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Are you having back pain with any of the following?

  • Severe pain, weakness or tingling in your leg(s).
  • Difficulty stopping urination or loss of control of bladder or bowels.
  • Unexplained fever, nausea or vomiting.
  • A history of cancer or unexplained weight loss.

We understand that you are experiencing one or more of the health issues that might be impacting your back pain.

We recommend that you discuss these health issues with your doctor before proceeding with this program.

Once you are cleared by your doctor to do this program, we hope it helps you find relief from your back pain.

Abnormal Vaginal Bleeding (Irregular Periods) in Adults

Overview

Abnormal bleeding is a common and often uncomfortable experience. It can occur at any age, but is more common in adolescents, during pregnancy, and in perimenopause. Uterine bleeding is most common, but bleeding can also come from the vulva, vagina and cervix, as well as the bladder and bowel.

If you continue to experience bleeding that is irregular or unusually heavy, I recommend you contact me. Some issues get better on their own, but others may require further evaluation and treatment.

Normal menstrual cycle

A typical menstrual cycle is between 24 to 35 days long. Menstrual bleeding usually lasts from 4 to 7 days and average blood loss is about 3.5 tablespoons (3-4 pads/tampons a day). Between 2 teaspoons to 5.5 tablespoons (2-6 pads/tampons a day) and up to 10 days is considered normal.

Some women also experience light bleeding (spotting) for a day or two around the middle of their cycles, between periods. This may be a normal pattern for some women but if this starts in your 40s or is new for you, please contact me. Generally, mid-cycle spotting is caused by the drop in hormone levels around the time that you ovulate (release an egg). 

Heavy or frequent bleeding

We may consider your bleeding too heavy or too frequent if:

  • Your periods regularly last more than 10 days.
  • Your usual flow is heavy (more than 6 saturated pads or tampons per day).
  • You pass large blood clots.
  • You have frequent periods with cycles shorter than 21 days.
  • You have frequent spotting or irregular bleeding.

If you have any of the above issues, especially if it continues beyond 1.5 to 2 years from the time you begin menstruating, you should contact me for an evaluation.

Infrequent or no bleeding

You should contact me if:

  • You have no period by age 16.
  • You frequently skip periods or go more than 3 months between periods (especially if it’s been more than 2 years since your periods started).
  • You have monthly pelvic pains with no bleeding by age 13.

Pregnancy

Pregnancy is the most common reason for missed periods. If you have skipped your period and you have had sex, take a pregnancy test. Home pregnancy tests are very accurate. You can also stop by our lab. You don’t need to make an appointment or bring any paperwork.

Spotting is common during the first trimester. It can happen after an internal exam in the office or after having sex. It happens because the cervix is very sensitive to touch during pregnancy.

Miscarriage or tubal pregnancy

Spotting can also be a sign of a miscarriage or tubal pregnancy. A tubal pregnancy is when the fertilized egg implants outside the uterus. The most common place is in the fallopian tube.

If you are pregnant and experience bleeding or spotting, we will do an ultrasound and/or blood work to determine if the pregnancy is progressing normally.

The female reproductive organs include the ovaries and fallopian tubes, the uterus, the cervix, and the vagina.


Common Causes of Heavy or Frequent Bleeding

There are several causes for heavy or frequent bleeding, including the following conditions:

Dysfunctional uterine bleeding (DUB)

Dysfunctional uterine bleeding (also called DUB) is a term for irregular bleeding from the uterus. The bleeding can be heavy or light and is usually caused by changes in hormone levels. Sometimes, the ovaries fail to release an egg. This is called anovulation and can cause unusual bleeding.

A diagnosis of DUB is made after we have ruled out other causes of the heavy bleeding, such as fibroids, endometriosis, or polyps. An evaluation can include a pelvic exam, blood and urine tests, and sometimes a biopsy. This allows us to make the correct diagnosis to treat your condition.

Endometriosis and adenomyosis

In endometriosis, parts of the lining of the uterus (the endometrium) attach to organs outside the uterus in the abdominal area. These are called implants. During the menstrual cycle, these implants swell and bleed. This can cause pain and abnormal bleeding.

Treatment for endometriosis usually includes medications and/or surgery to remove the endometriosis implants.

In adenomyosis, the lining of the uterus grows into the muscle layer of the uterus. It can cause long or heavy bleeding, painful menstruation, or pelvic pain with intercourse. Most women don’t require any treatment for adenomyosis but if it is causing a lot of pain or bleeding for you, treatments are available. Treatments can include medications and/or surgery.

Bleeding disorders

Very heavy periods, starting with your first periods in adolescence, can be a symptom of a bleeding disorder. Certain hereditary conditions, such as von Willebrand disease, idiopathic thrombocytopenia purpura, and platelets dysfunction can cause heavy bleeding.

If we suspect these conditions, there are blood tests that can check for them. Treatment for these disorders will depend on the final diagnosis and the severity of the symptoms.

For other possible causes of heavy or frequent bleeding, see the sections on “Growths in the Pelvic Organs,” “Other Medical Conditions,” and “Medications that May Affect Bleeding.”

Common Causes of Infrequent or No Bleeding

Light or infrequent bleeding may be caused by one of the following conditions:

Ovulation problems are the most common cause of irregular and infrequent periods. Ovulation is when you release an egg. Polycystic ovary syndrome (PCOS) is the most common ovulation disorder. When your hormones (estrogen and progesterone) are out of balance, you can develop small cysts in your ovaries and have irregular periods. The ovaries may fail to release an egg or release them infrequently. Some people with PCOS develop male-pattern baldness and facial hair, gain weight, or develop acne. These symptoms can appear suddenly or develop slowly over time. Women with PCOS are also at higher risk for diabetes.

Treatment for PCOS focuses on balancing the hormones and treating the resulting weight problems and metabolism issues. Hormonal contraceptives can help regulate your periods and reduce acne and excessive body hair.

Some women do not have PCOS, but have other hormonal irregularities that affect ovulation and cause irregular bleeding. This is sometimes referred to as dysfunctional uterine bleeding, or DUB. A diagnosis of DUB is made after we have ruled out other causes of the irregular bleeding, such as PCOS, fibroids, or polyps. An evaluation can include a pelvic exam, blood and urine tests, and sometimes a biopsy. This allows us to make the correct diagnosis to treat your condition.

Stress can cause irregular bleeding or missed periods. Your body may experience stress from travel, relationships, family problems, work issues, and many other things.

If you have very little body fat, you may not ovulate (release an egg from your ovaries). If you don’t ovulate, you may not have a period. This happens more often in women with very little body fat or among intense athletes, like gymnasts and ballet dancers.

Eating disorders (anorexia and bulimia) and malabsortion disorders like Celiac sprue, Crohn’s disease, or ulcerative colitis, can also interfere with ovulation and stop menstrual cycles.

Women who have too much body fat may also experience irregular bleeding. Sudden weight gain or weight loss may also impact your bleeding.

For other possible causes of light or infrequent bleeding, see the sections on “Other Medical Conditions” and “Medications that May Affect Bleeding.”

Growths in the Pelvic Organs

In some cases, unusual bleeding is caused by an abnormality in the pelvic organs, such as a growth in or around the uterus or cervix. 

Uterine fibroids are non-cancerous growths in the wall of the uterus. Fibroids can be as small as a seed or as large as a grapefruit. They can grow as a single tumor or in several places in the uterus. Fibroids are most common in women in their 40s and 50s but may occur in younger women.

Many fibroids cause no symptoms. However, they can cause bleeding and more frequent periods, as well as menstrual cramps, back pain, difficulty with bowel movements or urination, or pain during intercourse. Abnormal bleeding may be the only sign of possible fibroids for women who do not experience pain.

If your symptoms are severe, treatments could include medication, other procedures, or surgery.

A cervical polyp is a small finger-like growth on the cervix. Polyps can also be found in the uterus. They are typically benign (non-cancerous).  Polyps can cause heavy or irregular bleeding and may also develop in the uterus. Cervical polyps can be found during a pelvic exam and are usually simple to remove. Removing a uterine polyp may require a minor procedure.

Certain rare hormone-producing tumors can stop menstrual cycles.
A physical exam, blood tests and possible ultrasounds can help make the diagnosis if something like this is suspected. 

Certain types of cancers, such as cancer of the uterus, cervix, or vagina can cause vaginal bleeding. These serious diseases can be screened by regular pelvic exams and Pap tests.

Other Medical Conditions

Several other underlying medical conditions may cause abnormal bleeding.

Infections of the vagina, cervix, uterus, fallopian tubes, or ovaries may cause vaginal bleeding.

  • Sexually transmitted diseases (STDs) are often the cause of infections.
  • Pelvic Inflammatory Disease or PID can cause inflammation or infection of the uterus, fallopian tubes, or ovaries. All of these can cause abnormal bleeding.
  • Genital warts on the vulva or in the vagina can also cause bleeding.

Treatment for these conditions ranges from minor office procedures to prescription medications. Practicing safer sex can greatly reduce the risk of STD infection or genital warts.

In some cases, the bleeding is coming from the bladder. You may notice pink or light brown colored urine, especially when you wipe. Blood in the urine may be a sign of a bladder infection or urinary tract infection (UTI). Other symptoms of a urinary tract infection are pain when urinating and a frequent need to urinate.

Women with hypothyroidism (underactive thyroid) can have heavy and prolonged vaginal bleeding. Hyperthyroidism (overactive thyroid) can also cause unusual bleeding. Bleeding from thyroid problems is more common in women over 40.

Prolactinoma is a noncancerous growth in the pituitary gland. The pituitary gland produces hormones and is located at the base of your brain. One of the symptoms of prolactinoma is unusual vaginal bleeding, typically light or infrequent, caused by too much prolactin in the blood.

Women with Cushing’s syndrome can have irregular bleeding which is often light or infrequent. Cushing’s syndrome is caused by a growth in the pituitary gland that leads to too much cortisol in the blood. Cortisol is a hormone that helps your body respond to stress.

Medications that May Affect Bleeding

Many medications may cause unusual vaginal bleeding, including the following:

Hormonal contraception

Hormonal contraception, including birth control pills, patches and rings, the Depo-Provera shot, implants containing progestin, and IUDs can all cause changes to your menstrual patterns. If you are using your contraceptive method exactly as prescribed, irregular bleeding or lack of bleeding is probably not a cause for concern. However, if you experience any symptoms of pregnancy (like nausea, fatigue or tender breasts), or if you have not used the method exactly as prescribed, take a pregnancy test.

Other medications

Many other medications can cause lighter, heavier, less frequent or more frequent bleeding, or skipped periods, including:

  • Aspirin, Coumadin, and other anticoagulant medicines
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
  • Psychiatric medications like antidepressants
  • Seizure medications like Dilantin
  • Prednisone and other corticosteroids
  • Medicines to prevent organ transplant rejection
  • Hormone therapy
  • Medications to treat cancer (chemotherapy) like Cytoxan or tamoxifen
  • Radiation therapy
  • Thyroid medicines like Synthroid or Levothroid

If you are having changes in menstrual bleeding that you think may be related to prescribed medications call or e-mail us. If you are taking a medication that is not prescribed by a doctor, stop taking it and call us.

Treatment

We will work with you to determine the cause of your bleeding and find the right treatment for you. When you talk with us, be sure to: 

  • Discuss any plans to get pregnant in the future. Many of these treatments may affect your fertility.
  • Ask about risks or complications.
  • Ask how recovery will affect your daily activities.
Medication

We may prescribe hormone pills to help with irregular bleeding. Progesterone-only pills are taken monthly (or less often) for 10 days. Birth control pills are taken daily. Both progesterone shots and luprolide shots can stop your periods entirely. Non-steroidal anti-inflammatory drugs (e.g. ibuprofen, naprosyn) can reduce heavy menstrual flow for some women.

Nonsurgical treatment

The Mirena IUD is a plastic T-shaped device placed inside the uterus during an office visit. It releases hormones that thin the uterine lining. Common side effects are lighter periods or no periods at all. It is common to spot for a few months after insertion. You may also have mild abdominal cramping after insertion. The Mirena also prevents pregnancy and lasts for five years. If you decide to get pregnant, it can be removed. If the Mirena comes out, we can insert a new one.

In an endometrial (uterine) ablation, the lining of the uterus is destroyed using heat or another type of energy. Scar tissue develops and decreases the amount of bleeding during your period. Your period may stop altogether. It can be performed in our office. This procedure is not recommended if you’re thinking about getting pregnant in the future.

A uterine artery embolization (UAE) is used to treat uterine fibroids. With a UAE, a tiny tube is inserted into an artery in the upper thigh. Small particles inserted into the tube block blood flow to the fibroids. The fibroids shrink and become inactive. As a result, your periods usually become lighter and pain may decrease. A UAE is not recommended if you’re thinking about getting pregnant in the future.

Hysteroscopy is a procedure performed in the office. If uterine polyps are causing your symptoms, we can remove them with a hysteroscopy. We use a small camera, called a hysteroscope, to look inside your uterus through the cervix. The polyps can then be removed through the cervix. Small fibroids can sometimes be removed using this procedure as well.

Surgery

If medication and non-surgical treatments do not improve your symptoms, surgery is an option. We can discuss the benefits and risks of surgery with you and decide if it is a good option given your specific symptoms. There are several types of surgery:

Myomectomy is surgery to remove fibroids. Fibroids are removed through a large cut or smaller cuts in the belly. They may also be removed through the cervix and vagina. The uterus is left in place. The size and location of your fibroids help determine the best method to use. Once the fibroids are removed, your period may be lighter. Pelvic pain may also decrease. Sometimes, your ability to get pregnant improves.

Hysterectomy is surgery to remove the uterus. If you have endometriosis, cancers, or if other treatments fail, hysterectomy may be an option. The fallopian tubes, cervix and ovaries may also be removed along with the uterus. Vaginal bleeding, including your period, will stop. You also cannot get pregnant anymore. If the ovaries are removed, you may go through early menopause.

An intrauterine device (IUD) is a small plastic or copper device shaped like a T that is placed into the uterus to prevent pregnancy. It can also be used to treat abnormal vaginal bleeding.

Uterine artery embolization (UAE) is used to treat uterine fibroids. With a UAE, a tiny tube is inserted into an artery in the upper thigh. Then, small particles are inserted into the tube to block blood flow to the fibroids. The fibroids shrink and become inactive.


Other Causes of Bleeding in the Genital Area

Bleeding in the genital area may also be caused by hemorrhoids or an injury.

Hemorrhoids

Hemorrhoids occur when the veins around your bottom (rectum and anus) swell and bleed. Constipation, diarrhea, pregnancy and delivering a baby, aging, and anal sex may cause hemorrhoids.

Hemorrhoids may be painful, especially when sitting. You might also notice anal itching, pain, or a hard lump around the anus. Hemorrhoids often bleed during a bowel movement, so you might notice blood in the toilet or on the toilet seat.

You can treat hemorrhoids with nonprescription corticosteroid creams, which reduce pain and swelling, or hemorrhoid creams that contain lidocaine to reduce pain. You can also apply witch hazel to the area to relieve itching. Use moist wipes after a bowel movement. Avoid scratching the area if you can. Wear cotton underwear and try soaking in a sitz bath. If you are constipated, use a stool softener or add more fiber to your diet. Exercise can also help you be more regular. Try not to strain with your bowel movements as this could make it worse.

Hemorrhoids usually go away within a few days. Let us know if you have a hemorrhoid that does not heal.

Injury to the rectum or vagina

Bleeding may occur due to trauma to the genital tract during sex, tampon insertion, or strenuous exercise. A retained tampon or any foreign body in the vagina can also cause irregular bleeding. We can check for these with a pelvic exam.

Please tell us if you are experiencing intimate partner violence

If you think you're being abused or may be abusing someone else, you can get help by talking to us or:

  • Contact the National Domestic Violence Hotline, 1-800-799-7233 or 1-800-787-3224 for hearing/speech impaired.

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This information is not intended to diagnose health problems or to take the place of specific medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.