Whether you're 13 or 53, abnormal or unexpected gynaecological bleeding can be a massive source of stress, worry and confusion. But, while it could be an early sign of uterine or cervical cancer, it may also be a sign of something far more benign. The difficulty is knowing how to tell the difference! We speak to specialist gynae nurse Tracie Miles, from charity The Eve Appeal, to find out what your bleeding might be a symptom of, and when you should be concerned.
Firstly, Miles says, it's important to understand what 'abnormal bleeding' might look like.
"Bleeding is not just necessarily that Snow White moment of fresh red blood on a white panty liner," she says. "It could be a sort of sludgy brown staining, like the kind you might get towards the end of your period, or it can be a mucus with a bit of a pink tinge. Be aware of any kind of abnormal discharge or bleeding, and any changes to your 'normal' monthly cycle."
Once you've passed the menopause - on average around the age of 51-52 years - this is the time in your reproductive life when it's most easy to define what 'normal' is, so it should be fairly obvious if something's awry. Technically, the menopause is when you have your last period, but in fact doctors don't class a woman as being postmenopausal until at least 12 months after her last period, assuming she's within the normal age range for menopause (over 45).
"If your periods have definitely finished, you should not have any bleeding at all," Miles explains. "There should be no postmenopausal bleeding, so if you do experience bleeding after this point, it's not your periods starting up again," she adds.
If you are bleeding after the menopause, there are several possible causes, and it's important to see your GP to tease out the underlying cause. Do bear in mind that if you're on HRT, some forms give regular periods while others are 'period free'. However, with the latter you can still get irregular bleeding, especially in the first few months - 'period free' does not necessarily mean 'bleed free'. Speak to your GP if in doubt.
The most likely explanation of postmenopausal bleeding is vaginal atrophy, a condition where reduced oestrogen levels cause vaginal tissue to become drier and less elastic.
"As the skin atrophies and gets older, you can get some abrasive bleeding, especially after sex," Miles explains.
"It's still a reason to go to the GP, as vaginal atrophy can be managed with local application of oestrogen - or hormone replacement therapy (HRT) - which can make the vagina more comfortable," she says.
Uterine (womb) cancer
However, postmenopausal bleeding is also a classic sign of womb cancer, so it's really important to see your GP and get this ruled out at the first sign of blood.
"Don't panic, it is probably vaginal atrophy, but it is also a classic sign of womb cancer so it's really, really important that you take yourself to the GP and get checked out as soon as possible," Miles says.
The perimenopause - the period of transition between regular menstruation and the menopause - is the most difficult time to identify what's 'normal' or 'abnormal', because fluctuating hormone levels may mean your cycle is all over the place anyway.
"One of our big things at The Eve Appeal is #KnowYourOwnNormal," Miles says, "which is fine until you get to the perimenopausal stage, when everything starts changing and there is no normal."
Despite this, she insists, it's important for women to feel confident about going to their GP with any concerns.
"It's less likely at this stage that abnormal bleeding is a signal of either cancer or vaginal atrophy, but we need to give women the confidence that it's ok to go to their GP and say, 'I know I'm on my way to being menopausal, and this is probably nothing, but my bleeding pattern has changed and I just need the reassurance that this is my new normal.' It's still really important to get everything checked out," says Miles.
Similarly, there are all sorts of things that may disrupt your 'normal' regular cycle during the years between menarche (the first period) and perimenopause - from hormonal contraceptives to pregnancy and childbirth. However, if you're having a normal, regular cycle, or you're using a long-term contraceptive, abnormal bleeding may still be a cause for concern.
If you've had a coil fitted - either the copper contraceptive coil, or the hormonal Mirena coil - your discharge is likely to change, and you're likely to get spotting (bleeding between periods) for the first couple of months, Miles explains. The same thing applies to the contraceptive implant and injection.
"Because you've had a contraceptive intervention, talk to your GP or nurse about what to expect over the next couple of months, and follow their guidance. If it doesn't settle down after a couple of months, go back and get checked out," she advises.
One of the benefits of the combined oral contraceptive pill is that it makes your 'periods' (which are actually withdrawal bleeds, rather than normal menstruation) more regular and predictable. It's important to remember that the progestogen-only pill (sometimes called the 'mini pill') commonly leads to irregular periods. And it may take a couple of months before your periods settle down on the combined pill too.
However, the combined pill can also cause changes to the cervix, known as cervical ectropion. These changes, Miles says, "are totally and utterly benign, but can cause bleeding after sex, which can be really really scary and messy."
The cervix is a very vascular part of the body, she explains, with a very big blood flow.
"What we often see with women on the pill is that the cervix becomes even more vascular, so if you have sex and the penis bangs against the cervix - which it often does with deep penetration - then you might get a lot of bleeding from the ectropion. For a woman who's protected herself with contraception so she can enjoy her sex life, it can be really awful to then be put off by bleeding after sex."
Unfortunately though, in some cases, postcoital bleeding can be an early indication of cervical cancer. There's no need to panic, but it is important to see your GP as soon as possible to get it checked out.
"In a lot of these cases of postcoital bleeding, if we see patients straightaway and they've got an early cancer, we can manage this with simple surgery, done in the outpatient department, under a local anaesthetic. If women put off seeing their GP, cancer can do nothing but grow," Miles says. "We also really need to emphasise how important it is to go for your smear - it's a screening test that really does work - and that it's ok to get anything abnormal checked out."
Endometriosis or fibroids
Endometriosis is a painful condition where the uterine tissue (endometrium) grows outside of the womb, and fibroids are non-cancerous growths that develop in or around the womb. Neither condition is life-threatening but both can cause heavy bleeding, discomfort, and even extreme, debilitating pain.
Crucially, Miles says, "there's no way for individual women to differentiate between these benign conditions and gynaecological cancer. If you've got very heavy bleeding, and pain in places other than the uterus when you're menstruating, it's really important to get yourself referred to a gynaecologist who can identify and manage whatever the problem is. Even if it's not cancer, it's important to get checked out so your pain and discomfort can be treated."
Alternatively, if you're experiencing irregular or no periods, this may be an indication of polycystic ovary syndrome (PCOS). Other symptoms of PCOS include excessive body hair growth (hirsutism) and oily or acne-prone skin.
Sexually transmitted infections (STIs)
Bleeding between periods or after sex could also be a symptom of an STI like chlamydia or gonorrhoea. If you've had unprotected sex, be sure to get yourself checked at your local GP surgery or GUM clinic.
Getting checked out
Visiting your GP about abnormal gynaecological bleeding can be nerve-wracking, particularly if you've had a previous bad experience of being dismissed or fobbed off. Miles recommends writing down a list of your symptoms, or keeping a diary to track any irregular periods or spotting, so you can give your GP as much information as possible within the space of your short appointment.
It's also worth identifying which GP at your practice has a particular interest in women's health, and then making an appointment to see them. You could do this by speaking to the receptionist or a friend who goes to the same practice, looking at each GP's profile on the practice website, or even through trial and error, to find a GP who you're confident will take your concerns seriously.