13.06.06 Intermenstrual bleeding

Causes

• Pregnancy-related

  • • Ectopic pregnancy

    • Gestational trophoblastic disease

• Physiological

• • 1-2% spot around ovulation

• Iatrogenic

  • • Combined oral contraceptive pill (COCP)

    • Either in too low dose or in combination with an enzyme-inducing drug

• • Progesterone-only pill

  • Contraceptive depot injections

    • Intrauterine systems (IUS) or implant

    • Emergency contraception

  • Tamoxifen

  • Following smear or treatment to the cervix

  • Caesarean section scars

  • Drugs altering clotting parameters

    • Anticoagulants, SSRIs, corticosteroids

  • Alternative remedies

    • • Ginseng, ginkgo, soy supplements, St John's wort

• Vaginal causes

• • Adenosis

    • Vaginitis

    • Bleeding uncommon before the menopause

  • Tumours

• Cervical causes

• • Infection

    • Chlamydia, gonorrhoea

  • Cancer

    • But bleeding is most often postcoital

  • Cervical polyps

    • Cervical ectropion

    • Condylomata acuminata (genital warts) of the cervix

• Uterine causes

• • Endometrial polyps

  • Cancer

    • • Endometrial adenocarcinoma, adenosarcoma and leiomyosarcoma

• • • Adenomyosis

    • Usually only symptomatic in later reproductive years

• • Endometritis

  • Fibroids

  • Ovarian causes

  • Oestrogen-secreting ovarian cancers