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What causes intermenstrual spotting?

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Practicing since : 1985
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Over the past 3 yeas i have intermenstrual spotting off and on. It started in February of 2011 where I spotted continually for 12 days (starting at ovulation), straight into my period (which lasts 7 days). I had a transvaginal sonography, as well as a saline infusion sonohysterography (they thought they saw something on the transvaginal ultrasound – turned out it was most likely a tiny clot, as I was bleeding during the ultrasound). Had off and on spotting for the following 7 months. In October 2011 I asked for uterine biopsy, which I had. Everything was fine. After the biopsy my periods were completely normal (no spotting) for a year. In fall 2012 I had one month of continual spotting and passed a large clot. Had another ultrasound and everything looked fine. Again went almost a year with normal cycles (no spotting) when the spotting started again in September 2013. Since then I have spotted off and on between ovulation (comes Ov mucous) and my period. My Dr. says it is just a symptom of perimenopause (I am 41) and that going on the pill or using the Mirena IUD could help. For now, I can live with the inconvenience of the spotting, I just worry that there could be something more ‘sinister’ going on. Is this type of spotting common with perimenopause? Is another biopsy warranted?
Posted Mon, 24 Mar 2014 in Menstruation and Miscarriage
Answered by Dr. Cori Baill 28 minutes later
Brief Answer: I assume you had more of a work up the described above. Detailed Answer: While perimenopausal hormonal fluctuations can cause abnormal bleeding, it is never an explanation unless everything else is been ruled out. I assume in addition to imaging your doctor tested you for infection ordered labs to check your thyroid and prolactin levels and yes I would think a recent biopsy is in order. In my practice my rule of thumb is unexplained bleeding which persists despite negative ultrasound and biopsy warrants a hysteroscopic D&C. Even with a negative sonohystogram sometimes there are surprises. Office biopsy and ultrasound are reassuring the first time around but if abnormal bleeding persists or is recurrent, I repeat the work up and then proceed to direct visualization and sampling. I would encourage you to discuss a more aggressive approach with your physician. Chances are he's right and everything will be okay. But I go to great lengths to make sure because the worst thing you can do is overlook an early malignancy. By the way I assume you have a track record of normal Pap smears and are up to date. Please do not worry unnecessarily. Chances are everything is okay. It usually is. But it is the doctor's job to make sure that that is the case. I hope this helps. If your doctor is reluctant to pursue things further it may be time to consider another doctor. 41 is a little early for pre-menopause. The average age of menopause is 51 with approximately 4 to 5 year lead in. Some families however cluster around an earlier age. If your sisters mother grandmother all went through menopause closer to 40 then you probably will too but it is early on the normal curve
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Follow-up: What causes intermenstrual spotting? 51 minutes later
Thank you for your response. I plan to make another appointment with my dr next week. Yes my Dr tested for infection (negative), as well some of my hormones and thyroid which were also normal. I am not sure if she tested my prolactin levels. What does prolactin tell you/ mean? All my paps have been clear (last one done 3 weeks ago). Are there times when no cause for the spotring can be found?? One other thing, I was found to have non alcoholic fatty liver disease in an ultrasound 3 years ago. My BMI was 30 at the time. I have since lost a bit of weight and my BMI is now about 28. In my last blood test my liver function tests were all normal (alt, ast).
Answered by Dr. Cori Baill 34 minutes later
Brief Answer: I am glad you're following up with your doctor. Detailed Answer: Lliver disease has to be quite severe to affect blood coagulation. What you describe has nothing to do with vaginal spotting. The most common cause of mild fatty liver is glucose intolerance and has to do with fatty stores being necessary for energy since the cells aren't sensitive to insulin. Losing weight and increasing exercise are the best treatment for early glucose intolerance, a forerunner of adult onset diabetes. Lifestyle changes can prevent it from ever progressing to full-blown diabetes. It may even reverse the mild fatty liver. Keep up the good work. Yes it is possible to not find an explanation other than hormonal fluctuations. Prolactin is made by the pituitary it is increased when women breast-feed. It can also be increased by little growths in the pituitary that are benign. Elevated prolactin tends to make women skip periods but sometimes it can cause other menstrual cycle abnormalities. It is a simple blood test to check a prolactin level. Medication is usually used to treat the condition. Thyroid abnormalities are much more common (1000X) than prolactin abnormalities however when abnormal bleeding occurs it's easy enough to check both. If you are you on any new medications, some psych meds can also cause changes in prolactin levels. Again this is usually associated with skipping. But sometimes the effect is mild. That can result in spotting. Also excessive use of aspirin or other anti-inflammatories can produce easy bruising and bleeding from delicate tissues like the inside of the cervix. I did not see him medication history. If you not if you're not using any medication or over-the-counter supplements then ignore those remarks. Some herbal products can also affect bleeding and clotting. And some are difficult for the liver to metabolize. Herbal compounds from overseas can sometimes contain contaminants including blood thinners. I would recommend stopping all aspirin and aspirin like anti-inflammatories, herbs and supplements if no other explanation is found. But even after all this the explanation made be a variant in your physiology that is age-related and unimportant. That would be a good thing!
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