Metrorrhagia, now commonly called intermenstrual bleeding, is vaginal bleeding that occurs at irregular intervals not associated with the menstrual cycle. While the blood comes from the uterus as it does during menstruation, the bleeding does not represent a normal period.
Pathophysiology of metrorrhagia –
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.
When bleeding occurs outside the expected timeframe of the menstrual cycle, it is sometimes referred to as abnormal or dysfunctional uterine bleeding.
Some people who menstruate regularly experience light bleeding or spotting at various times throughout their cycle, especially at ovulation. In these cases, symptoms such as mild discomfort and spotting at mid-cycle, may not be unusual for a person.
• Sometimes the bleeding seems to follow a pattern and may feel like you’re having “a second period” at another time during the month. In other cases, the bleeding is entirely random and unpredictable.
• It may be painless when the bleeding occurs, or you may experience cramps and other symptoms associated with your period, such as bloating.
• Intermenstrual bleeding is often light but can also be quite heavy. In some cases, it may even be heavier than your regular period.
• The color of the blood can range from dark brown to red to light pink. Some people may see clots or mucus in their underwear or when they wipe.
• 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.
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.
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.
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.
A single, heavy bleed may be due to a miscarriage.
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.
• Your doctor will review your medical history and symptoms. Your doctor will perform a physical examination for metrorrhagia diagnosis.
• During your pelvic examination, cultures may be taken to test for infection or sexually transmitted disease. Blood tests may be used to test your thyroid and hormone levels.
• You may be tested for pregnancy.
• A Pap smear may be taken to check for cervical cancer.
• An ultrasound may be used to create pictures of your reproductive organs to allow your doctor to check for abnormal growths.
The treatment of metrorrhagia depends on the cause of the problem.
• Some people decide to use different types of hormonal therapy, especially progestin, to treat abnormal bleeding. These can include birth control pills, IUDs, estrogen patches, and other options.
If you are not sexually active or have never had sex, you can still use hormonal methods to treat problems with your menstrual cycle. Your healthcare provider will help you decide which one is best for you.
• If an IUD is causing the problem, it may be removed.
• Erosion of the cervix may be treated removing or destroying some of the cervical tissue.
Sometimes surgery is needed. Possible surgical treatments include:
• D&C, in which tissue is scraped or suctioned from the uterus
• hysteroscopy (to remove a polyp, for example)
• hysterectomy, which is removal of the uterus.
• Endometrial ablation, which is perfomed in the office.
If cancer is found, it may be treated with surgery, radiation, or chemotherapy (anticancer drugs).
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