What could be causing vaginal bleeding in a female of reproductive age with a history of regular menstrual periods, one week after her last period?

Bleeding One Week After Your Period

Bleeding one week after your period is most commonly caused by ovulation (mid-cycle spotting), but requires evaluation to exclude structural lesions, hormonal contraceptive effects, pregnancy-related complications, or underlying bleeding disorders.

Common Causes in Reproductive-Age Women

Ovulation-Related Bleeding

• Mid-cycle spotting occurs in approximately 5% of women and typically happens 10-16 days after the start of the last period, coinciding with ovulation. 1
• This bleeding is usually light, pink or brown in color, and lasts 1-2 days without associated pain beyond mild mittelschmerz.

Hormonal Contraceptive Effects

• Unscheduled spotting or bleeding is common during the first 3-6 months of combined hormonal contraceptive use (pills, patches, or rings) and generally decreases with continued use. 2
• Extended or continuous hormonal contraceptive regimens are particularly associated with breakthrough bleeding during the first 3-6 months. 2
• This bleeding is generally not harmful and does not indicate contraceptive failure. 2

Structural Causes

• Cervical polyps, cervical lesions, or cervicitis can cause intermenstrual bleeding and are typically identified through speculum examination. 3
• Endometrial polyps and submucosal fibroids may present with irregular bleeding patterns. 1
• Adenomyosis can cause both heavy menstrual bleeding and intermenstrual spotting. 1

When to Pursue Urgent Evaluation

Pregnancy-Related Causes (Must Be Excluded First)

• Always obtain a pregnancy test in any reproductive-age woman with abnormal vaginal bleeding, as ectopic pregnancy affects approximately 1-2% of pregnancies and can be life-threatening. 3
• First trimester bleeding occurs in 20-30% of pregnancies and may indicate threatened miscarriage, ectopic pregnancy, or subchorionic hemorrhage. 3
• If pregnancy is confirmed, transvaginal ultrasound is the primary diagnostic tool and should be performed before any digital pelvic examination. 3

Warning Signs Requiring Immediate Evaluation

• Bleeding accompanied by lightheadedness or dizziness suggests significant blood loss and requires urgent assessment for ectopic pregnancy or other serious pathology. 3
• Severe abdominal pain with bleeding may indicate ectopic pregnancy rupture or ovarian torsion. 4
• Heavy bleeding that soaks through pads hourly or passage of large clots warrants immediate evaluation. 5

Diagnostic Approach

Initial Assessment

• Document the bleeding pattern: timing relative to last menstrual period, volume (number of pads/tampons), color (bright red vs. pink/brown), duration, and associated symptoms. 5
• Obtain menstrual history including cycle regularity, duration, and typical flow to establish baseline pattern. 1
• Review medications, particularly anticoagulants, antiplatelets, and hormonal contraceptives. 6
• Assess for personal or family history of bleeding disorders, including easy bruising, prolonged bleeding from minor cuts, epistaxis, or gingival bleeding. 5, 7

Physical Examination

• Perform speculum examination to identify cervical lesions, polyps, or inflammation as potential bleeding sources. 3
• Assess for signs of anemia (pallor, tachycardia) if bleeding has been recurrent or heavy. 5
• Look for signs of hyperandrogenism (hirsutism, acne) that may suggest polycystic ovary syndrome as a cause of anovulatory bleeding. 5

Laboratory Testing

• Obtain quantitative beta-hCG to definitively exclude pregnancy, regardless of patient report of contraceptive use or recent negative home test. 3
• Complete blood count if bleeding is recurrent or heavy to assess for anemia. 5
• Consider thyroid-stimulating hormone (TSH) and prolactin, as thyroid dysfunction and hyperprolactinemia are common endocrine causes of irregular bleeding. 5
• If personal or family history suggests bleeding disorder, obtain prothrombin time (PT), partial thromboplastin time (PTT), von Willebrand factor testing, and factor VIII level. 5, 7

Imaging Considerations

• Transvaginal ultrasound is indicated if structural pathology is suspected (fibroids, polyps, adenomyosis), medical management fails, or presentation is atypical. 5
• Ultrasound is not routinely required for isolated mid-cycle spotting in women with regular cycles and normal examination. 1

Management Based on Etiology

Ovulatory Mid-Cycle Bleeding

• Reassurance is appropriate if bleeding is minimal, self-limited, and occurs consistently at mid-cycle. 1
• No specific treatment is required unless bleeding is bothersome to the patient.

Hormonal Contraceptive-Related Bleeding

• Counsel that unscheduled bleeding typically resolves within 3-6 months of continued contraceptive use. 2
• If clinically indicated, rule out inconsistent contraceptive use, drug interactions, smoking, sexually transmitted infections, pregnancy, or new uterine pathology (polyps, fibroids). 2
• If no underlying problem is found and bleeding persists beyond 6 months, consider a 3-4 day hormone-free interval (not during the first 21 days of continuous use and not more than once monthly). 2
• If bleeding remains unacceptable despite these measures, counsel on alternative contraceptive methods. 2

Anovulatory Bleeding

• Anovulation is the most common cause of abnormal uterine bleeding in reproductive-age women without structural pathology. 1
• Treatment options include cyclic progestins (such as progesterone 400 mg daily for 10 days) to induce withdrawal bleeding and regulate cycles. 8
• Combined hormonal contraceptives provide cycle regulation and endometrial protection. 2

Structural Lesions

• Cervical polyps can often be removed in the office setting. 3
• Endometrial polyps or submucosal fibroids may require hysteroscopic evaluation and treatment. 1

Critical Pitfalls to Avoid

• Never perform digital pelvic examination before ultrasound in pregnant patients with vaginal bleeding, as this can precipitate catastrophic hemorrhage if placenta previa or vasa previa is present. 2, 3
• Do not assume bleeding is benign based solely on timing; always obtain pregnancy test in reproductive-age women. 3
• Do not dismiss recurrent intermenstrual bleeding without evaluation, as it may indicate endometrial pathology, particularly in women over age 35 or with risk factors for endometrial cancer. 1
• Recognize that normal coagulation studies (PT/PTT) do not exclude platelet disorders or von Willebrand disease, which are the most common inherited bleeding disorders. 7

Follow-Up Recommendations

• If bleeding resolves spontaneously and pregnancy is excluded, observe for recurrence over 2-3 cycles. 1
• If bleeding persists, worsens, or recurs, proceed with pelvic ultrasound and consider endometrial sampling in women over 35 or with risk factors for endometrial hyperplasia/cancer. 1
• Refer to gynecology if structural pathology is identified, bleeding disorder is suspected, or medical management fails. 5