Spotting Between Periods: Common Causes

TL;DR: Spotting between periods is usually not serious, and contraception, infections, small growths and hormone changes are common causes. It should still be checked, because it can sometimes point to an infection, a pregnancy problem or cancer. If you could be pregnant and have bleeding with tummy pain, get urgent help. Any bleeding after menopause needs checking.

You go to the toilet in the middle of your cycle and there it is: a smear of pink or brown on the tissue, nowhere near when your period is due. It stops by evening, and you tell yourself it was nothing. Then it happens again the next month. Many women wait it out, especially when a clinic visit means time off work, a long queue or an awkward conversation. Most of the time the cause is minor, but the only way to know is to get it looked at.

This post is about bleeding that appears between otherwise recognisable periods. If your cycles themselves have become unpredictable, read why your period is irregular and what is normal and what is worth a doctor's visit.

Is spotting between periods normal?

It is common, but it is not something to ignore. The NHS says bleeding between periods or after sex is not usually serious, and should always be checked by a doctor, at a GP surgery or sexual health clinic. MedlinePlus, from the US National Library of Medicine, says most causes are easily treatable.

Hormonal contraception

This is one of the most common explanations. The NHS lists hormonal contraception first among its common causes.

UK sexual health guidance says bleeding is common in the initial months of progestogen-only methods, which include the implant, the injection and the hormonal coil, and may settle without treatment. It also says bleeding on the combined pill often settles within the first three months. Irregular use of a method, such as skipping or restarting pills, can also cause bleeding, and an intrauterine device, or coil, may cause occasional spotting.

The same guidance says people on hormonal contraception with problematic bleeding should have a pregnancy test if sexually active and an STI test if at risk, and that persistent bleeding or a change after at least three months of use calls for an examination. So do not assume the implant is to blame if it has been a year and the pattern has suddenly changed. Our contraception methods compared post explains how each method tends to affect bleeding.

Ovulation

Some women notice a little spotting around the middle of their cycle. A review in American Family Physician explains that midcycle spotting occurs before ovulation as oestrogen levels fall. It is less common than many people assume: in a US study that followed 201 women with regular cycles, only 4.8% had midcycle bleeding. So do not explain away repeated spotting as ovulation without having it checked.

Infections

Sexually transmitted infections are a cause that is easy to miss, because most people with chlamydia have no symptoms. When there are symptoms, they can include bleeding after sex or between periods, unusual discharge, burning when you pee and lower tummy pain.

STIs like chlamydia and gonorrhoea are the usual cause of pelvic inflammatory disease, which also lists bleeding between periods or after sex among its symptoms and can lead to long-term pain, fertility problems and a higher risk of ectopic pregnancy. It is treated mainly with antibiotics. Getting tested is routine healthcare and says nothing about your character, and a stable relationship does not rule out an infection.

Pregnancy

If there is any chance you could be pregnant, take a pregnancy test. Light bleeding very early on can be implantation bleeding, which happens when the fertilised egg attaches to the womb lining. But bleeding in pregnancy always needs advice, because it can also be a sign of a miscarriage, an ectopic pregnancy or another complication.

An ectopic pregnancy usually shows up between the 4th and 12th weeks of pregnancy, often with vaginal bleeding that is a bit different from a normal period, sometimes watery and dark brown, and tummy pain low on one side. Read the signs of ectopic pregnancy so you know what to look for.

Growths and changes in the womb and cervix

Polyps and fibroids are common non-cancerous causes. Bleeding after sex can also come from cervical ectropion, a harmless change on the surface of the cervix, from cervical polyps or from vaginal dryness.

Other possible causes on the MedlinePlus list include stress, an underactive thyroid, blood thinners and recent procedures such as a smear or biopsy.

Perimenopause

As you approach menopause, changing periods are often one of the first signs of perimenopause, and they may become irregular, lighter or heavier. If you are on HRT, some irregular bleeding or spotting is common and should settle within six months. See your GP if it continues or gets heavier. Do not put every new bleed down to perimenopause: the causes above can still apply, so get it checked. Our post on periods in perimenopause explains what to expect.

Once you have gone 12 months without a period, any bleeding needs checking, even if it happened once or was only pink or brown spotting.

Could spotting be a sign of cancer?

Sometimes, although most spotting is not. The NHS says bleeding between periods or after sex can sometimes be a sign of cancer. Cervical cancer and womb cancer both list bleeding between periods among their symptoms.

For African women, this deserves extra attention. The WHO says cervical cancer is the leading cause of cancer death in women in 26 countries, primarily in sub-Saharan Africa and parts of South and Central America, and that women living with HIV are six times more likely to develop it. If you are not up to date with screening, your appointment is a good moment to ask. Read about HPV self-sampling, which lets you take your own sample, and our guides to cervical cancer and screening and womb cancer signs.

When should you get checked?

Book an appointment for any bleeding between periods or after sex, even if it stops. The NHS advises seeing a GP or going to a sexual health clinic, and in Nigeria, Kenya, Ghana or South Africa a family planning clinic, general hospital or gynaecology clinic is a sensible place to start.

Get urgent help the same day if you have recently missed a period, have unusual bleeding and have tummy pain, since this could be an ectopic pregnancy. Go to your nearest hospital emergency department straight away if you have sudden, sharp and intense tummy pain, feel faint or very dizzy, have pelvic pain with heavy bleeding, or a very high temperature with severe pelvic pain.

At the appointment you can expect questions about your symptoms and history, and possibly a pregnancy test, a blood test, an STI test and an examination of your vagina and cervix. You may be referred for an ultrasound, colposcopy or hysteroscopy if more tests are needed.

What to note before your appointment

A few details make the visit far more useful, and they are easy to lose once the bleeding has stopped. Our guide to periods has more on tracking your cycle.

Logging spotting separately from your period in Asele keeps this record over several cycles, and the Health Brief can turn it into a summary for your appointment. You can find us at Asele.

This post is education, not medical advice. Please speak to a qualified clinician about any unexpected bleeding.

References

1. NHS. Vaginal bleeding between periods or after sex. nhs.uk
2. MedlinePlus. Vaginal bleeding between periods. medlineplus.gov
3. Faculty of Sexual and Reproductive Healthcare. Problematic bleeding with hormonal contraception, 2015. cosrh.org
4. Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. American Family Physician, 2004. aafp.org
5. Dasharathy SS, et al. Menstrual bleeding patterns among regularly menstruating women. American Journal of Epidemiology, 2012. pubmed.ncbi.nlm.nih.gov
6. NHS. Chlamydia symptoms. nhs.uk
7. NHS. Pelvic inflammatory disease. nhs.uk
8. NHS. Vaginal bleeding in pregnancy. nhs.uk
9. NHS. Symptoms of an ectopic pregnancy. nhs.uk
10. NHS. Menopause symptoms. nhs.uk
11. NHS. Symptoms of cervical cancer. nhs.uk
12. NHS. Symptoms of womb cancer. nhs.uk
13. World Health Organization. Cervical cancer fact sheet. who.int