Intermenstrual metrorrhagia

Specialty: Gynecology and breast.

• Bleed between rules
• intermenstrual spotting
• intermenstrual spotting
• acyclic vaginal bleeding

Why it occurs

• Endometrial or cervical polyp
• Chronic endometritis or subclinical cervicitis
• Hormonal contraceptives (especially pure progestogens or low doses of estrogen during the first months of use)
• Endometrial hyperplasia or endometrial cancer
• Physiological ovulatory bleeding (due to a sudden drop in estrogen in the middle of the cycle, self-limited)

Initial workup

Colposcopic examination of the cervix to rule out visible cervical polyps or suspicious lesions. Updated cervico-vaginal cytology. High-resolution transvaginal ultrasound to measure the thickness of the double endometrium and look for intracavitary masses. Consultation diagnostic hysteroscopy with directed endometrial biopsy in case of thickened endometrium (>4 mm in postmenopausal women or >12-14 mm in premenopausal women).

Standard management

• Hormonal treatment according to etiology — combined contraceptives to stabilize the endometrium if organic pathology is ruled out
• Doxycycline 100 mg orally every 12 hours for 10-14 days if chronic infectious endometritis or associated cervicitis is suspected
• Tranexamic acid 500-1000 mg every 8 hours for short-term symptomatic control (note: symptomatic endometrial polyps require removal by outpatient hysteroscopic resection).