Last edited 09/2018

The following causes should be considered in assessment of intermenstrual bleeding:

  • hormonal imbalance
    • during perimnopausal period
      • however bleeding in this group should be investigated since it can be a symptom of underlying endometrial cancer
    • as a result of progesterone-only or low-dose oestrogen contraceptive pills
      • underdosing with the combined contraceptive pill causing breakthrough bleeding. Causes include:
        • too low a prescription
        • concurrent antiepileptic treatment
        • diarrhoea
    • contraceptive injection e.g. depoprovera
    • intrauterine contraceptive device
    • anovulatory uterine bleeding

  • non hormonal
    • an ectropion which bleeds spontaneously or after intercourse
    • cervical polyps or cancer
    • fibroids
      • submucosal or pedunculated fibroids lead to irregular or heavy bleeding
    • endometrial polyps or cancer
    • inflammatory endometrial response to a copper intrauterine device
      • a malpositioned device (low lying or abnormally rotated in the uterine cavity) has a higher risk of irregular bleeding and pain
    • infection
      • endometritis caused by Chlamydia
      • gonorrhoea - less prevalent than Chlamydia
    • drugs which alter clotting parameters
      • antipsychotics, corticosteroids and anticoagulants
    • pregnancy related e.g. – ectopic pregnancy (1,2)