As easy as ABC…
Abnormal vaginal bleeding is concerning for women who suffer with this problem, whether they are pregnant or at any other time in their gynaecological life. Women who are in the early stages of pregnancy are naturally concerned about the well-being of their baby and for those women who know they are not pregnant, concerns regarding the cause of the abnormal bleeding is a considerable cause for stress. The Alana Bleeding Clinic, has been developed to simplify and streamline the symptom of abnormal bleeding, so that you are seen quickly, diagnosed promptly and then managed efficiently to optimise your health. The following information relates to the areas of bleeding during early pregnancy and at other times, so that you have more information to understand the problem of abnormal bleeding.
Bleeding in Early Pregnancy
Once you have become pregnant, you want the very best for your baby. Bleeding is always concerning, but is in fact very common, with approximately 25% of women having bleeding in early pregnancy, and it is important to note that this does not necessarily mean you are going to miscarry. If you do suffer from bleeding in early pregnancy and/or have period-like pain we recommend that you seek advice and appropriate investigations. If your GP refers you to the Alana Bleeding Clinic, we will see you (within 24 hours), will take a history and organise appropriate tests. This may include blood tests such as your pregnancy hormone level (called a Beta HCG), your blood group and probably perform an internal pelvic ultrasound scan to determine where the pregnancy is located and to find out how the pregnancy is progressing.
The bleeding may simply be caused by the pregnancy nestling into the lining of your uterus, but if it is more heavy and ongoing it may represent a miscarriage. We will be able to provide you with advice and direction as to the best management and a range of options for your care. These options may include one or more of the following:
Reassurance that the pregnancy is located inside the uterus. The pregnancy itself may be very early and therefore whether it is going to be a progressive pregnancy may not be able to be confirmed. In this setting, close observation and a repeat ultrasound will be organised in 1-2 weeks. You will need to monitor your bleeding and contact us if you have any concerns in the interim.
In 2-3% of women with bleeding and pain, the pregnancy may be located outside the uterus. This is called an ectopic pregnancy. Risk factors for an ectopic pregnancy include:
- Previous infections in the pelvic (sexually transmitted infections like Chlamydia)
- A previous ectopic pregnancy
- Younger (less than 20) or older (more than 40) age
- Any previous damage or surgery to the tubes, pelvis or abdomen
- A current intrauterine device (it is important to note that if you have an intrauterine device you are NOT more likely to have an ectopic than other women, but if you happen to become pregnant with the IUD in place, then the pregnancy is more likely to be an ectopic).
Most ectopic pregnancies occur in women without any risk factors and they may be a serious risk to your health, since if they rupture (burst), this may result in life-threatening bleeding. If you experience any shoulder tip pain, feel lightheaded, have passed out, or have extreme abdominal pain you should present to the Emergency Department of your nearest hospital for immediate assessment. When you experience these symptoms the ectopic pregnancy may have ruptured which causes bleeding from the fallopian tube. This requires urgent surgery to remove the ectopic pregnancy and therefore stopping the bleeding.
An ectopic pregnancy may be diagnosed when the pregnancy hormone is positive and the ultrasound reveals an empty uterus. If an ectopic pregnancy is indeed diagnosed, the option is to have a laparoscopy and removal of the ectopic pregnancy or medical management with methotrexate. Both treatment options have their own advantages and disadvantages and these are discussed in the associated information link on ectopic pregnancy. We will discuss these options with you if required.
Pregnancy of unknown location (PUL). This means that you are pregnant, as the pregnancy hormone (HGC) is positive but that the ultrasound is unable to detect its location. This may mean that the pregnancy is in a very early stage and is developing within the uterus, and will go on to develop into a normal pregnancy. It is not possible to know if there is likely to be a variant of pregnancy such as miscarriage or ectopic pregnancy at this time. In there is a PUL, then we will need to follow you with both the HCG level and ultrasound.
Miscarriage. This means that unfortunately the pregnancy has failed to develop and has stopped growing. We will be able to diagnose a miscarriage if there is no heartbeat detected once the baby is beyond a certain measurement on ultrasound or if there has not ben proper formation of the baby from the outset. Most miscarriages occur due to a significant chromosomal problem. Since these major problems are not compatible with life, these are identified early and result in miscarriage usually prior to 12 weeks.
In the unfortunate circumstance that the pregnancy is not going to progress due to a miscarriage we will discuss management options, which include a careful ‘watch and wait approach’ to see if the pregnancy naturally expels itself – this is more likely in certain situations and less likely in others, treatment with medications to facilitate the process more rapidly or a simple surgical procedure called a “D&C”. This stands for a dilatation and curettage and is performed in theatre as a day procedure. We will help you decide which treatment option may be most suitable.
Abnormal Uterine Bleeding when not pregnant
Abnormal bleeding for a woman when she is not pregnant may be just as worrying as bleeding during pregnancy. During the menstrual cycle the lining of the uterus called the endometrium is building up in preparation for a pregnancy, and if this does not occur this lining is being shed during your “period”. The amount of bleeding is usually small – less than 5 tablespoons (or 50ml) and bleeding more than this may cause anaemia or be a sign of other gynaecological or general health conditions. If bleeding occurs in between periods or is excessive (an easy way to assess this is the number of pads or tampons that you need to change during a cycle and if this is more than every second hour, you should talk to your GP about this as it may be a problem), this is considered abnormal uterine bleeding. If a woman has reached the menopause and has not had a period for more than 2 years, then any bleeding that occurs after this time is considered abnormal and requires an assessment.
Women are often concerned about what is causing their bleeding and most causes are simple, and not related to conditions such as cancer, although it is important to perform the appropriate tests to exclude these uncommon but important causes of abnormal bleeding. Polyps, fibroids , changes in the cervix and a change in a woman’s hormonal responsiveness are more common causes of abnormal bleeding and are more easily treated.
There are many conditions that cause abnormal uterine bleeding. If your bleeding is unusually heavy – for example you are changing a pad every 20 minutes, feel dizzy or faint, we recommend that you present to your nearest Hospital emergency department for immediate assessment.
At the Alana Bleeding Clinic we see women with abnormal bleeding who require assessment by a gynaecologist within the same week. Our consultation will include a detailed history, physical examination, pelvic ultrasound scan and any blood tests that are necessary. In suspected abnormalities involving the lining of the uterus (the endometrium) a biopsy is necessary. This biopsy will be obtained with a simple procedure called a hysteroscopy and targeted biopsy.
Frequently Asked Questions
- Breakthrough bleeding: which happens as the pregnancy hormones interfere with the hormones of your normal menstrual cycle. This causes some the endometrial lining to be shed. Spotting or light bleeding may come and go for several days.
- Implantation bleeding: which happens when the fertilised egg implants in the endometrial lining of the uterus. The endometrial lining has been prepared for the nestling of the fertilised egg during the menstrual cycle and has now got a very good blood supply. The implantation may therefore be associated with some light bleeding.
- Other causes: which may include changes to your cervix by the pregnancy hormones; it softens the cervix and causes an area of cells covering the cervix to move towards the outside of the cervix. These cells are more prone to bleeding, especially when touched during intercourse. It is important to be up to date with your Pap smear screening tests as bleeding may also be caused by abnormal cells. Bleeding can also be linked to vaginal or cervical infection which would require further investigation with a vaginal swab and may need treatment. A harmless growth on the cervix called a polyp may also cause bleeding at any stage in the pregnancy. A speculum examination (as is done with the Pap smear) will reveal this polyp, and usually nothing needs to be done about it during your pregnancy.