently the best way to sort out the source of the bleeding. This exam can be accomplished even while you are bleeding. Do not delay getting an exam just because you are currently bleeding.

• Cancer of the cervix, uterus, or (very rarely) fallopian tube
• Cervical or endometrial biopsy or other procedures
• Changes in hormone levels
• Injury or disease of the vaginal opening (caused by intercourse, infection, polyp, genital warts , ulcer, or varicose veins)
• IUD use (may cause occasional spotting)
• Ectopic pregnancy
• Miscarriage
• Other pregnancy complications
• Uterine fibroids or polyps
• Vaginal dryness due to lack of estrogen after menopause
• Stress
• Stopping and starting birth control pills or estrogens
• Underactive thyroid (low thyroid function )
• Use of blood thinners (anticoagulants)

Immediately contact a health care provider if bleeding is very heavy.

Keep track of the number of pads or tampons used over time so that the amount of bleeding can be determined. Uterine blood loss can be estimated by keeping track of how frequently a pad or tampon is soaked and how often one needs to be changed.

Because aspirin may prolong bleeding, it should be avoided, if possible.

Call your health care provider if:

• You are pregnant
• There is any unexplained bleeding between periods
• There is any bleeding after menopause
• Abnormal bleeding is accompanied by other symptoms

The doctor will peform a physical exam and ask questions about your medical history. The physical examination with include an emphasis on the pelvic area.

Questions may include:

• Time pattern
  • When did this bleeding between periods begin?
  • Does it occur consistently, such as every month?
  • When (during the course of a menstrual cycle) does this bleeding begin?
  • How long does the in-between bleeding last?
• Quality
  • Is the bleeding heavy?
  • How many tampons or pads are required?
  • Do cramps accompany the bleeding?
• Aggravating factors
  • What makes it worse?
  • Does increased physical activity make the bleeding worse?
  • Does intercourse bring on the bleeding?
  • Is increased stress associated with the bleeding?
• Relieving factors
  • Does anything relieve or prevent it?
• Other symptoms
  • What other symptoms do you have?
  • Do you have abdominal pain or cramps?
  • Is there increased bruising elsewhere on the body?
  • Do you have any difficulty, pain or burning with urination?
  • Is there bloody urine or blood in the stools ?
• Other important information
  • Are you pregnant?
  • Have you had a miscarriage or abortion?
  • Have you had a D and C?
  • Have you ever had an abnormal Pap smear?
  • What medications are you taking? Do you take hormones or supplements?
  • Are you using tampons? What kind? What size?
  • At what age did your periods start?
  • Have you had normal periods without bleeding between in the past?
  • Are you sexually active?
  • Do you have a history of sexually transmitted disease?
  • Are you using birth control ? What kind?
  • Have you been injured?
  • Have you received any medical or surgical treatments?

Tests that may be done include:

• Blood tests for thyroid and ovarian functions
• Cervical cultures for sexually transmitted diseases
• Colposcopy
• Endometrial biopsy
• Pap smear
• Pelvic ultrasound
• Pregnancy test

Lobo RA. Abnormal Uterine Bleeding: Ovulatory and Anovulatory Dysfunctional Uterine Bleeding, Management of Acute and Chronic Excessive Bleeding. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: chap. 37.

Casablanca Y. Management of Dysfunctional Uterine Bleeding. Obstet Gynecol Clin North Am. June 2008; 35(2); 219-234.