Intermenstrual bleeding

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Intermenstrual bleeding
Other names: Metrorrhagia, irregular vaginal bleeding
Blausen 0399 FemaleReproSystem 01.png
SymptomsBleeding in between periods
Risk factorsFamily history
Diagnostic methodBased on physical examination
Differential diagnosisIrregular menstruation

Intermenstrual bleeding (IMB) is vaginal bleeding at irregular intervals between expected menstrual periods.[1] It may be associated with bleeding with sexual intercourse.[2]

It may be difficult to distinguish IMB from frequent menstruation.[3]


In some women, menstrual spotting between periods occurs as a normal and harmless part of ovulation. Some women experience acute mid-cycle abdominal pain around the time of ovulation (sometimes referred to by the German term for this phenomenon, mittelschmerz). This may also occur at the same time as menstrual spotting. The term breakthrough bleeding or breakthrough spotting is usually used for women using hormonal contraceptives, such as IUDs or oral contraceptives, in which it refers to bleeding or spotting between any expected withdrawal bleedings, or bleeding or spotting at any time if none is expected. If spotting continues beyond the first 3-4 cycles of oral contraceptive use, a woman should have her prescription adjusted to a pill containing higher estrogen:progesterone ratio by either increasing the estrogen dose or decreasing the relative progestin dose.[4]

Besides the aforementioned physiologic forms, metrorrhagia may also represent abnormal uterine bleeding and be a sign of an underlying disorder, such as hormone imbalance, endometriosis, uterine fibroids, uterine cancer, or vaginal cancer.

If the bleeding is repeated and heavy, it can cause significant iron-deficiency anemia.

Intermittent spotting between periods can result from any of numerous reproductive system disorders:[citation needed]



Endometrial abnormalities:

Endocrinological causes:

Bleeding disorders:

Drug induced:

Traumatic causes:

Related to pregnancy:

Other causes:

Breakthrough bleeding

Breakthrough bleeding (BTB) is any of various forms of vaginal bleeding,[5] usually referring to mid-cycle bleeding in users of combined oral contraceptives,[5] as attributed to insufficient estrogens.[5] It may also occur with other hormonal contraceptives. Sometimes, breakthrough bleeding is classified as abnormal and thereby as a form of metrorrhagia,[6] and sometimes it is classified as not abnormal.[5]

In the context of hemophilia, the term describes a bleeding that occurs while a patient is on prophylaxis.[7]


The bleeding is usually light, often referred to as "spotting," though a few people may experience heavier bleeding.[citation needed]

It is estimated that breakthrough bleeding affects around 25 % of combined oral contraceptive pill (COCP) users during the initial 3 to 4 months of use, it then usually resolves on its own.[8][9]


Breakthrough bleeding is commonly due to 4 factors: physiologic effects of OCs on the endometrium, OC-related parameters, (dose, formulation, and regimen), patient behavior, (compliance, using concomitant medications, and smoking) and benign or malignant pathology.[9]


Breakthrough bleeding that does not resolve on its own is a common reason for women to switch to different pill formulations, or to switch to a non-hormonal method of birth control.[citation needed]


Metrorrhagia is from metro = measure, -rrhagia = abnormal flow.[10] The term is no longer recommended.[1]

See also


  1. 1.0 1.1 Bacon, JL (June 2017). "Abnormal Uterine Bleeding: Current Classification and Clinical Management". Obstetrics and Gynecology Clinics of North America. 44 (2): 179–193. doi:10.1016/j.ogc.2017.02.012. PMID 28499529.
  2. Smith, Roger P. (2023). "60. Postcoital bleeding". Netter's Obstetrics and Gynecology: Netter's Obstetrics and Gynecology (4th ed.). Philadelphia: Elsevier. pp. 139–140. ISBN 978-0-443-10739-9. Archived from the original on 2023-10-31. Retrieved 2023-10-31.
  3. "Intermenstrual and Postcoital Bleeding | Doctor". 24 August 2020. Archived from the original on 9 January 2023. Retrieved 2 November 2023.
  4. Carlson, Karen J., MD; Eisenstat, Stephanie A., MD; Ziporyn, Terra (2004). The New Harvard Guide to Women's Health. Harvard University Press. p. 385. ISBN 0-674-01343-3.{{cite book}}: CS1 maint: multiple names: authors list (link)
  5. 5.0 5.1 5.2 5.3 Farlex Medical Dictionary > Breakthrough Bleeding Archived 2019-12-16 at the Wayback Machine, in turn citing:
    • Segen's Medical Dictionary. Copyright 2012
    • McGraw-Hill Concise Dictionary of Modern Medicine. Copyright 2002
  6. Merriam-Webster's Medical Dictionary > Breakthrough bleeding Archived 2016-11-02 at the Wayback Machine Retrieved on Feb 28, 2010
  7. "Prophylaxis: Barriers and challenges - World Federation of Hemophilia". Archived from the original on 2017-12-24. Retrieved 2018-07-05.
  8. M. Hickey; I. S. Fraser (2012). "Iatrogenic unscheduled (breakthrough) endometrial bleeding". Rev Endocr Metab Disord. 13 (4): 301–308. doi:10.1007/s11154-012-9227-3. hdl:11343/220598. PMID 23224719. S2CID 26184273.
  9. 9.0 9.1 Patricia A. Lohr; Mitchell D. Creinin (2006). "Oral contraceptives and breakthrough bleeding: What patients need to know". The Journal of Family Practise. 55 (10): 872–80. PMID 17014753.
  10. "Rrhagia | Define Rrhagia at". Archived from the original on 2016-03-03. Retrieved 2013-06-27.

External links