What to do about unexpected vaginal bleeding – Dr. Wilson answers your questions.

This article covers the investigation of unscheduled vaginal bleeding (bleeding outside a period or after periods have stopped). For treatment options and HRT adjustments, see here.

What is unscheduled (unexpected) vaginal bleeding?

Bleeding after the menopause, whether or not you are taking HRT
Bleeding in between periods or after sex, whether or not you are taking HRT

Women experiencing unscheduled (unexpected) vaginal bleeding will usually be referred for further investigation.

Dr. Wilson says: ‘Unscheduled bleeding is common and often the cause is not serious. It could be a hormonal imbalance, or small polyp. However, in a few cases, bleeding can be a sign of a cancer of the lining of the womb (endometrium) or cervix (neck of the womb) and it is not possible to tell without a closer look, so it’s really important to tell your doctor and get it checked.

Note: Unscheduled bleeding within the first 3-6 months after starting HRT is considered NORMAL and can simply be part of adjusting to treatment. Investigation will not usually be required as in most cases, it will settle down on its own. It should be reported and monitored, so that you and your doctor can make sure it stops.’

What happens when I see my doctor?

Your doctor will take a detailed description of when the bleeding occurred, how often and any medication you are taking. They will then arrange any other investigations that may be needed.

What kinds of investigations can I expect?

The kinds of investigations you may be offered include:

A speculum examination: to look at the cervix and take swab samples to test for infection. This is very similar to having a smear test and can be done at the GP surgery.
An ultrasound scan: to look at the ovaries, womb and lining of the womb. In particular, it is often performed to measure the thickness of the lining of the womb. This will be performed by a radiographer.
Endometrial sampling (also called pipelle biopsy): This is where a small amount of the lining of the womb is taken for analysis under a microscope, to check whether the cells look normal and healthy or not. This is usually done by a gynaecologist once you have been referred by your GP.
Hysteroscopy: This is where a camera is inserted into the womb in order to see exactly what the lining of the womb looks like and to take further samples to look at under a microscope.

Once the cells have been checked, if everything is normal you can discuss with your doctor whether any treatment to stop the bleeding is needed.

Dr. Wilson adds ‘The one thing I want women to know if they have been referred for investigation of bleeding is that they should be offered a conversation about pain relief. This would be with the team carrying out the investigations.’

While endometrial sampling can be quick, I speak to many women who are unprepared for the level of discomfort they experience. There are also women who have experienced trauma in their past for whom this may be particularly difficult. They won’t necessarily have disclosed this to a doctor, especially if they’ve been referred and never met the person before. In ‘see and treat’ clinics, women may not even realise they are going to have a procedure in the appointment leaving them little time to question details such as comfort, so clinics need to lead the way. It’s absolutely imperative that the profession doesn’t downplay or dismiss the reality of women’s experiences and offers the same high-quality of care that we would in other clinical situations, where pain relief is offered as standard.

Women need to know that the The British Society for Gynaecological Endoscopy published this statement in December 2018:

“Diagnostic hysteroscopy is a commonly performed investigation; it is safe and of short duration. Most women are able to have the procedure in an outpatient setting, with or without local anaesthesia, and find it convenient and acceptable. However, it is important that women are offered, from the outset, the choice of having the procedure performed as a day case procedure under general or regional anaesthetic.”

There are also clear recommendations from the Royal College of Obstetrics and Gynaecology that set out women’s right to be made aware of their options. There is certainly scope for more research into the most effective options for making these important procedures as comfortable and stress-free as possible.

Dr. Wilson describes her experiences talking with women: A lot of women talk to me about their experiences and it remains something of a taboo. Women don’t talk to each other as they don’t want to scare other women. The intention of this article is not to increase anxiety about such important procedures. On the contrary. A bad experience can put women off getting important checks in the future, so it’s critical that the experience of care is positive. This article is to empower women to consider in advance what’s right for them. I’ve received several thank yous from women who have been able to influence their care as a direct result of our conversation and we need to share this knowledge more widely.’

‘The second important point to note is that if you are being referred for investigation AND you are considering having a Mirena coil, you may be able to have it inserted at the same time, thereby reducing the number of appointments needed and overall discomfort. For women who are planning to have their investigations under anaesthetic, having the Mirena inserted at the same time makes a lot of sense. You or your doctor need to let the team know in advance, however, so the right equipment can be on hand on the day’

The Mirena coil is a very effective option for controlling bleeding in perimenopause and can be used as the progesterone component of HRT for up to 5 years. It is a treatment for heavy menstrual bleeding and a thickened endometrium (endometrial hyperplasia). It needs to be inserted by a trained professional.


Unscheduled bleeding should always be checked
Ask about pain relief options if you are referred for investigation
If you’re planning to have a Mirena coil fitted, ask if it can be done at the same time.

Please feel free to share this article with your friends and colleagues who may find it useful.

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