Other than pregnancy, the most common cause of non-menstrual bleeding is contraception related, such as missed or malabsorbed pills. Intermenstrual bleeding occurs in 30–40% of combined oral contraceptive pill users in the first 3 months and 40% of women with an intrauterine contraceptive device have irregular bleeding in the first month. It is also common with the progestogen-only pill, Depo-Provera, the intrauterine system and implants.
|Minor complications of physiological events (e.g. anovulatory cycle)||Expectant management|
Rescan or review in 6 weeks
|Hormonal contraception||Check compliance with oral contraceptives|
Check for interactions with other drugs
Consider changing to alternative preparation or switching method
|Pelvic inflammatory disease or infective cervicitis||Full sexually transmitted infection screen|
Antibiotics as per protocol
Advise abstinence until treatment complete
|Benign endometrial or cervical pathology||Consider hysteroscopic resection of endometrial polyp|
Avulsion of endocervical polyp
Antibiotics / cautery / surgical management of cervical bleeding after LLETZ Consider packing in the emergency situation if cervical bleeding.
|Cervical ectropion||Expectant management or cautery|
Try alternative contraception
|Malignant genital tract lesions||Consider packing in the emergency situation|
Gynaecological oncology referral.
|Other vaginal or vulval lesions (e.g. trauma)||Treat the cause (see trauma explanation)|
|Haematological abnormalities||Correct coagulation|
Liaise with haematologist
(Adapted with permission from Connolly A et al, 2004 ).
Anovulatory cycles are common and have a typical presentation of delayed menstruation followed by a prolonged bleed. Pain may occur due to the persistence of follicular cyst. The condition is self-limiting and most women will return to normal cycles with cyst resolution within 4–6 weeks.
Trauma (accidental or related to abuse) is a rare cause of profuse haemorrhage. Vaginal tears occur classically in the upper lateral vagina and may warrant urgent surgical suturing to arrest bleeding. Where abuse is suspected discussion with seniors and appropriate services is vital as soon as possible.
In older women, cervical carcinoma and neglected vulval carcinoma are significant causes of bleeding in addition to endometrial carcinoma. These conditions are dealt with in the relevant StratOG tutorials on malignant disease.
A vaginal pack should be inserted in cases of profuse bleeding from the cervix or vagina to allow resuscitation and transfer to theatre if necessary.