By Fred Licciardi, M.D.
Really frustrating. Where does it come from? We first look for an anatomical reason (a problem due to some sort of growth that we can see usually with the ultrasound). The most common reason is that there is a polyp inside the uterus. A polyp is a benign growth inside the uterus, kind of like a skin tag on the inside. They are easily removed via hysteroscopy. If you have had polyps removed and still have spotting, you need to have a sono hysterogram to be sure that the polyps were completely removed. Or maybe they grew back. If the lining is pristine, you we have to look for other causes. Adenomyosis is another reason for spotting. Usually there is evidence of adenomyosis on ultrasound. If not, an MRI will make the diagnosis.
Women with endometriosis are more likely to have spotting, and this may be may be due to a few causes. With endometriosis, the glands of the uterus grow in areas they shouldn’t. The most common abnormal areas are around the ovary and tubes, but there can also be spots of endometriosis on the surface of the cervix. Because the glands don’t always behave as the normal endometrium, they can bleed anytime, causing spotting.
Another source of spotting in women with endometriosis is a hydrosalpinx. A hydroslapinx is a big scarred fallopian tube that is blocked on the part away from the uterus, near the ovary. If the hydro is caused by the chronic inflammation of endometriosis, blood can slowly built up inside the tube. This blood can sometimes back up from the tube into the uterus and then out the cervix, causing spotting. It’s usually not red, but more of a chocolate brown.
Occasionally no reason for the spotting is discovered. So we blame in on being “hormonal”, but we really don’t know what the specific hormonal abnormality is. Could spotting a few days before the period be due to a luteal phase defect and low progesterone levels? There may be one rare woman who has this issue, but for most women with pre-period spotting, their hormones are just fine. I have found that persistent spotting stops when moving to injectables, which do increase both of those hormones.
Post ovulation spotting can in many cases be controlled with progesterone and estradiol in the luteal phase. I remember one patient from years past who had the spotting mid cycle, had a negative hysteroscopy, and got pregnant on her own a few months later. So even though she had monthly spotting it had little effect on her ability to conceive. Maybe the spotting was normal for her and it stopped once she became pregnant.
If you are anovulatory due to PCO and you have frequent spotting, you may need to have a biopsy of the endometrium. PCO women who rarely get a period are at higher risk for endometrial hyperplasia or even cancer. This usually causes heavy irregular periods, but sometimes it’s just spotting. An office biopsy can usually make that diagnosis.
Other Variations in Bleeding
“I don’t bleed for a long as I used to”. I hear this a lot. Typically someone will say they used to bleed for 4-5 days and now they are finished after 3. There is no evidence that this means anything bad. Certainly after a delivery such changes are more common. But even without pregnancy, some women have changes that are hard to explain. I don’t think this means there is a change in fertility.
Heavier bleeding is more of a problem because it is more likely to signify a change that may be important. Remember that fibroid the doctor told you you had, but said it’s not a problem because it’s small? Unfortunately they can grow and become a problem with time. Increased estrogen levels associated with repeated drug cycles can accelerate their growth. Adenomyosis can also progress, leading to increased bleeding.
Consistent heavy bleeding in the setting of normal anatomy may require a consultation with a hematologist. Many of us are born with blood abnormalities that don’t’ allow for proper blood clotting. These issues are usually discovered in adolescence after the first periods are found to be abnormally heavy.
And of course, unexplained heavy bleeding may also require an office biopsy or hysteroscopy to rule out pre-cancerous or cancerous cells.