Living with Metrorrhagia
(Intermenstrual Bleeding)

If you have metrorrhagia, it means you experience abnormal vaginal bleeding between periods or not associated with, or due to, you having your period (menstruation).
It is commonly called intermenstrual bleeding.

There are several causes of metrorrhagia, some of which are harmless. However, in some cases, abnormal bleeding may be due to an underlying reproductive system disorder.

Metrorrhagia/bleeding between periods can be heavy or light and may be associated with menstrual pain/cramps (dysmenorrhoea) as well.

If you have menometrorrhagia, it means that you have menorrhagia (heavy and prolonged bleeding during your periods) and metrorrhagia.

What is ‘spotting’?

Spotting is a type of light vaginal bleeding you experience outside of your regular menstrual cycle (not in association with having your period).

Spotting involves the loss of small amounts of blood and may only be noticeable on your underwear or on toilet paper when you are going to the bathroom.
Spotting can also be a side-effect of hormonal contraceptive use.

What causes bleeding between periods?

The menstrual cycle is regulated by hormones, and, as such, should be a roughly regular process. The average menstrual cycle lasts around 28 days, but it can vary among individuals.

Each month (28 days), the outer uterine lining (the endometrium) thickens as it vascularises (builds up extra blood vessels and tissue) in preparation for the potential implantation of a fertilised egg (ovum).

While a fertilised egg will implant itself into the uterus and develop into a baby, an unfertilised egg, or a fertilised egg that does not implant, passes through the reproductive system. During menstruation hormone-like substances, called prostaglandins, cause the uterus to contract, shedding the endometrium through the vagina – this is known as menstruation, or your period. Any interruption to this cycle may result in metrorrhagia.

Causes of irregular bleeding between periods include:

• Menarche or menopause: When you first start experiencing puberty and menstruation (a transition period known as menarche), it is not abnormal for your menstrual cycle to be irregular. This can include spotting that occurs at various times throughout your cycle. Usually, the spotting resolves as adolescence progresses and hormone levels stabilise.
  This type of unpredictable, irregular bleeding may also occur during menopause.
• Hormone imbalances: A balance between the hormones oestrogen and progesterone regulates a normal menstrual cycle. If a hormone imbalance occurs, this cycle may be interrupted.
  A number of conditions can cause hormone imbalances, including ovarian dysfunction, polycystic ovary syndrome (PCOS), obesity, insulin resistance and thyroid disease.
• Hormonal birth control: You can experience abnormal bleeding if you start or stop using a form of hormonal oral contraceptive, such as “the pill”.
  Irregular use of hormonal contraception can also cause abnormal patterns of bleeding that resolve once you start using your contraceptive more consistently.
• Other medications: Medications such as the progesterone (Depo-Provera) contraception injection, anticoagulants (like warfarin or aspirin) and certain supplements (such as ginseng), can also cause abnormal bleeding.
• Stress: Emotional and psychological stress can also imbalance hormones.
• Uterine fibroids: These are benign (non-cancerous) growths in the wall of the uterus that can cause abnormal bleeding.
• Uterine polyps: These are small, benign growths on the endometrium that may cause abnormal bleeding.
• Adenomyosis: This is a disorder where the tissue that lines the endometrium begins to grow into the muscular wall (myometrium) of the uterus beneath. This can cause heavy and abnormal bleeding and dysmenorrhoea (painful menstrual cramps).
• The presence of an intrauterine device (IUD): The non-hormonal intrauterine device is a contraceptive for birth control that is known to cause metrorrhagia and menorrhagia as side-effects.
• Endometriosis: This is a condition that is known to cause abnormal bleeding between periods. In this condition, uterine tissue becomes implanted outside of your uterus, most commonly in your ovarian tubes (also known as the fallopian tubes), ovaries or the pelvic cavity.
• Miscarriage: A single, heavy bleed may be due to a miscarriage.
• Cancer: Uterine cancer and cervical cancer can cause abnormal bleeding or excessive menstrual bleeding, especially if you are post-menopausal.
• Dry or inflamed vaginal walls (vaginitis): This may be from decreased oestrogen levels, such as after menopause.
• Other medical conditions: These include adrenal gland insufficiency, thyroid problems, diabetes and genetic blood-clotting disorders.

What treatment is available for metrorrhagia?

If you are worried about irregular bleeding between your periods, then talk to your doctor, as there is treatment available, including:

• Pain relief: This is for the associated dysmenorrhoea (link) and includes non-steroidal anti-inflammatories (NSAIDs). These medications may also help reduce menstrual flow if you have menorrhagia.
• Hormonal birth control/ “the pill”: Oral birth control tablets contain hormones that prevent the release of an unfertilised egg from the uterus, thereby preventing pregnancy.
  These medications can also help regulate the menstrual cycle and reduce menorrhagia and the severity of period pain.
  These hormones can be delivered in other contraceptive forms, such as an injection, skin patch, implant placed under the skin of your arm, a flexible ring that you insert into your vagina or by an intrauterine device (IUD).

Treating the underlying cause of your menorrhagia is important, such as getting treatment for thyroid disease.

If you have irregular bleeding from taking hormone medication, you must talk to your doctor about changing or stopping your medication.

Additionally, if you also have anaemia due to long-term blood loss, your doctor may recommend that you take iron supplements regularly.

However, you may need surgery for treatment of irregular bleeding if medication is unsuccessful. Many of these procedures can be done on an outpatient basis; although you may need a general anaesthetic, it is likely that you can go home later on the same day. An abdominal myomectomy or a hysterectomy usually requires a hospital stay though.

Types of surgical procedures that can help in treatment of irregular bleeding include:

• Dilation and curettage (D&C): In this very effective procedure, your doctor dilates (widens and opens) your cervix and then scrapes or suctions the endometrial tissue away to stop or reduce menstrual bleeding. You may need additional D&C procedures if irregular or heavy bleeding recurs.
• Uterine artery embolisation: If you have large fibroids causing metrorrhagia, you can shrink the fibroids by blocking the uterine arteries, cutting off their blood supply.
• Focused ultrasound surgery: This procedure is similar to uterine artery embolisation. It involves using ultrasound waves to destroy fibroid tissue. There are no surgical incisions (or cuts) required for this procedure.
• Myomectomy: This is the surgical removal of uterine fibroids. Your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
• Hysterectomy: This is the surgical removal of your uterus and cervix. Hysterectomy is a permanent procedure that causes sterility (you can no longer fall pregnant) and ends menstruation. Hysterectomy is performed under anaesthesia and requires hospitalisation. This procedure may cause premature menopause.