What is the term for bleeding outside of a normal menstrual cycle?

Abnormal Uterine Bleeding Outside the Normal Menstrual Cycle

Bleeding that occurs outside of your normal menstrual cycle is called intermenstrual bleeding or metrorrhagia. 1, 2

Types of Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is defined as bleeding from the uterus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of pregnancy. It can be categorized as:

• Intermenstrual bleeding (metrorrhagia): Bleeding between regular menstrual periods
• Heavy menstrual bleeding (menorrhagia): Excessive bleeding during regular periods
• Irregular bleeding: Unpredictable timing of bleeding episodes

Classification System: PALM-COEIN

The American College of Obstetricians and Gynecologists (ACOG) uses the PALM-COEIN classification system to describe uterine bleeding abnormalities 1:

Structural Causes (PALM):

• Polyps
• Adenomyosis
• Leiomyoma (fibroids)
• Malignancy and hyperplasia

Non-structural Causes (COEIN):

• Coagulopathy
• Ovulatory dysfunction
• Endometrial
• Iatrogenic
• Not yet classified

Common Causes of Intermenstrual Bleeding

1. Structural causes:

   • Endometrial polyps
   • Fibroids (especially submucosal)
   • Adenomyosis
   • Endometrial hyperplasia or cancer

2. Non-structural causes:

   • Hormonal fluctuations (ovulatory dysfunction)
   • Hormonal contraceptives
   • Intrauterine devices
   • Medications affecting hormonal balance
   • Thyroid disorders
   • Stress
   • Infection

Evaluation Process

For women experiencing intermenstrual bleeding, evaluation typically includes:

• Laboratory tests: Pregnancy test, thyroid function, prolactin levels 1
• Imaging: Transvaginal ultrasound is the initial and often only imaging needed 3
• Additional procedures when indicated:
  • Saline infusion sonohysterography (more accurate for detecting polyps and submucous fibroids) 4
  • Hysteroscopy with biopsy (reference method for definitive diagnosis) 4
  • Endometrial biopsy (indicated for women >45 years or those with risk factors for endometrial cancer) 2

Management Approaches

Management depends on the underlying cause:

1. For hormonal causes:

   • Combined hormonal contraceptives or progestin-only options 1, 5
   • Levonorgestrel-releasing IUD (highly effective for reducing bleeding) 5, 6

2. For structural causes:

   • Polyps or fibroids may require surgical removal
   • Endometrial ablation for heavy bleeding
   • Hysterectomy as definitive treatment when other options fail 6

3. Symptomatic treatment:

   • NSAIDs for 5-7 days during bleeding episodes 5
   • Tranexamic acid for acute management of heavy bleeding 2, 6

Important Considerations

• Intermenstrual bleeding in women over 45 years requires endometrial biopsy to rule out endometrial cancer 2
• Breakthrough bleeding is common in the first 3-6 months of hormonal contraceptive use 5
• Persistent unexplained bleeding warrants further investigation

When to Seek Immediate Medical Attention

• Heavy bleeding with signs of hemodynamic instability
• Severe pain accompanying bleeding
• Bleeding that persists despite treatment
• Postmenopausal bleeding (requires prompt evaluation)

Remember that while intermenstrual bleeding is common, persistent or recurrent episodes should be evaluated to identify and address the underlying cause.