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Assessment of intermenstrual bleeding

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

A careful history will usually reveal possible causes of unscheduled bleeding and guide on the need for examination and further investigations (1).


  • age – causes tend to differ with age
  • menstrual history
    • last menstrual period - to determine the likelihood of pregnancy
    • length of cycle - establish the probability of anovulation
    • frequency, heaviness, and duration of the irregular bleeding and its association with menses
    • associated symptoms – abdominal pain, fever
  • sexual history
    • starting a relationship with a new partner or presence of vaginal discharge – may indicate an infection, such as Chlamydia
    • past history of STIs
  • hormonal and contraceptive history
    • failure to adhere to the hormonal contraceptive regimen is most often the cause of bleeding, especially if started within the past three months
    • further evaluation is required in cases with bleeding of more than 3 months duration, particularly if heavy
    • use of an intrauterine contraceptive device (IUCD)
  • medical history
    • bleeding disorders
  • family history of cancers
  • current medication


  • observe whether the patient is obese since anovulatory cycles are associated with obesity
  • abdominal examination
    • a pelvic mass suggests fibroid, especially if the patient has heavy periods
  • bimanual examination
    • can be used to support the diagnosis of a pelvic mass
  • digital examination
    • may reveal cervical excitation (indicative of infection) or craggy irregular cervix (in cervical cancer)
  • vaginal speculum examination
    • most important examination and can detect cervical ectropian and cancer (1)


  • investigations undertaken in the primary care
    • cervical smear – if indicated
    • endocervical or vaginal swab – if there is a risk of infection
    • blood tests (FBC, clotting studies, thyroid function tests) if indicated from history. FSH/LH if the patient is suspected to be perimenopausal.
    • pregnancy test should be considered
    • consider a pelvic ultrasound if there is suspicion of uterine fibroids
  • investigations in the secondary care may include:
    • hysteroscopy and endometrial biopsy
    • MRI (1)


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