If you have written down the dates and amount of bleeding and any symptoms that came with it, that record becomes the starting point of the visit. Your next question may be, “So what will the doctor look at, and which tests will I have?”
Abnormal vaginal bleeding is a broad term. It covers not only bleeding when you are not on your period, but also bleeding that is clearly different from your usual period in amount or length. In medical terms, it is also described under the name “abnormal uterine bleeding.” This article explains in what order a clinic visit narrows down the possibilities and what question each test is trying to answer.
This is a generated image expressing the process of narrowing down the cause step by step. It does not show actual testing tools or results.
What is checked first during the visit?
Where the blood is coming from and whether pregnancy is possible are checked first. Not all blood found on underwear comes from inside the uterus, and bleeding related to pregnancy needs to be checked without delay.
Blood can come from the surface of the vagina or the cervix, which is the entrance to the uterus. Rarely, blood that came out with urine or stool is mistaken for vaginal bleeding. That is why, along with when you noticed the blood, you will be asked about the situation in which you found it, such as whether it appeared after sex or whether you first noticed it in the bathroom.
If there is even a small chance of pregnancy, a pregnancy test comes first, even if the bleeding looks like a period. This step is not skipped just because someone is young or close to menopause.
During the history-taking, your current medications and contraceptive method are also checked. Bleeding can become more frequent or last longer depending on when you started or changed birth control pills or hormone medication, when an intrauterine device was placed, or whether you take medication that keeps your blood from clotting easily. Whether you have bruised easily for a long time, or have often had gum bleeding or nosebleeds, is also a clue.
How are the causes of abnormal vaginal bleeding grouped?
Causes are divided into “structural causes,” where there is a change in the uterus that can be seen, and “non-structural causes,” which do not show up on imaging. The classification used internationally is also built on these two branches so that no cause is overlooked.
| Category | Examples | Main ways to check |
|---|---|---|
| Structural causes | Endometrial polyps, uterine fibroids, adenomyosis, changes in which the uterine lining becomes too thick, and rarely malignant disease | Examination and transvaginal ultrasound, plus a tissue test or hysteroscopy if needed |
| Non-structural causes | Hormonal changes from irregular ovulation, effects of medication such as birth control pills or hormone medication, blood clotting problems, infection or inflammation | History-taking and bleeding records, plus blood tests and infection tests as needed |
An endometrial polyp is a lump-like growth of the lining inside the uterus, and a uterine fibroid is a lump that grows from the muscle of the uterus. Both are usually benign, but their location can matter more for bleeding than their size, so the ultrasound looks at how closely they touch the space inside the uterus. Having a fibroid does not mean that all of the current bleeding is assumed to be caused by the fibroid.
Among non-structural causes, a common one is hormonal change when ovulation is irregular. It often appears when hormones fluctuate greatly, such as in the first few years after periods begin, after childbirth, and during the transition to menopause. However, this explanation is often reached only after other possibilities have been looked into.
What question does each test answer?
Even with the same abnormal bleeding, the tests needed differ depending on the clues from history-taking and examination. The table below is not a list of tests everyone must have. It is a summary to help you understand the purpose of a test when one is recommended.
| Test | The question it tries to answer |
|---|---|
| Pregnancy test | Is this bleeding related to pregnancy? |
| Examination with a speculum | Is there a bleeding spot, inflammation, or a growth on the surface of the vagina or cervix? |
| Transvaginal ultrasound | What are the thickness and shape of the uterine lining, where are any polyps or fibroids, and are there changes in the ovaries to check? |
| Cervical screening test | If your last screening is overdue or you have bleeding after sex, are there changes in the cervical cells? |
| Infection test | Are changes in discharge or signs of inflammation related to the bleeding? |
| Blood test | Has the bleeding caused anemia? If needed, hormone problems such as thyroid problems, as well as blood clotting problems, are also checked. |
| Endometrial biopsy and hysteroscopy | Are there changes in the cells of the lining inside the uterus? Does an area seen on ultrasound need to be checked directly? |
A transvaginal ultrasound places a thin probe inside the vagina to look at the uterus and ovaries from close up. It is useful for seeing the condition of the uterine lining and the location of growths, but the lining looks different depending on the point in the menstrual cycle when it is checked, so the result is interpreted together with the timing of the bleeding. If you have not had sexual experience or a transvaginal ultrasound is difficult for you, ask whether the scan can be done over the abdomen or by another method.
A cervical screening test is less a test to find the cause of bleeding and more a check to avoid missing changes in the cervical cells. The difference between a cytology test and an HPV test is covered separately in the column on cervical screening tests. For the purpose of hormone tests used when the menstrual cycle changes, see the column on menstrual cycle changes.
An endometrial biopsy collects part of the lining with a thin instrument so the cells can be analyzed, and hysteroscopy looks directly inside the uterus with a thin camera. Being recommended these tests does not mean that cancer is suspected. They are a step to check what is hard to judge with ultrasound alone. During the test, you may have discomfort like period cramps or some bleeding, and rarely there can be complications such as infection. You can check the preparation and process in the endometrial biopsy guide and the hysteroscopy guide.
What changes depending on age and whether you have reached menopause?
With older age, and especially after menopause, there are more cases in which the uterine lining needs to be checked directly. This is because, even with the same amount of bleeding, the causes considered first and the scope of the evaluation differ depending on the stage of life in which it occurs.
- When periods began only a few years ago Ovulation may not yet be settled into a regular pattern, so bleeding can be irregular. However, if periods have been unusually heavy from the start, the doctor may check for a blood clotting problem.
- During the years when pregnancy is possible Pregnancy-related bleeding, effects of the contraceptive method, polyps or fibroids, and infection are all looked at. If there are risk factors related to changes in the uterine lining, such as obesity or diabetes, or if bleeding continues despite treatment, a test of the lining may be discussed even at a young age.
- During the transition to menopause Skipped periods or changes in the amount of bleeding are common due to hormonal fluctuation, but bleeding is not simply explained away as a change of this stage. From the mid-40s onward, depending on how the bleeding continues, more weight may be placed on checking the lining.
- After menopause Bleeding after periods have ended is checked for its cause even if it is a small amount or happened only once. Bleeding from thinning of the vagina or uterine lining is relatively common, but it is important to confirm that it is not a change in the lining.
Age is one of several pieces of information taken into account. Even at the same age, the testing plan varies with the amount of bleeding, whether it keeps happening, previous test results, and risk factors.
What if the tests do not show the cause right away?
A clear cause may not appear on the first tests, but that does not mean the evaluation is over. The next plan is made by separating what those tests have ruled out from the questions that still remain.
Even if the ultrasound looks normal, there may be changes that do not show up well on ultrasound, such as small polyps, and if a biopsy does not collect enough tissue for analysis, it may be repeated. If hormonal change is thought to be the cause, the bleeding is watched while suitable care or medication is used, and that response itself becomes the basis for the next decision.
Even after testing, keep writing down the dates and amount of bleeding and how often you change period products. Being able to compare with your first visit makes it easier to judge whether the treatment is suitable or whether other causes need to be looked for.