Women's Health Community

Dear Jill2James: There are two basic culprits that can cause erratic spotting: problems with the cervix and things that create bleeding from the uterine lining. Bleeding coming from the cervix could come from a cervical lesion---if one has had a recent normal PAP smear this is unlikely. An infection of the cervix (eg "cervicitis" from Chlamydia) can make the cervix more easier to bleed. Yet if you are in a monogamous relationship this is not going to apply to you.

If the uterine lining is easily destabilized,even having sex or heavy exercise can prompt spotting. Some women will have this type of spotting if sex occurs during ovulation, or during the premenstrual week. That your spotting begins after ovulation suggests that you might have "luteal phase defect". This fancy name just means that, after an ovulation, the ovary may not be making enough progesterone to keep the lining of the uterus stable. Sometimes women may even skip ovulations altogether. Then almost no progesterone is produced.

Polyps of the lining of the uterus or uterine fibroids can create a focus for unstable uterine lining.Yet your ultrasound did not show these as present.

My best GUESS Is that your GYN suspects inadequate progesterone--- which is why you were given 10 days a month of synthetic progesterone (Provera). You mentioned that even on 5 mg for 10 days a month the spotting persists, and you do not like the side effects. Your GYN could opt to go back to 2.5 mg dose and extend the duration to 12-14 days. She could opt to do more invasive testing to look for polyps, but you mentioned that the spotting is very time specific. Polyp caused spotting tends to be very erratic.

She could decide to take you off all medication and draw a progesterone level during the worst day of spotting. But you should know that the level will simply indicate in a general way if your levels are normal or low. Moreover, hormone blood test results may not correlate well with a woman's symptoms.

Given that you have a good relationship with the GYN it is reasonable to go back and say the medication hasn't fixed the spotting. Ask her about other options. You could also get a second opinion, but your current GYN sounds like she is trying a medically appropriate treatment. ...Hope this spotting resolves as abruptly as it appeared.

Yours,
Jane

Thank you for your reply. I don't feel unhappy with my GYN or her treatment, I guess I just feel frustrated by the whole situation and needed to hear from someone else that her treatment sounded reasonable since I don't know if it is the common course. I think I will schedule another visit with her after my next cycle of provera to let her know how I feel. I feel much better now, Thank You.

Dear J2J: Let us know how it turns out. Through the magic of the internet search your experience could provide valuable input for other women with a similar condition.

In Appreciation,
Jane

Dear Jane,

You are right. I read this because the symptoms seemed similar to what I was looking for. I was having spotting in between periods but no pain.

I am 43, no children, in a monogamous relationship and just assumed I was experiencing early "pause" symptoms as my girlfriends advised. I am being told that the heavy period I 've been having for weeks is normal as well.

Do you agree?

Dear LifeBeginsAt: In the case of Jill2James, her spotting was only in the second half of the menstrual month (ie the two week after ovulation until flow). From your description it sounds like the spotting is more random--erratic across the entire month. IF this is correct then your culprit might be different from J2J.

In your specific case I would rather doubt that the problem is from the cervix. These causes can often been detected during a GYN exam, or may produce more bleeding after intercourse.

There are two major reasons for very prolonged/heavy periods: hormonal and what I call "structural". "Structural" means when excessive bleeding is due to actual problems within the cavity or walls of the uterus. Some examples of this would include fibroids of the uterus, endometriosis of the muscular wall of the uterus ("adenomyosis"), infections of the lining of the uterus, polyps of the uterine lining, or even uterine cancer.

Hormonal causes are usually linked to missed or erratic ovulations. As you may have read, in a normal cycle, estrogen is produced all month. Estrogen is responsible for building up the lining of your uterus so you have something to shed each month.

In a normal cycle, progesterone production increases following ovulation. Progesterone "stabilizes" the uterine lining in preparation for a possible implantation of a new pregnancy. If you are not pregnant that month the levels of estrogen and progesterone fall, triggering the release of the uterine lining—your period. So, if you do not ovulate, the estrogen build up of the lining continues, but without the usual ovulation associated progesterone. Thus, the hormone levels don't decline, and the lining stays up inside the uterus—as a late missed/late period. Alternatively the lining can begin to shed under its own weight producing prolonged bleeding, and/or erratic spotting if just bits from the top layer are shed.

Another way inadequate progesterone production from missed ovulations can create too heavy a flow is as follows. Simply stated, if the uterine lining is like grass or lawn, estrogen is like the fertilizer (causes proliferation and a thickening of the lining ), and progesterone is like the lawnmower (keeps the lining thin by three different mechanisms). This is why DepoProvera (high dose synthetic progesterone) brings about a thin lining, and why birth control pills (relatively progesterone dominant) bring about shorter, lighter periods. It is also why women who miss ovulations (no progesterone produced) are at a greater risk for too thick lining.

There can be MANY causes for not ovulating: thyroid problems, pituitary problems, ovarian cysts, physical stressors (eg sudden increases in exercise, crash dieting), emotional stressors (problems with aging parents, partners, finances), increased body weight, anorexia, rotating shifts at work, etc. Just moving through our 40's is linked to less frequent ovulations, and less progesterone production when a ovulation does occur.

I would urge you to see a GYN given the prolonged bleeding. They can give you the most for sure answer after a brief ultrasound (looks for ovarian cysts, uterine fibroids, and measures the thickness of the uterine lining). If there is a concerning appearance to the lining a GYN might want to do an endometrial biopsy. A short course of hormones can usually get prolonged bleeding to stop. Welcome to the 40's!

Yours,
Jane

Jane,
I have been reading this board after wondering about my own spotting situation. I feel that I have similar symptoms to Jill above. I'm a 29 year old female, have been on birth control for 10 years (different types of the pill), most currently Nortrel 7/7/7 for the last couple years, have had a some female problems such as an abnormal pap (the last two were normal, have a third in the 6 month series scheduled for next month), and have had chronic yeast/bv infections which my doctor prescribed boric acid tablets twice a week about 9 months ago. Those seemed to have really helped so I have continued to use them.
Within the last couple months I have noticed even more spotting than the occasional day spotting when I am ovulating. Even after I ovulate I have been spotting and bleeding (sometimes heavily) the week after ovulation but before my period actually starts. Because I have been on the pill so long I can pretty much know when my period is scheduled to start, so this extra spotting and period symptoms (tired, backaches, headaches, bloating) has really got me confused.
I was planning on waiting until my doctor appointment next month to discuss this, but I'm debating if I should go in before? I recently started dating a new guy (about a month ago, so after this all started) and its kind of embarrassing to be spotting and bleeding every two weeks! Any advice would be appreciated. I'm wondering if maybe I need to be put on different pills or stop using the boric acid or if it could be something more serious... Any advice you have would be greatly appreciated! Thank you!

Dear Ms. Harrison-Hohner,

I just wanted to post an update and ask for your opinion. I have been on the 5 mg dose of Provera for two months with absolutely no change and I asked my dr what the next step would be. She is now recommending that I start on birth control to help regulate my cycle. I am confused by this sudden switch since my understanding was that I had low progesterone levels, which is why my dr tried provera to stablize the spotting. So why would she want me to take birth control pills with estrogen? Wouldn't this cause problems? I have a very limited knowledge of the estrogen/progesterone cycle or balance, but I do know that too much estrogen (or lack of progesterone to counteract the effects of estrogen) can cause more health problems or issues. Am I incorrect in this knowledge? Should I reconsider the birth control? I have tried to avoid birth control because I have kidney issues and it always raises my blood pressure, so it has been a long time since I have taken it. But I am willing to try it for a short time to see if it helps. Sorry this is so long, and I hope that I have been clear in my concerns.

Dear Jill2James: Nice to hear back from you! It is interesting that despite the synthetic progesterone (Provera) 5 mg for the last 10 days of your menstrual month that the spotting during that specific interval has persisted. As we discussed before she could opt to extend the duration of Provera to 12 days--or do more testing (eg an endometrial biopsy during the last two weeks of your menstrual month. This latter, when done during a month without medications, could look at the condition of your lining and check for fragments of polyps.

Your question about the use of birth control pills (BCPs) is excellent. While all of our BCPs are progesterone dominant (to prevent a too thickened lining), the addition of some low dose estrogen can improve cycle control. Estrogen can actually help restabilize a uterine lining--both in a too-thin lining and in a lining which is too thick but where bleeding needs to be halted for the time being.

The amount of estrogen in today's very low dose BCPs (eg 20-25 micrograms of ethinyl estradiol) is considered generally safe for a healthy, nonsmoking woman up to age 50. However, in your specific case of blood pressure concerns, you would likely merit close attention to blood pressure monitoring for the initial three months of use. I remember a slim 20 year old patient with a family history of early hypertension where seemingly all the BCPs we tried did elevate her blood pressure. Ultimately she was able to use the tiny dose of synthetic progesterone found in the progestin only "minipill".

Bottom line, her suggestion is reasonable as a trial to see if the spotting can be abated. Your blood pressure should be watched, and any kidney blood testing (eg creatinine, BUN, etc) done if you have renal disease. Hopefully this will work without other, unwanted, effects. Let us know, OK?

Yours,
Jane

Ms. Harrison Hohner, RN, RNP

Hello Again! I just wanted to post an update and ask a couple of question. Your help so far has been great. I started taking Microgesten (birth control) two months ago and my spotting has stopped completely. Although I am very, very happy about these results (it is what I have been looking for), I am not sure that the side effects of the Microgesten are much better. I have regular headaches, vaginal dryness, very little sex drive (aggghhhhh!), and my blood pressure is slowly inching up the longer I take the birth control. My blood pressure is not that high, but I only have one kidney and I have been cautioned in the past to not let it get high or stay high since I have to make this kidney last. I was wondering it was possible that the birth control may have kick started my body into making enough progestone without the birth control? Is that reasonable? I made it clear that no matter what the results of taking the birth control were, I did not see it as a long term solution because of my blood pressure issues. Is there any other avenues that I could explore, or do I need to just live with the spotting? Is low progesterone a dangerous thing? Thanks again!
Jill

Hi my name is Lily and i was looking for some info about my problem well im 22 years old trying to have kids and I been on my period on and off since Feb. 2012. Im sick of it... I bleed all month with big clots and then I stop for one day then keep spoting for one week and after a week i start with the same thing again I dont know what to do?

Dear Jill2James: Wouldn't it be great if taking the low dose progestin only "mini-pill" could make the body start making more of its own natural progesterone? Sadly, that has not been the case.

In terms of your symptoms, remember that the minipill has ZERO estrogen and only one third the amount of progestin found in a regular low dose birth control pill. Usually the elevation in blood pressure is linked to the estrogen dose. You do have a risk factor for hypertension (renal problems) that could also have a contributing factor. Vaginal dryness MIGHT be related to the minipill. Sex drive does not usually worsen with lower birth control pill doses.

Bottom line, you may have to try a number of different approaches to find one that is the best fit for your specific health care concerns.

Yours,
Jane

Dear lillyangel: Glad I found your question; sometimes they get lost when buried in another series of posts.

The most common reason for a menstrual pattern like you have described is not having an ovulation every month. In a normal cycle, estrogen is produced all month. Estrogen is responsible for building up the lining of your uterus so you have something to shed each month.

In a normal cycle, progesterone production increases following ovulation and release of an egg.. Progesterone "stabilizes" the uterine lining in preparation for a possible implantation of a new pregnancy. If you are not pregnant that month the levels of estrogen and progesterone fall, triggering the release of the uterine lining—your period.

So, if you do not ovulate, the estrogen build up of the lining continues, but without the usual ovulation associated progesterone. Thus, the hormone levels don't decline, and the lining stays up inside the uterus—your missed/irregular period. Alternatively, the built up lining can begin to shed on its own creating erratic bleeding patterns which are usually "too-light" or super heavy and prolonged.

There can be many causes for not ovulating:: low thyroid, pituitary problems, ovarian cysts, physical stressors (eg sudden increases in exercise, crash dieting), emotional stressors (problems with boyfriends/girlfriends, money), increased body weight, anorexia, rotating shifts at work, etc.

In terms of the big clots, there is an enzyme produced by the lining of the uterus designed to keep menstrual blood from clotting. This allows the menstrual fluid to more readily pass out of the tiny cervical canal and into the vagina. When a woman is bleeding very heavily during her period the amount of flow surpasses the amount of enzyme--thus leading to passage of large clots.

lillyangel, given that you are trying to get pregnant, it would be very important to assess if you are missing ovulations. Missed ovulations can create major fertility problems. You should see a GYN or even your local county family planning clinic. A short course of hormones can get your current bleeding problems to stop. If you have risks for a new chlamydia infection (eg new sexual partner) since the bleeding started, a clinic can also test for infections. Infections of the lining of the uterus can also prompt more erratic bleeding.

In Concern,
Jane[br>

I thought that Microgestin had estrogen. That is what I was told by my GYN. I am the same person who posted the discussions above, that is why I did not fill in the rest of the details.

Dear Jill: You are absolutely correct! I apologize for being briefly confused; sometimes I can get lost with multiple threads in one post. As I too hastily reviewed your information I misread the Microgestin (similar to LoEstrin a combined estrogen progestin pill) for Micronor ( a progestin only type).

One does get much better cycle control with the combined type of birth control pills, yet the estrogen component can be linked with elevating blood pressure, and in some cases suppression of libido. I am assuming that you are on the 20 microgram of estrogen version of Microgestin because of your blood pressure concerns. If this is true, perhaps your GYN can find another 20 microgram combined pill which has a better side effect profile for you. There is only one lower dose combined type of Pill. In October 2010 the FDA approved "Lo-Loestrin" which contains 10 micrograms, but there is estrogen in 26 of 28 pills.

Yours,
Jane