Abnormal Bleeding and Spotting Overview

Abnormal bleeding and spotting are on a continuum. Significance varies with age. However, some irregular bleeding and anovulatory bleeding are characteristics of both adolescents and women approaching menopause. Certainly, causes and concerns of unusual bleeding are different at each end of the age spectrum.

Some considerations need to be taken into account when assessing a woman who reports abnormal bleeding or spotting. These basics are outlined in the Basic Triage Assessment Form for Abnormal Bleeding. You may have other basic questions that are deemed important in your practice. Please feel free to add these to this section for future reference. Some truisms must be kept in mind when evaluating these women.

All women of reproductive age are at risk for pregnancy if they are sexually active with male partners, even if they consistently use birth control.
Any spotting or bleeding in an established postmenopausal patient, unless such patient has begun a continuous dose of hormone replacement therapy (HRT) regimen in the last 6 to 9 months, is suspicious.
A sexually active woman of any age who is not monogamous, or who has a partner who is not monogamous, is at risk for sexually transmitted infections (STIs).

Patients have different definitions of normal. Table 12-1: Facts on Normal Menstruation is included in this section as a review of the parameters of onset, interval, duration, amount, and composition. Patients also vary in their descriptions of what is not normal for them. Criteria for what each office or clinic will define as abnormal need to be established between triage nurses and providers.

Abnormal bleeding usually is described in terms of numbers of pads or tampons saturated during a certain number of hours. This is dependent on several factors, which should be clarified with the patient and with the providers in the practice.

The type of pad or tampon used (mini versus maxi; slim versus super)
Patient hygiene: Some patients can’t stand a “dirty pad.” Have the patient estimate the size of the area of saturation in terms agreed on by the providers (i.e., the size of a quarter or “soaked through to underwear”).
Associated symptoms, such as clots, require a previously agreed upon classification. The classifications can be based on coins (dime, nickel, quarter), fruit (grape, plum, orange), or balls (ping-pong, golf, softball).

For the purposes of this book, the criterion for heavy, serious bleeding is defined as soaking one or more pads in 1 hour or six or more in a 12-hour period. “Soaking” is defined as saturating through a regular pad or tampon to the patient’s underwear. Patients also experiencing dizziness or abdominal, rectal, or vaginal pain associated with their bleeding are considered to have a serious problem.

My office/clinic’s definition of serious, heavy bleeding is: ______________________________ _______________________________________________________________________________________________________.

» BASIC TRIAGE ASSESSMENT FORM FOR ABNORMAL BLEEDING

How old are you? _____________________________________________________________________________
When was your last menstrual period? _________________________________________________________
Was it normal for you? _______________________________________________________________________
What are the frequency, duration, and amount of bleeding? ____________________________________
Do you have any associated symptoms, such as cramping, abdominal pain, clotting, referred pain? _________________________________________________________________________________________
How long has the problem been occurring? _____________________________________________________
Are you taking any medication(s)? ____________________________________________________________
Are you taking any hormones or hormonal birth control? _______________________________________
Do you use any other method of birth control? ________________________________________________

Table 12-1 Facts on Normal Menstruation

Onset

Interval

Duration

Amount

Composition

Cessation

Age: 10-16 years, 95% have started by age 15 years

Mean age: 12 years

Precocious menstruation: menses before age 9 years

Delayed menstruation: menses after age 16 years

Interval: counted from the first day of flow 1 month to the first day of flow in the next menstrual cycle

Average: 21-35 days in length; 95% of cycles are from 21 to 45 days in length

Abnormal intervals: less than 21 days or greater than 42 days; frequently caused by anovulation

Average: 3-5 days

Abnormal duration: less than 1 day or more than 8 days

Average: 30-40 mL

Variability in amount: 70-100 mL.

Variability is normal, but most have 30-<80 mL.

Perimenopausal women: not unusual to see 150-200 mL

Primary components: bacteria, endometrial debris, enzymes, mucous, prostaglandins, vaginal cells

Mean age: 50½ years

Premature menopause: generally prior to age 40 years

Average of menopause is 51 years. In women ≥45 years of age, a follicle-stimulating hormone (FSH) is not required to diagnose menopause.

Abnormal Bleeding in Adolescents

» Key Questions

ASSESSMENT	ACTION
1. Is this your first menstrual period?
	YES	Go to Step A.
	NO ↓	Go to Question 2.
2. Are you soaking one or more pads in 1 hour or six or more in a 12-hour period? Are you light-headed or dizzy? Do you have any abdominal, rectal, or vaginal pain associated with the bleeding?
	YES	Go to Step B.
	NO ↓	Go to Question 3.
3. Have you established any regularity to your menstrual cycle?
	YES	Go to Question 4.
	NO ↓	Go to Step C.
4. Are you sexually active?
	YES	Go to protocol Abnormal Bleeding in Women of Reproductive Age.
	NO	Go to Step D.

» Actions

STEP A: First Menses

The first period may catch an adolescent girl off guard. The first cycle experienced does not set any pattern for coming cycles. It is not unusual for the first few cycles to be anovulatory.

Assess the patient’s understanding of the menstrual cycle.

Assess the patient’s readiness in terms of available supplies.

Assess any need for contraception.

STEP B: Heavy Bleeding

If the patient meets the criteria for heavy, serious bleeding, she should be instructed to come to the office immediately or go to the nearest emergency room (ER). The patient should not drive herself. If there is any question of loss of sensorimotor skills, the patient or her agent should call 911.

STEP C: Bleeding in Adolescents

It is not unusual for adolescents to have irregular, often anovulatory cycles, particularly during the first year after menarche.

Determine if the patient’s cycles are consistently 21 days or less or are exceeding 8 days in length.

Assess for signs of anemia, which is common in adolescents.

If the patient had regular cycles for 1 year or more and now has gone 3 months without a cycle, assess for signs of weight loss or gain, increase in athletic activity, stress from school or home, or an increase in lethargy or depression.

Schedule the patient for evaluation within 2 weeks if the answers to any of these questions are positive.

Continue to Question 4.

STEP D: Bleeding and Sexually Active

Ascertain if the answer is “no” to the question “Are you sexually active?” means (1) never have been, (2) not now, or (3) everything but vaginal penetration.

Reassure an adolescent who has never been sexually active that most of the evaluation may be done via blood work or a sonogram and a pelvic examination may not be necessary.

If the patient has been sexually active in the past, determine if the interval warrants evaluation for pregnancy.

Refer to the protocols Chapter 12: Abnormal Bleeding in Women of Reproductive Age and Chapter 8: 1st Trimester Bleeding, if appropriate.

» Patient Education

Adolescents may not know what is normal menstrual bleeding or related symptoms, so question thoroughly to establish normalcy for each individual.
It is important that adolescents understand that although much of early bleeding may be anovulatory, it is not safe to assume they cannot get pregnant if they become sexually active.
Adolescents may be at risk for conditions that may alter their cycles, such as eating disorders and extreme exercise patterns. If appropriate, arrange for evaluation of these potential problems.
Don’t miss an opportunity to offer counseling on contraception and STI protection.
Abnormal bleeding usually is described in terms of the numbers of pads or tampons saturated during a certain number of hours. Adolescents may not be good at such estimations and may need more help in describing their symptoms. Clarify with them:
- Quantify bleeding. Some patients can’t stand a “dirty pad.” Have the patient estimate the size of the area of saturation in terms you have agreed upon with providers (i.e., the size of a quarter or “soaked through to underwear”).
- Type of pad or tampon used (mini versus maxi; slim versus super)
- Associated symptoms, such as clots, require a previously agreed upon classification. The classifications can be based on coins (dime, nickel, quarter), fruit (grape, plum, orange), or balls (ping-pong, golf, softball).

Abnormal Bleeding in Women of Reproductive Age

» Key Questions

ASSESSMENT	ACTION
1. Are you soaking one or more pads in 1 hour or six or more in a 12-hour period? Are you light-headed or dizzy? Do you have any abdominal, rectal, or vaginal pain associated with the bleeding?
	YES	Go to Step A.
	NO ↓	Go to Question 2.
2. Are you sexually active?
	YES	Go to Question 3.
	NO ↓	Go to Question 3.
3. Are you, or do you think you could be, pregnant?
	YES	Go to Step B.
	NO ↓	Go to Question 4.
4. Do you consistently use a form of hormones, either to provide you with birth control or to control menstrual cycle symptoms?
	YES	Go to Step C.
	NO ↓	Go to Step D.
5. Do you consistently use a form of barrier contraception, such as condoms?
	YES	Go to Step E.
	NO	Go to Step F.