Continuous or persistent scant menstrual flow

Specialty: Gynecology and breast.

• prolonged hypomenorrhea
• persistent light menstrual bleeding

Why it occurs

• Depot progestin-induced endometrial dysfunction (continuous atrophic effect on the endometrium from subdermal etonogestrel implants or levonorgestrel IUDs causing minimal persistent low-quantity spotting)
• Tuberculous endometritis (chronic granulomatous infection by Mycobacterium tuberculosis that partially destroys the endometrial stroma, causing patchy endometrial atrophy)
• Mild Asherman syndrome (fine intrauterine adhesions that limit generalized endometrial shedding while maintaining minimal areas of chronic bleeding)
• Incomplete Sheehan syndrome (partial postpartum pituitary necrosis that causes suboptimal and sustained secretion of gonadotropins, resulting in minimal continuous estrogenic stimulation)

Initial workup

Quantitative determination of Beta-hCG in peripheral blood; high-resolution transvaginal ultrasound with power Doppler to measure endometrial thickness and evaluate irregular endometrial vascularization; office hysteroscopy with targeted endometrial biopsy; endometrial culture and PCR for Mycobacterium tuberculosis.

Standard management

• Ethinylestradiol in low doses — 10-20 mcg daily for 10-14 days, useful to induce rapid proliferation of the endometrium and stop continuous scant bleeding in users of contraceptive implants
• Estrogen therapy combined with cyclical progestogens if secondary to atrophy due to central hypoestrogenism
• Specific four-drug antituberculous treatment if a granulomatous infectious cause is confirmed.