Intermenstrual bleeding

Specialty: Gynecology and breast.

• metrorrhagia
• intermenstrual spotting
• staining between rules

Why it occurs

• Endocervical or endometrial polyps (benign, highly vascularized lesions that bleed easily with minimal changes in pressure or friction)
• Spotting due to hormonal contraception (breakthrough bleeding common in the first months of using low-dose oral contraceptives, patches, implants or vaginal ring)
• Chronic endometritis (subclinical persistent bacterial infection of the endometrium)
• Endometrial hyperplasia or endometrial adenocarcinoma (irregular intermenstrual bleeding is the most common presenting symptom in endometrial cancer)
• Hypothyroidism (thyroid hormone deficiency alters the hepatic synthesis of sex hormone-binding globulins, interfering with the endometrial cycle)

Initial workup

Urine pregnancy test or quantitative determination of serum Beta-hCG (essential for all women of childbearing age with irregular bleeding); cervicovaginal cytology (Pap smear) for screening for cervical neoplasia; transvaginal ultrasound to measure the thickness of the endometrial line (a thickness >4-5 mm in postmenopausal women is pathological and requires histological study); diagnostic hysteroscopy with targeted biopsy.

Standard management

• Adjustment of the contraceptive regimen — for example, switch to a preparation with a higher dose of estrogen to stabilize the endometrium if the spotting is persistent
• Levothyroxine sodium — dose adjusted according to weight and TSH levels, if it is confirmed that intermenstrual bleeding is secondary to primary hypothyroidism
• Natural micronized progesterone (100-200 mg orally or vaginally at night from day 15 to 26 of the cycle for endometrial stabilization in anovulatory cycles).