AD_HTT_027_034___MAY18_07 11/5/07 4:01 PM Page 27

How to treat
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inside
What causes
irregular
bleeding?

Assessing
irregular vaginal
bleeding

Management and
referral

Case studies

The authors

DR CHRISTINE READ,
medical director,

IRREGULAR
Family Planning NSW.

vaginal bleeding DR TANIA MAY,

Background
IN this article, irregular bleeding is
defined as bleeding that occurs out-
side of the normal menstrual pat-
tern. A normal menstrual pattern is
taken to be a ‘monthly bleed’. The
cycle length can vary, with a gener-
ally accepted normal range of 21-
35 days and a bleeding duration of
4-7 days.
Irregular bleeding can consist of
intermenstrual bleeding with a flow
similar to that of a menstrual
period. It can be ‘spotting’ that is
noted as stains on the underwear or
after toileting. It also includes post-
coital bleeding and postmenopausal
bleeding.
Amenorrhoea and menorrhagia
may occur as part of the irregular
menstrual pattern, but a full discus-
sion of these topics is not covered in
this article.
The physiology of menstruation
A regular menstrual pattern depends
on the presence of a functioning
reproductive hormone feedback
system including the hypothalamus,
anterior pituitary gland and ovaries,
as well as normal uterine and vagi-
nal anatomy.
The menstrual cycle is ‘switched
on’ at puberty when the hypothala-
mus secretes gonadotrophin-releas-
ing hormone (GnRH). Pulses of this
hormone cause the release of folli-
cle-stimulating hormone (FSH) from
the anterior pituitary.
FSH in turn stimulates the growth
senior clinician and educator in
sexual and reproductive health,
Family Planning NSW.
of a cohort of ovarian follicles, the
granulosa cells of which produce
increased amounts of the hormone
oestradiol, which in turn triggers a
surge of luteinising hormone (LH)
that causes the dominant follicle to
ovulate. DR MARGARET
As a result of stimulation by STELLINGWERFF,
oestradiol, the endometrium thick- medical officer,
ens in preparation for implantation Family Planning NSW.
of an embryo, should fertilisation
and pregnancy occur. The dominant
cont’d next page

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AD_HTT_027_034___MAY18_07 11/5/07 4:01 PM Page 28

How to treat – irregular vaginal bleeding

from previous page
follicle resolves to become the
corpus luteum, which then
produces the hormone prog-
esterone as well as oestradiol.
If a pregnancy does not
eventuate, the corpus luteum
becomes non-functional and
stops producing hormones,
causing the breakdown of
the endometrium and men-
strual bleeding starts.
Irregular bleeding —
what can be normal?
It is important to understand
that menstrual patterns that
do not conform to the regu-
lar cycling discussed above
can be a normal occurrence.
The age of the woman is a
critical factor in assessing the
need to investigate or
manage an irregular men-
strual pattern.
During puberty and the
perimenopause — the
extremes of reproductive life
— regular menstruation may
not be recognisable. In both
these transitional phases
anovulatory cycles occur,
leading to failure to estab-
lish a distinct ‘withdrawal’
menstrual bleed. With con-
tinued endometrial stimula-
tion there is often an irregu-
lar and sometimes heavy and
prolonged breakdown of the
endometrial lining.
In periovulatory bleeding,
bleeding or spotting can
occur at ovulation, about 14
days before the following
menstrual period.
If there is a luteal phase
defect, spotting can occur
premenstrually each month,
said to be due to a lack of
progesterone. However,
endometriosis is a more
common diagnosis for
episodes of spotting or
bleeding that occur in the
days leading up to menstru-
ation.
How common is irregular
vaginal bleeding?
Women commonly present
to their doctor for bleeding
problems. One study in the
US found menstrual disor-
ders were the reason for
19.1% of gynaecological
consultations over a two-
year period and that 25% of
gynaecological surgery
involved abnormal uterine
1
bleeding.
However, the incidence of
irregular bleeding is low over-
all, and the incidence of sig-
nificant pathology is also low,
making the issue a difficult
one in terms of how much
investigation is warranted.
In a study of menstruation
in 621 normal women over
20,672 cycles, intermen-
strual bleeding was reported
in 100 cycles (39 women;
6.3% of the women studied
2
and 0.5% of cycles studied).
These women were all inves-
tigated and no pathology
was found.
A study looking at refer-
rals to a gynaecology depart-
ment for postcoital bleeding
reviewed the records of 248
women referred over a five-
year period and found that
benign polyps (including
endometrial polyps) were
found in 20% of cases, 25%
had a cervical ectropion,
while cervical intraepithelial
neoplasia was detected in
3
6.8% of cases.
Intermenstrual or post-
coital bleeding has been
reported in 13% of women
diagnosed with chlamydial
cervicitis.

What causes irregular bleeding?

IT is beyond the scope of this arti-
cle to give an exhaustive coverage
of all the causes of abnormal bleed-
ing. We have attempted to high-
light causes that are relatively
common and straightforward to
manage, as well as illustrating the
more serious conditions that may
present as irregular bleeding.
Of the causative factors listed in
table 1, the most common are use
of hormones, either as contracep-
tion or menopausal hormone ther-
apy, pregnancy, endometrial
hyperplasia, cervical ectropion and
cervicitis. The causes of irregular
bleeding tend to be related to age
and stage of reproductive life (table
2).
Exogenous hormones and
menstruation
The physiological menstrual cycle
is particularly dependent on the
pattern of hormonal biofeedback
systems that connect the function-
ing of the hypothalamus, pituitary
and ovary.
Exogenous hormones, particu-
larly in the form of steroidal con-
traceptives or menopausal hor-
mone therapy, are a potent
influence on this system, and an
ensuing irregular cycle is not nec-
essarily a sign of abnormality. It is
therefore important to know the
menstrual changes expected with
the administration of steroidal con-
traceptives and HRT (table 3).
Because irregular vaginal bleed-
ing in women using hormonal con-
traception or other hormonal ther-
apies is common (usually known
as break-through bleeding), it is
obviously impractical, unreason-
ably worrying and inappropriate
to refer every case for immediate
investigation.
It may be appropriate to stop the
hormonal medication for 2-3
months, making sure that if con-
traception is needed another
method, such as condoms, is used
during this time. If the bleeding
problem persists, it should be inves-
tigated.
While the rate of significant
pathology (particularly malignancy
in the reproductive age group) is
low, there are good reasons to con-
sider serious causes when irregular
bleeding is a presenting symptom.
The age of the woman is an impor-
tant factor in assessing her risk (see
table 4).
Genital tract malignancy is an
Figure 1: Endometrial hyperplasia and carcinoma.
(Image courtesy of Dr Glenn McNally of Warren and McNally Ultrasound, Sydney.)
Figure 2: Cervical cancer.
Table 1: Causes of irregular
bleeding
General
■ Contraceptives — hormonal
contraceptive methods and
intrauterine devices
■ Menopausal hormone therapy,
including with tibolone, in a
woman with an intact uterus
■ Endometriosis — may cause
pre- and postmenstrual spotting.
Generally presents with
dysmenorrhoea, which
worsens with time
Uterine
■ Endometrial polyps
■ Endometrial hyperplasia
■ Fibroids — generally cause
menorrhagia but can present with
intermenstrual bleeding
■ Pregnancy — ectopic, early
pregnancy loss
■ Endometritis — postnatal and
postsurgical
■ Endometrial/myometrial
malignancy
Lower genital tract
■ Cervical ectropion
■ Cervical polyps
■ Cervicitis
■ Cervical malignancy
Cervical cancer: a
cautionary tale
A 22-YEAR-old woman presented
to a gynaecologist with break-
through bleeding while using the
combined OCP. A Pap test was
done and reported as normal.
Several times over the following
year the patient presented to a GP,
with a history of intermittent break-
through bleeding and postcoital
bleeding while taking the pill. A
repeat Pap test reported monilia
and mild squamous atypia,
possibly due to inflammation, with
a recommendation to repeat in 3-6
months.
The patient continued to note
variable postcoital bleeding and
presented to another GP. She was
then referred to a gynaecologist.
The gynaecologist found an eroded
and friable cervix with contact
bleeding. Biopsy confirmed
malignancy.
Review of the previous Pap test
indicated abnormal cells, including
CIN 3. The patient went on to have
a radical hysterectomy for stage 1b
carcinoma of the cervix. Despite
further surgery, radiotherapy and
chemotherapy over several years,
she died of metastatic disease.
uncommon cause of bleeding at
any age and is rare in younger
women.
Endometrial hyperplasia and
carcinoma
This is the most common invasive
gynaecological cancer in Australia
(figure 1), ranking sixth in terms
of incident cancers in women. It
results in about 1400 new cases
and 260 deaths every year. Risk
increases with age. It is most com-
monly diagnosed in women aged
Table 2: Relation of age to common causes of irregular bleeding
Age group
15-20 20-30 30-45 45-55 55+
STIs: cervicitis (especially chlamydia) HRT
Cervical ectropion Endometrial cancer
Endometrial polyps
Endometrial hyperplasia
Uterine fibroids
Intrauterine devices
Pregnancy and complications: miscarriage/ectopic pregnancy
Contraceptive steroids (especially progestogens)
Endometriosis
Trauma/surgery
Table 3: Changes to bleeding pattern with use of steroidal
hormones
Steroidal hormone Bleeding problem
Combined oestrogen and Break-through bleeding may happen:
progestogen contraceptives ■ In the first 3-4 months of use
(pills and vaginal ring) ■ After missed pills or delay in inserting rings
■ After episodes of vomiting or diarrhoea
■ With concomitant use with
liver-enzyme-inducing drugs*
Progestogen-only All associated with irregular bleeding patterns,
contraceptives (pills, which may include episodes of amenorrhoea,
injectable depot spot bleeding and prolonged, frequent bleeding.
medroxyprogesterone Note that the effect of DMPA may persist for
acetate [DMPA], implant up to 12 months
[Implanon] and
levonorgestrel IUD [Mirena])
HRT — cyclical Expect a monthly bleed, but women may
experience breakthrough of their natural cycle in
the perimenopause
HRT — continuous Designed to be ‘bleed free’, but women may
(including tibolone) have break-through bleeding in the
perimenopause (for this reason it is not indicated
for use 12-18 months after menopause)
*Carbamazepine, oxcarbamazepine, phenobarbital, phenytoin, primidone, topiramate
rifampicin and rifabutin protease inhibitors, non-nucleoside reverse-transcriptase
inhibitors, griseofulvin and St John’s wort may interfere with drug metabolism in the liver
Table 4: Important ‘not to miss’ causes of irregular bleeding
15-20 20-30 30-45 45-55 55+ (Years)
Chlamydia/PID Endometrial/ovarian cancer
Pregnancy and pregnancy complications
Endometrial polyps
Endometrial hyperplasia
Cervical cancer
50-70 and is rare in those under of 1.7 per 100,000 women.
40. While the occurrence of inter-
Risk factors include age >40, menstrual or postcoital bleeding as
weight >90kg, prolonged exposure a presenting symptom in cervical
to endogenous or exogenous unop- cancer is low, it should not be
posed oestrogen. ignored. The case study above left
provides a cautionary tale for GPs
Cervical cancer and led to the development of the
The incidence of cervical cancer Guidelines for Referral for Investi-
(figure 2) in Australia has been gation of Intermenstrual and Post-
dramatically reduced as a result coital Bleeding, by the Royal Aus-
of the cervical screening program. tralian and New Zealand College
The incidence in 2002 was 6.9 per of Obstetricians and Gynaecolo-
4
100,000 women, with a mortality gists (RANZCOG).

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AD_HTT_027_034___MAY18_07 11/5/07 4:01 PM Page 29

Assessing irregular vaginal bleeding

History Figure 3: Algorithm for investigating intermenstrual and postcoital bleeding.
IMPORTANT signposts in
history taking include:
■ The woman’s age and stage

of reproductive life.
Investigating intermenstrual or postcoital bleeding
■ History of bleeding (how
Is the patient pregnant?
often, what time of the
month, postcoital, etc).
■ Risk of pregnancy/recent

delivery/recent gynaecolog- YES NO

ical surgery or instrumen- Exclude ectopic pregnancy and manage any Is there a iatrogenic cause, eg,
tation. complications of uterine pregnancy combined OCP, recent colposcopy
■ Use of hormonal therapy

and contraceptive history.

■ Previous abnormal Pap YES NO
tests. ■ Check Pap test up to date Look for pathological cause
■ Sexual history, including ■ Screen for chlamydia if ≤25 and risk factors If bleeding persists
risk for sexually transmis- ■ Discuss and cease or modify medication

sible infections, and rele-

vant partner history.
■ Previous history of STIs.
? Cervix ? Uterine
Figure 3 presents a flow
chart for investigating inter- Speculum exam Endometriosis Bimanual pelvic
menstrual and postcoital Pap test Laparoscopy examination
bleeding.
Speculum exam looking for:
Swabs Ultrasound
■ Ectropion

■ Endocervical polyp
Non-screening Pap Swabs for infection Hysteroscopy
Examination
■ Cervicitis
test looking for: (especially think of Endometrial
Conduct a speculum exami-
■ Cervical dysplasia chlamydia PCR)
nation with a good light and ■ IUD tail sampling for
look for: histopathology
■ Ectropion and contact

bleeding on the cervix.

■ Friability of tissue or ulcer-
ation of the cervix.
■ Presence of cervical polyps.
■ Other possible sites of
bleeding.
■ Signs of vaginal discharge,
foreign body or IUD tail.
■ If pregnant, whether the cer-
vical os is open or closed.
Perform an abdominal
and bimanual pelvic exami-
nation, assessing:
■ Tenderness on rocking the
cervix.
■ Size of the uterus.
■ Adnexal masses/tenderness.
Investigations for
intermenstrual and
postcoital bleeding
The information presented
in this section is adapted
from the RANZCOG guide-
4
lines:
■ If the patient has not had a
Pap smear within the pre-
vious three months, take a
Pap smear using the specu-
lum carefully so as not to
provoke further bleeding.
These diagnostic (rather
than screening) Pap smears
should be sent to laborato-
ries using appropriate qual-
■ Cervical swabs should be uterus, uterine size and obe-
Important practice points taken for Chlamydia tra- sity can limit its sensitivity.
chomatis if appropriate. Saline infusion sonohys-
■ Intermenstrual bleeding and postcoital bleeding are by nature intermittent, and duration, volume
terography (SIS) can clarify
and frequency need to be taken into account in determining whether symptoms are ‘persistent’. It
is not possible to give a simple and all-encompassing definition of ‘persistent’ but, for example, Ultrasound imaging the contours, symmetry and
High-resolution transvaginal thickness of the endometrium.
several minor episodes over a three-month period, or two episodes of heavy bleeding, should
generally prompt referral. If there is uncertainty, it may be useful to ask a woman to keep a ultrasound can be a useful A thin catheter is inserted
additional test in investigating through the cervix and 20mL
menstrual diary so that you can make an assessment of the frequency and timing of her bleeding.
■ Cervical ectopy (ectropion) is a common finding in premenopausal women, especially in
abnormal bleeding when an of saline instilled, which dis-
combined OCP users and pregnant women. Contact bleeding or ectopy should not prompt endometrial cause is sus- tends the uterine cavity.
referral unless other features are present or intermenstrual or postcoital bleeding have been pected. It permits the endome- SIS is particularly valuable
persistent. trial texture to be assessed, as in detecting endometrial
well as the myometrium and polyps that are not apparent
■ In women with intermenstrual or postcoital bleeding, a negative smear does not rule out the
possibility of pathology. ovaries. The addition of on a standard ultrasound
colour or power Doppler and it more clearly delineates
■ The Pap smear is a screening test, not a diagnostic test, and is only 80-90% sensitive and may
assists in detecting vascular areas of endometrial thick-
therefore not detect underlying pathology in 10-20% of affected women.
■ Practitioners should always bear in mind the need to re-examine the woman if bleeding recurs.
abnormalities, including neo- ening and irregularity.
■ Pregnancy testing in women of childbearing age is important to exclude pregnancy complications
vascularisation, which may be The sensitivity of SIS can
as a cause of irregular bleeding. associated with malignancy. be similar to that of hys-
■ In some instances high-resolution transvaginal ultrasound scanning may provide additional
Focal thickening of the teroscopy. In experienced
information, and saline infusion sonohysterography may also be useful (see right) endometrium can be sugges- hands it has been found to
■ It is important to keep adequate documentation in the clinical notes on the type of abnormal
tive of polyps, and submu- have a sensitivity of 80-
bleeding, any hormonal therapy being used, any past history of bleeding and previous cosal fibroids may distort the 100% and a specificity of
investigations, the date and report of the last Pap smear, examination findings, action taken for endometrial stripe, while 76-96% for detecting
global thickening of the intrauterine pathology.
investigation and treatment, and the follow-up recommended.
endometrium can be indica- A more recent technique
tive of hyperplasia, and gross is hysterosalpingo-contrast-
ity control procedures. also be sent if bleeding is myometrial involvement is sonography (hy-co-sy). This
Contact bleeding from the likely to obscure the cells suggestive of malignancy. technique, using a special
cervix is relatively common on the slide. The occurrence Unenhanced endovaginal occlusive catheter and either
when taking a smear, par- of contact bleeding or ultrasonography is non-inva- ultrasonic contrast agent or
ticularly from the endo- abnormal bleeding in the sive and convenient, but fac- a mix of air and saline, is
cervix using a cytobrush. A case history should be tors such as residual bladder also capable of assessing
ThinPrep sample should noted on the request form. volume, the orientation of the tubal patency.

Management and referral

Persistent intermenstrual
and/or postcoital bleeding
without any unusual features
WOMEN with persistent bleeding
— even if Pap smears and other
tests are normal and regardless of
whether or not an ectropion is pre-
sent — should be referred for spe-
cialist opinion.
In general, a hysteroscopy/D&C
by a specialist should be the primary
procedure in women with persistent
intermenstrual bleeding, while col-
poscopy should be the primary pro-
cedure with persistent postcoital
bleeding or if a suspicious lesion is
present on the cervix. Both investiga-
tions may be required.
Women with a friable cervix ■ The smear report suggests the
When this is causing persistent presence of CIN-1 (low-grade
symptoms, women should be squamous intraepithelial lesion
referred for assessment and possi- [LSIL]) or a higher grade abnor-
ble treatment. After careful exclu- mality or the presence of any glan-
sion of significant pathology by dular abnormality.
colposcopy, a variety of ablative ■ On repeated diagnostic Pap smear
methods may be used. Generally testing 2-3 times over a 12-month
the problem will resolve without period, the smear contains cells
treatment. suggestive of an underlying squa-
mous lesion of lower grade than
Intermenstrual or CIN-1 (possible LSIL).
postcoital bleeding and an However, if bleeding is persis-
abnormal Pap smear tent, immediate referral is
Even if these women have minor needed, as per the first guideline
intermittent episodes of bleeding above.
(ie, not ‘persistent’) they should be Practitioners in remote areas
referred for colposcopy if: should consider telephone consul-
tation with a specialist if the cir-
cumstances are unclear.
Women using hormonal therapy
Women with intermenstrual
bleeding who are on the
progestogen-only minipill or in
the first six months of Depo-
Provera treatment (often called
break-through bleeding) should
generally not be referred in the
first instance unless bleeding is
excessively frequent or pro-
longed, and provided Pap smears
are normal and up to date.
Low-oestrogen-dose combined
pills and IUDs are also frequent
cont’d next page

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How to treat – irregular vaginal bleeding

from previous page Figure 4: Transformation zone of the cervix.

causes of intermenstrual
bleeding, especially in the
first few months of use.
Postmenopausal bleeding
When a woman presents
with a history of post-
menopausal bleeding (more
than 12 months since
menopause), referral should
be made for transvaginal
ultrasound. If the ultrasound
reveals that the endometrial
stripe is homogenous and
uniformly 5mm or less, no
further evaluation is gener-
ally required. The likelihood
of missing a significant
endometrial abnormality is
very low (0.1% in HRT
users and 1% in non-users).
Tamoxifen can increase
the risk of endometrial
cancer. When a woman
taking tamoxifen presents
with postmenopausal bleed-
ing, prompt referral should
be made for transvaginal
ultrasound, as above.
Recurrent postmenopausal
bleeding
A postmenopausal woman
with a normal transvaginal
ultrasound report and per-
sistent bleeding should be
further investigated by hys-
teroscopy/D&C/endometrial
biopsy.
Columnar cells
Area of metaplasia
(transformation zone)
Original squamo-
columnar junction
Squamous cells
Transformation zone
Is your patient pregnant?
Ectopic pregnancy or
miscarriage
Pregnancy should be
excluded when a woman of
childbearing age at risk of
pregnancy presents with
irregular bleeding and/or
abdominal pain. A simple
qualitative urine dipstick test
for human chorionic gon-
adotrophin is quick, easy
and sensitive.
Even if a woman reports
a normal period within the
last four weeks, a negative
urine pregnancy test will
exclude a clinically signifi-
cant ectopic pregnancy.
Time period
transformation zone,
endocervical canal and
During puberty,
pregnancy and when
on the OCP when
oestrogen levels are
high
Cells lining
endocervical During reproductive
canal life
Cells on
ectocervix
When oestrogen
levels are low,
eg, menopause,
breastfeeding
Serum pregnancy testing to be associated with a poor
offers little advantage over pregnancy outcome (eg,
these sensitive urine tests. spontaneous abortion or
In modern practice, trans- ectopic pregnancy), while a
vaginal ultrasonography is level >60nmol/L is associated
the diagnostic tool of choice with a probable viable preg-
for detecting an intrauterine nancy (based on levels used
or ectopic pregnancy in the by the Early Pregnancy
presence of a positive preg- Assessment Service, Royal
nancy test. Prince Alfred Hospital,
A single progesterone level Sydney, NSW).
can be helpful in predicting Early diagnosis and referral
pregnancy outcome in the to an early pregnancy unit
first eight weeks of gestation where possible allows the clin-
and may be useful in women ician to consider conservative
who have a positive preg- management options such as
nancy test and no uterine sac methotrexate, or an expectant
on ultrasound. approach for ectopic preg-
A level <20nmol/L is likely nancy.
Position of the External appearance of the
cervix when viewed with a
speculum
cervix
External os of
endocervical
canal
External os of
endocervical
canal
External os of
endocervical
canal
The diagnosis of a threat-
ened miscarriage does not
always require hospital
admission and raises the
question of whether GPs
should consider the prophy-
lactic use of RhD immuno-
globulin in this circumstance.
A dose of 250IU (50µg)
RhD immunoglobulin (anti-D)
should be offered to every
RhD-negative woman with no
preformed anti-D to ensure
adequate protection against
immunisation for the follow-
ing indications, up to and
including 12 weeks’ gestation:
■ Miscarriage.
■ Termination of pregnancy.
Sampling
Cervix sampler
(or spatula
alone)
Cervix sampler
(or spatula
alone)
Cervix sampler
(or spatula) and
cytobrush
■ Ectopic pregnancy.
■ Chorionic villus sampling.
Beyond 12 weeks, a higher
dose of RhD immunoglobulin
is used.
There is insufficient evidence
to support the use of RhD
immunoglobulin for bleeding
before 12 weeks’ gestation in
an ongoing pregnancy.
For successful immuno-
prophylaxis, RhD immuno-
globulin should be adminis-
tered as soon as possible
after the sensitising event,
but always within 72 hours.
If RhD immunoglobulin has
not been offered within 72
hours, a dose within 9-10

Confidence

†1 patient-year of experience = 1 patient on LIPITOR therapy for 1 year. LIPITOR is indicated as an adjunct to diet for the treatment of patients with hypercholesterolaemia. Also indicated in hypertensive
patients with risk factors for heart disease to reduce risk of non-fatal myocardial infarction and non-fatal stroke. Refer to Product Information before prescribing. The full disclosure Product Information
is available on request from Pfizer Australia Pty Ltd. LIPITOR (atorvastatin calcium). Supplier: Pfizer Australia Pty Ltd, ABN 50 008 422 348, 38–42 Wharf Road, West Ryde NSW 2114. Pfizer Medical Affairs 1800 675 229. Dosage and administration:
10–80mg/day as a single daily dose. LIPITOR can be taken at any time of the day, with or without food. Contraindications: Hypersensitivity to any component of this medication; active liver disease or unexplained persistent elevations of serum transaminases;
pregnancy and lactation. Women of child-bearing potential, unless on an effective contraceptive and highly unlikely to conceive. Precautions: Patients who consume substantial quantities of alcohol and/or have a history of liver disease; Myopathy (monitor CK); Risk
factors predisposing to development of renal failure secondary to rhabdomyolysis; Use of concomitant medication that may reduce activity/ levels of steroid hormones (ketoconazole, spironolactone and cimetidine); Interactions with other medicines: inhibitors of

30 | Australian Doctor | 18 May 2007 www.australiandoctor.com.au

AD_HTT_027_034___MAY18_07 11/5/07 4:01 PM Page 31

days may offer some protec- Figure 5: Cervicitis. always postcoital, the bleed- chomatis is the most pregnancy. (NB: azithro-
tion. ing is most likely due to the common sexually transmis- mycin is indicated only for
ectropion. sible bacterial pathogen in cervicitis and is not at pre-
Cervical ectropion However, if there is any Australia. There were sent indicated for the man-
In the past, cervical ectopy, doubt about the ectropion 36,100 notifications in Aus- agement of PID).
or cervical ectropion, was being responsible for the tralia in 2004. ■ Doxycycline 100mg twice

known as cervical erosion. It bleeding, it is preferable to Between 10% and 40% of daily for 10 days. Alert
is the transformation zone of refer for further investiga- chlamydial infections in patients to the risk of pho-
the cervix (figure 4), visible tion. In any case if the bleed- women can lead to pelvic tosensitivity. Doxycycline is
on the ectocervix. It is seen ing is regularly present after inflammatory disease (PID) contraindicated during
when, due to hormonal intercourse (ie, persistent), if left untreated; of those pregnancy and/or breast-
changes, the columnar referral is appropriate as per with PID, up to 20% may feeding (discoloration of
epithelium moves onto the the guidelines above. become infertile. permanent teeth).
vaginal portion of the cervix. Indications for testing for ■ Roxithromycin 150mg bd

A cervical ectropion looks Cervicitis chlamydia include: or 300mg daily as a single

red and may appear Inflammation of the cervix, ■ Mucopurulent discharge dose for 10 days.
inflamed because the colum- or cervicitis (figure 5), may from the cervix. In pregnant women ery-
nar epithelium is thinner be responsible for postcoital ■ An inflamed friable ectro- thromycin should be used in
than the squamous epithe- or intermenstrual bleeding. pion with contact bleeding. place of doxycycline at a
lium, making the underlying Depending on the cause of ■ Suspected PID. dose of 800mg bd for 10
blood vessels more apparent. the inflammation there may ■ Sterile pyuria. days. If this dose is not tol-
The columnar epithelium be associated symptoms such In the absence of national erated, 250mg qid for 10
may also secrete more as vaginal discharge, pain guidelines, opportunistic days can be used. Alterna-
mucus, which sometimes with intercourse or odour. testing has been recom- tively, give roxithromycin
causes a vaginal discharge The most common sexu- mended for all sexually 150mg bd or 300mg daily
This is a normal finding in ally transmissible infection active women aged 25 or for 10 days.
high-oestrogen states, such causing cervicitis is chlamy- younger, pregnant, or who General advice includes:
as being young, during preg- dia, and this should be report a new sexual partner ■ Limit or stop alcohol con-

nancy and in women using actively searched for. Gon- within the past 12 months sumption while on medica-
oestrogen therapy, including orrhoea, trichomonas and and are not using condoms tion.
5,6
the combined OCP. genital herpes are other all the time. ■ Partners should be given

Contact bleeding is It is not easy to determine possible causes. Cervicitis Treatment options for treatment regardless of
common with this condition, whether an ectropion found may also be due to allergic chlamydial cervicitis and whether or not they show
as the ectropion can bleed on clinical examination can reactions and to bacterial urethritis include: infection on testing.
easily with minimal trauma be attributed as the cause of vaginosos. ■ Azithromycin 1g orally ■ Advise abstinence from

such as penetrative sexual intermenstrual or postcoital once (preferred treatment). sexual intercourse until
intercourse, inserting a bleeding. If an ectropion Chlamydia It is important that the part- seven days after both part-
speculum or taking a Pap bleeds easily on a Pap test or Chlamydiae are specialised, ner takes the treatment at ners have completed their
test. The condition regresses by brushing over it with a intracellular Gram-negative the same time. Azithro- treatments, even if taken at
with age. swab and the bleeding is bacteria. Chlamydia tra- mycin may be taken during the same time.

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www.australiandoctor.com.au 18 May 2007 | Australian Doctor | 31

AD_HTT_027_034___MAY18_07 11/5/07 4:01 PM Page 32

How to treat – irregular vaginal bleeding

References
1. Nicholson WK, et al.
Authors’ case studies
Patterns of ambulatory care
use for gynecologic conditions:
Intermenstrual bleeding Figure 6: Endometrial fibroid and polyp.
a national study. American
in a young woman (Image courtesy of Dr Glenn McNally of Warren and McNally Ultrasound, Sydney.)
Journal of Obstetrics and
SARAH, 15, presents
Gynecology 2001; 184:523-
because she is concerned she
30.
is pregnant. She had previ-
2. Vollman RF. The Menstrual
ously been on the OCP but
Cycle. WB Saunders,
had run out four months
Philadelphia, 1977.
previously. She had been in a
3. Selo-Ojeme D, et al. A
new sexual relationship for
clinico-pathological study of
one month and was only
postcoital bleeding. Archives of
using condoms some of the
Gynecology and Obstetrics
time.
2004; 270:34-36.
Her last menstrual period
4. The Royal Australian &
had been three weeks previ-
New Zealand College of
ously, her last episode of Summary
Obstetricians &
unprotected sex two weeks
previously, and she had had ■ Always exclude
Gynaecologists. College pregnancy in a woman of
statement C-Gyn 6. Guidelines
two days of spotting one
week before her presenta- reproductive age.
for Referral for Investigation of
tion. She had had a urine ■ Irregular vaginal bleeding
Intermenstrual and Postcoital
pregnancy test, which was is commonly associated
Bleeding. July 2004 [cited 7
negative, and a urine sent off with hormone-containing
February 2007]. Available
for a chlamydia PCR. medications.
from: www.ranzcog.edu.au/
publications/statements/
Sarah’s chlamydia test ■ Assess risk of chlamydia.
C-gyn6.pdf
came back positive. She was
■ Look at the cervix for
5. Chen YM, Donovan B.
recalled for treatment with
signs of lesions that could
Genital Chlamydia trachomatis
azithromycin 1g stat and
bleed.
infection in Australia:
advised to tell her current Practice tips — bleeding while using hormonal contraception
partner so he could be tested ■ Is the Pap test normal?
epidemiology and clinical
and treated as well. ■ Exclude underlying causes: pregnancy, chlamydia, missed pills, vomiting or diarrhoea, concomitant ■ Ask the woman to keep a
implications. Sexual Health
medications. menstrual diary for three
2004; 1:189-96.
6. Harris M, et al (editors).
Intermenstrual bleeding ■ Is the Pap test normal? months and place her on a
Guidelines for preventive
in a middle-aged woman ■ Increase the oestrogen dose if the patient is taking the combined OCP, or change the progestogen recall system.
activities in general practice.
Mary, 39, presented with a to either a 1mg norethisterone combined OCP or a desogestrel- or gestodene-containing combined ■ If irregular bleeding is
6th edn. Royal Australian
small amount of bleeding OCP. persistent, refer for
College of General
lasting one day, occurring specialist assessment.
■ Progesterone-only OCP methods can cause irregular bleeding. In women who are not
Practitioners, Melbourne,
about a week before her
contraindicated to using oestrogen, additional oestrogen for women using Depo Provera or Implanon ■ Bleeding that occurs more
2005.
period. Her vaginal dis-
may help. than 12 months after the
7. Federal Health Department.
charge was different —
Stopping the hormonal contraception for some months and using condoms will indicate whether the menopause requires
National Sexually
“vinegary”. She had been in ■

bleeding is related to the hormonal contraceptive. investigation.

Transmissible Infections
the same monogamous rela-
Strategy 2005-2008. Federal
tionship for 14 years. She
Health Department, Canberra,
had no postcoital bleeding. stromal invasion of <1mm. trial hyperplasia with mild three months ago and this
2005.
Many years earlier she Mary was advised to have a atypia. was reported as normal. At
had had two atypical Pap hysterectomy, in view of the Because Naomi was trying the time Mei started to use Guidelines
Online resources smears, which had needed nature of the lesion. to fall pregnant the decision the Loette she started a new ■ In women with
■ Guidelines for the use of Rh
no treatment, and all bien- She had a radical, modi- was made to allow her a sexual relationship and said intermenstrual or
D Immunoglobulin (Anti-D)
nial Pap smears since then fied vaginal hysterectomy short period of time for this she uses condoms inconsis- postcoital bleeding, a
in Obstetrics in Australia,
had been negative. Mary without complications. No to happen and then to repeat tently. negative smear does not
College Statement C-Obs 6
had experienced minor residual carcinoma was iden- her hysteroscopy. She failed A speculum examination rule out the possibility of
RANZCOG March 2006:
amounts of pre- and post- tified in the cervix. There was to fall pregnant and had a reveals an ectropion but pathology (RANZCOG
www.ranzcog.edu.au
menstrual spotting close to no obvious parametrial or repeat hysteroscopy eight there is no contact bleeding 4
guidelines ).
■ National library for health
her period, but this most lymphatic spread. Mary will months later. This time a or unusual features. The his-
■ It is important to exclude
clinical knowledge
recent intermenstrual bleed- continue to have annual vault repeat biopsy showed a tory of unprotected sex and
chlamydia as a cause of
summaries:
ing was different. smears for 10 years for stage grade 1 well-differentiated Mei’s age indicate the need
intermenstrual and post-
www.cks.library.nhs.uk/
Physical examination was 1A carcinoma of the cervix. adenocarcinoma. She was to exclude chlamydia. A cer-
coital bleeding, as it is
clinical_knowledge
normal. The cervix appeared referred to a specialist vical swab sent to pathology
common, can lead to PID
■ Royal College of
healthy and the vaginal dis- Intermenstrual bleeding gynaeoncology unit. for chlamydia PCR testing is
if left untreated and, of
Obstetricians and
charge was normal. A non- persisting after stopping At operation Naomi was reported as negative.
patients with PID, up to
Gynaecologists. National
screening Pap smear was a progesterone-only pill found to have stage 3C ade- A negative chlamydia test
20% may become infertile
Evidence-Based Clinical
taken and a high-resolution Naomi was 41 when she nocarcinoma with involve- and a screening Pap test that
(from National Sexually
Guidelines: The Initial
ultrasound requested. A high- presented with an 18-month ment of the obturator and was normal three months
Transmissible Infections
Management of
vaginal swab for microscopy history of abnormal vaginal para-aortic lymph nodes. ago, combined with a his- 7
Strategy 2005-08 ).
Menorrhagia, 2006:
and culture and a cervical bleeding. She had been using She had total abdominal tory of no bleeding until
swab for chlamydia PCR was the progesterone-only pill for hysterectomy and bilateral starting to take Loette, indi- ■ Opportunistic testing for
www.rcog.org.uk/index.asp?
taken although Mary was at a contraception because she salpingo-oophorectomy as cate that the OCP may be chlamydia has been
PageID=698.
very low risk of an infection. was a smoker and unable to well as adjuvant radiother- the cause of the bleeding. recommended for all
■ New Zealand Guidelines
The ultrasound did not take the combined OCP. She apy. She had no signs of Loette is a low-dose com- sexually active women
Group. Heavy Menstrual
reveal any focal abnormal- had developed irregular recurrence four years after bined OCP containing 20µg ≤25, or who are pregnant,
Bleeding. www.nzgg.org.nz
ity that could account for bleeding while using the her surgery. ethinyloestradiol and 100µg or who report a new
■ Royal College of
the bleeding, and vaginal progesterone-only pill, which levonorgestrel. The low dose sexual partner within the
Obstetricians and
and cervical swabs were neg- persisted when she stopped. A 23-year-old on the of oestrogen means cycle past 12 months and are
Gynaecologists. National
ative, as expected. However, Naomi was getting a combined OCP with control is very vulnerable to not using condoms all the
Evidence-Based Clinical 6
the Pap smear detected a period every 21 days but intermenstrual bleeding any situations where pills are time (RACGP guidelines ).
Guidelines. The Management
of Menorrhagia in Secondary
high-grade epithelial abnor- after the period finished she Mei had been taking Loette missed, vomiting or diar- ■ Women with persistent
Care; The Initial
mality (CIN3). was left with a smelly dis- for four months. She rhoea occurs or concomitant minor episodes of
Management of
Mary was referred for col- charge and light spotting. A reported that she has had liver-enzyme-inducing drugs bleeding over a
Menorrhagia.
poscopy. Macroscopically pelvic ultrasound showed a some bleeding each month are used. three-month period or
www.rcog.org.uk/index.
the cervix was normal but complex echogenic lesion in while taking the three weeks However, Mei was sure two episodes of heavy
asp?PageID=1046
application of acetic acid the right fundal region. Hys- of active hormone pills. She she was taking her pills prop- bleeding should be
■ Royal Women’s Hospital.
showed dense aceto-white teroscopy was recommended had a withdrawal bleed each erly, so it seemed useful to referred for investigation
4
Women’s Health Nurse
areas with punctation and to exclude sub-mucous month as well. try switching to a 30µg (RANZCOG guidelines ).
Practitioner Assessment
mosaic change consistent fibroid or endometrial polyp Before starting the pill Mei ethinyloestradiol pill, such as ■ Investigation of irregular
Clinical Practice Guidelines.
with high-grade dysplasia. (figure 6). was using condoms for con- Microgynon 30 or Yasmin. vaginal bleeding may
Abnormal Vaginal Bleeding.
Biopsy revealed extensive At hysteroscopy Naomi traception and did not have On review four months later, include transvaginal
www.rwh.org.au/rwhcpg/
adenocarcinoma in situ, with was found to have a sub- any intermenstrual bleeding. Mei reported that, with the ultrasound, colposcopy,
womenshealth.cfm?doc_id=
features suggestive of early mucous fibroid with reason- There had not been any change of pill, there had been hysteroscopy and D&C.
6068
invasion. Histopathology on ably normal material around postcoital bleeding. A no irregular bleeding while (RANZCOG guidelines ).
4

core biopsy confirmed early it. A biopsy showed endome- screening Pap test was taken taking the active pills.

32 | Australian Doctor | 18 May 2007 www.australiandoctor.com.au

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How to treat – irregular vaginal bleeding

GP’s contribution
current contraception was ment after history-taking public health unit of the posi- ment makes any difference
Depo-Provera (which made and basic examination in the tive result. It is important that to long-term management of
her amenorrhoeic) and she absence of diagnostic testing, we do have an epidemiologi- bleeding problems with
used condoms — sometimes! with a combination of drugs cal picture of this increasingly either Depo Provera or
On examination, Estelle known to treat organisms common disease, so GPs Implanon.
had one (new) clitoral and responsible for that syn- should be alert to the possi-
numerous labial piercings, drome, eg, vaginal discharge. bility of infection in young When a Pap smear is per-
which looked red and Despite your fear that sexually active people and formed (and reported
DR FIONA ROBINSON
swollen. The cervix looked Estelle will not use condoms, proactively offer chlamydia normal) but in the presence
Balmain, NSW
angry and friable, with an it is important that you con- PCR testing. of vaginal/cervical infection,
ectropion, and there was sig- tinue to encourage their use. should the smear be done
Case study nificant contact bleeding. The Sex Workers Outreach General questions for the again (eg, in three months’
ESTELLE, 26, had recently There was no cervical or Project (SWOP), funded by authors time) when the infection has
moved into the area and was adnexal tenderness and no NSW Health, provides a In a patient with break- cleared?
working in a local massage palpable lymph nodes. I per- impossible. Her Pap smear range of health, safety, sup- through bleeding on Depo- If the pathologist has
parlour. She presented to me formed another Pap smear revealed LSIL (CIN 1), so I port and information services Provera or Implanon, (when reported a completely
because of postcoital bleeding, (including ThinPrep), high referred her for a colposcopy. for sex workers. They also pathology has been normal Pap test in this situa-
worsening over the last few vaginal swabs, cervical swabs have counselling and referral excluded) would it be better tion, the test is repeated at
months. and a test for chlamydial Questions for the authors services. For more informa- to give some supplemental the normal two-year screen-
She had been a sex worker PCR. A pregnancy test was In high-risk patients, is there tion visit www.swop.org.au oestrogen or change the reg- ing interval. A Pap test that
for eight years, had a history negative. any evidence to suggest pro- Outside of NSW the imen completely? is reported as ‘negative with
of abnormal Pap smears (CIN We discussed not working phylactic treatment against national peak body is known A short-term prescription inflammation’, should also
1 and 2), numerous colpo- until the results were known, chlamydia is beneficial, and as the Scarlet Alliance; their of ethinyloestradiol can be be repeated at the normal
scopies and a cone biopsy. but she said this was not an if so, what does it comprise? web site is www.scarlet useful, such as three weeks’ two-year screening interval.
Paps had been done irregu- option. After a lengthy chat There is no evidence for the alliance.org.au treatment with any of the However, national guide-
larly, but the last one had about the importance of using usefulness of prophylactic active combined OCPs, to lines indicate that when a
been reported as normal six condoms, I did not feel confi- treatment of chlamydia Should the local public health settle bleeding (provided the Pap test has been reported
months ago. dent this would happen. except in cases of sexual unit become involved in this patient does not have a med- as ‘unsatisfactory’, it should
Other history included Diagnosis of a chlamydial assault. However, in type of situation? ical condition that con- be repeated in 6-12 weeks,
numerous sexually transmit- infection prompted treatment resource-poor countries, a Chlamydia is a notifiable traindicates the use of with correction (if possible)
ted infections over the years with azithromycin for Estelle, syndromic approach is often infection, so the pathology oestrogen). However, there of the problem that resulted
and three terminations. Her but partner tracing was used to treat STIs, ie, treat- laboratory will notify the is no evidence that this treat- in the unsatisfactory smear.

INSTRUCTIONS
How to Treat Quiz Complete this quiz to earn 2 CPD points and/or 1 PDP point by marking the correct answer(s) with an X on this form.
Fill in your contact details and return to us by fax or free post.
FAX BACK FREE POST ONLINE
Irregular vaginal bleeding Photocopy form How to Treat quiz www.australiandoctor.com.au/cpd/
— 18 May 2007 and fax to Reply Paid 60416 for immediate feedback
(02) 9422 2844 Chatswood DC NSW 2067

1. Which THREE statements about vaginal THREE elements of Stella’s history could 6. Vivienne, 69, presents with a history of two ❏ a) Cervical ectropion
bleeding are correct? explain her bleeding? days of vaginal spotting last week, which has ❏ b) Cervical carcinoma
❏ a) The normal menstrual cycle length is ❏ a) She has started taking St John’s wort for now resolved. She is generally well, with no ❏ c) Endometrial polyp
21-35 days mild depression past gynaecological history and is not taking ❏ d) Cervicitis
❏ b) During puberty, anovulation can cause ❏ b) She forgot a pill before the episode of HRT. She has not been sexually active for
irregular and heavy bleeding bleeding 15 years and had her last Pap smear at 65, 9. Which THREE statements about
❏ c) All mid-cycle bleeding is abnormal ❏ c) She also takes sodium valproate for which was normal. Which TWO initial investigating irregular vaginal bleeding are
❏ d) Premenstrual spotting may be caused by epilepsy investigations would you arrange for correct?
endometriosis ❏ d) She had an episode of gastroenteritis last Vivienne? ❏ a) Saline infusion sonohysterography is an
month ❏ a) Laparoscopy improved ultrasound technique for assessing
2. Which TWO statements about irregular ❏ b) Pap smear endometrial irregularities
vaginal bleeding are correct? 4. There are no obvious causes for ❏ c) Transvaginal ultrasound ❏ b) A Pap smear may be reported as normal in
❏ a) It is important to investigate all irregular Stella’s bleeding on history or physical ❏ d) Chlamydia PCR test up to 20% of women with cervical
bleeding because a large proportion of examination. She keeps a bleeding diary abnormalities
women with this symptom will have a serious for two more months and reports that 7. Vivienne is worried that the bleeding may ❏ c) If a transvaginal ultrasound shows the
cause bleeding is continuing to occur in the indicate cancer. Which THREE factors in endometrial lining is <5mm in a post-
❏ b) Endometrial cancer becomes a more likely second or third week of active pills. Which Vivienne’s history or examination would menopausal woman, no further investigation
cause in women over 45 TWO investigations would be most indicate an increased risk of endometrial is generally needed unless bleeding persists
❏ c) Most women with chlamydial cervicitis will appropriate? cancer? ❏ d) Women of childbearing age who report
report intermenstrual or postcoital bleeding ❏ a) Saline infusion sonohysterogram ❏ a) Her weight is 96kg having had a period within the past four
❏ d) Irregular bleeding is common during the ❏ b) Chlamydia PCR test ❏ b) She used the combined OCP for 20 years weeks do not require a pregnancy test
first few months of combined oral ❏ c) Pap smear ❏ c) She previously used oestrogen-only HRT
contraceptive pill use ❏ d) HPV DNA test ❏ d) Her age 10. Which TWO statements about chlamydia
cervicitis are correct?
3. Stella, 22, has been taking Microgynon 20 5. Stella’s investigations return normal 8. Brianna, 22, presents with postcoital ❏ a) It is less common in Australia than
for the past two months. She has had no results. Which TWO management options spotting over the last two months. Her gonorrhoeal cervicitis
significant side effects from the pill except would be appropriate at this stage? periods are regular and she has no additional ❏ b) All sexually active women ≤25 who are not
for several days of light vaginal bleeding ❏ a) Immediate referral for colposcopy intermenstrual bleeding. Brianna uses regularly using condoms should be offered
noted last month during the third week of ❏ b) Changing her contraceptive pill to one condoms inconsistently with her current testing for chlamydial infection
active pills. She is in a stable relationship, containing 30µg oestrogen partner of four months. She had a normal ❏ c) Partners of women with chlamydial
had previously used condoms for ❏ c) Stopping the OCP and going back to Pap smear six months ago. From the history cervicitis should be tested and treated if
contraception, had no irregular bleeding condom use for a few months to see if the alone, which TWO causes would you found also to be infected
before starting the Microgynon and had a bleeding continues consider most likely to be causing Brianna’s ❏ d) Azithromycin 1g orally provides adequate
normal Pap smear 21 months ago. Which ❏ d) Change Stella’s pill to Loette postcoital bleeding? treatment for chlamydial cervicitis

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HOW TO TREAT Editor: Dr Marcela Cox
Co-ordinator: Julian McAllan
Quiz: Dr Marcela Cox
Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.

NEXT WEEK Adult sexual assault is a distressing and difficult problem. Counselling and a non-judgmental approach are mandatory, and high-quality forensic and medical sexual assault care critical to
successful patient outcomes. The next How to Treat focuses on these medical and forensic aspects of care for adult victims of sexual assault. The authors are Dr Vanita Parekh, staff specialist, Canberra
Sexual Health Centre and forensic and medical sexual assault care, the Canberra Hospital, and Secretary of FAMSAC Australia; and Dr Ronald McCoy, GP, St Kilda, Victoria.

34 | Australian Doctor | 18 May 2007 www.australiandoctor.com.au