MID-CYCLE or intermenstrual bleeding is bleeding that occurs between two otherwise normal periods. It may affect as many as one in four women in the reproductive age group.
Obstetrician-gynaecologist (ObGyn) Dr Anna-Kay Taylor Christmas said that some bleeding that occurs in the middle of the menstrual cycle may be normal, and is often due to the sudden hormonal changes associated with ovulation.
“This bleed is due to the sudden surge and then fall in oestrogen levels which occur near to ovulation in women who are not on hormonal contraceptives. We can determine if this is the likely cause if the bleeding tends to occur about 14 days, give or take a few days, after the first day of the last period, and if it is accompanied by other features of ovulation such as breast tenderness, abdominal pain, bloating and mood changes,” she explained.
Also, in the case of the oral contraceptive pill usage, especially in formulations with very low doses of hormone, there may be breakthrough bleeding. Women who take the pill improperly also often experience irregular bleeding due to the hormonal changes that this causes.
ObGyn Dr Jordan Hardie said mid-cycle bleeding also manifests due to a number of causes including uterine fibroids, endometrial polyps, cervical polyps, cervicitis, cervical cancer, endometrial cancer, laceration to the vagina, anti-coagulants (blood thinners), anovulatory bleeding (failure to release a mature ovum, leading to anovulatory cycle), and bleeding disorders.
Other causes include polycystic ovarian syndrome (PCOS), abnormalities of the cervix, endometriosis, implantation bleeding, herbs that have an action on the hormone system, low progesterone, hormone balance disruption, menopause or peri-menopause, and ovarian cyst rupture.
Less common causes of mid-cycle bleeding include excessive exercise, having an intrauterine device, pelvic inflammatory disease, luteal phase defect (ovaries don't release enough progesterone) or poor nutrition.
Dr Hardie said if women experience mid-cycle bleeding, the first thing that should be conducted is a pregnancy test.
“All women who notice bleeding outside of their normal period should do a pregnancy test. Having ruled out pregnancy, chart the bleeding. Record the number of sanitary napkins/tampons, record the colour is it bright red or dark? Does the bleeding occur after intercourse? This information will be very helpful to your gynaecologist in making a diagnosis.”
Dr Taylor Christmas said the gynaecologist will first do an examination to check for common things such as infections in the vagina and cervix, polyps in the cervix, uterine fibroids and abnormal changes to the cervix.
“It is important to remember that irregular or abnormal bleeding outside of the menstrual cycle can be due to hormonal factors or can be coming from the vagina, cervix or uterus. When evaluating patients we check to see which of these may be the cause of the bleed,” the ObGyn said.
If there is no regular menstrual cycle, Dr Taylor Christmas said an evaluation for common hormonal abnormalities such as PCOS, which can lead to unpredictable, irregular bleeding in-between periods, is done.
She warned that symptoms such as abdominal pain and fever, vaginal discharge or painful sex may clue an ObGyn in to the presence of an infection at some level in the reproductive tract.
“Bleeding after sex, especially in the absence of a regular Pap smear or cervical screening, should never be ignored as it can be a sign of cervical cancer,” she said.
“Other conditions such as endometriosis and adenomyosis, where the uterine lining is abnormally located outside the uterus, can also cause irregular bleeding and pain.”
She said bleeding that is outside the norm should never be ignored.
“Don't be afraid to see your doctor and have the bleeding evaluated and treated if necessary,” she added.