Normal menstrual flow lasts about 4 days, produces a total blood loss of 30 to 80 ml (about 2 to 8 tablespoons), and occurs normally every 28 days (+/-7 days).

Vaginal bleeding may be something to worry about for women over age 50 (postmenopausal). The risk of malignancy increases with age.

Make sure that bleeding is coming from the vagina and is not from the rectum or in the urine. Inserting a tampon into the vagina will confirm the vagina/cervix/uterus as the source of bleeding.

A careful exam by your health care provider is frequently the best way to sort out the source of the bleeding. This exam can be accomplished even while you are bleeding. Do not delay getting an exam just because you are currently bleeding.

• Uterine fibroids or polyps
• Injury or disease of the vaginal opening (caused by intercourse, infection, polyp, genital warts, ulcer, or varicose veins)
• Vaginal injury from insertion of foreign objects, from malignancy, or from infection
• Dry vaginal walls resulting from lack of estrogen after menopause
• Pregnancy complicated by abortion (spontaneous or induced)
• Pregnancy complicated by ectopic pregnancy
• Fluctuation in hormone levels
• Stopping and starting birth control pills or estrogens
• Low thyroid function
• IUD use can cause occasional spotting (if bleeding is slight, it can be ignored)
• Drugs such as anticoagulants
• Cervical conization or cauterization procedures
• Stress

Bed rest is recommended if bleeding is heavy.

The number of pads or tampons used over time should be recorded (so that the amount of bleeding can be determined).

Because aspirin may prolong bleeding, it should be avoided if possible.

• You are pregnant!
• There is any unexplained bleeding between periods.
• There is any bleeding after menopause.
• Abnormal bleeding is accompanied by other symptoms.

The medical history will be obtained and a physical examination performed.

Medical history questions documenting vaginal bleeding between periods detail may include:

• Time pattern
  • When did this bleeding between periods begin?
  • Does it occur consistently, such as every month?
  • When (during the course of a menstrual cycle) does this bleeding begin?
  • How long does the in-between bleeding last?
• Quality
  • Is the bleeding heavy?
  • How many tampons or pads are required?
  • Do cramps accompany the bleeding?
• Aggravating factors
  • What makes it worse?
  • Does increased physical activity make the bleeding worse?
  • Does intercourse bring on the bleeding?
  • Is increased stress associated with the bleeding?
• Relieving factors
  • Does anything relieve or prevent it?
• Other symptoms
  • What other symptoms are also present?
  • Do you have abdominal pain or cramps?
  • Increased bruising elsewhere on the body?
  • Do you have any difficulty, pain or burning with urination?
  • Is there bloody urine or blood in the stools?
• Other important information
  • Are you pregnant?
  • Have you had a miscarriage or abortion?
  • Have you had a D and C?
  • What medications are being taken?
  • Are tampons used? What kind? What size?
  • At what age did menstruation start?
  • Have there been normal periods without bleeding between in the past?
  • Is sexual activity occurring?
  • Is there a history of sexually transmitted disease?
  • Is birth control being used? What kind?
  • Have there been any injuries?
  • Have there been any medical or surgical treatments?

A thorough menstrual history will be obtained and a physical examination performed with an emphasis on the pelvic area. Uterine blood loss can be estimated if the patient knows how many sanitary napkins or tampons were used during a period.

Diagnostic tests that may be performed include:

• Urine pregnancy test
• Cervical cultures for sexually transmitted diseases
• Blood tests for thyroid and ovarian functions.
• Pap smear (if bleeding is inactive)
• Endometrial biopsy
• Pelvic ultrasound