Inter-Menstrual Bleeding

Abstract: A woman becomes niddah not only with her normal menses, but also with any uterine bleeding not clearly due to trauma. A number of different patterns of abnormal uterine bleeding can lead to excess time in the niddah status and its resulting marital strain. Careful history, supplemented with a few laboratory or radiologic tests, can lead to the proper diagnosis and the most appropriate treatment. Depending on etiology, options include both medical and surgical intervention. Physicians should assure that women with minimal bleeding have consulted with a halachic authority prior to starting medical intervention, as halachic interventions are sometimes sufficient.

Discussion: A woman becomes niddah not only with her normal menses, but also with any uterine bleeding that is not clearly due to trauma. Examples include side effects of hormonal treatment [1] and bleeding at the time of ovulation [2]

It should be noted that, for both menses and inter-menstrual bleeding, even very slight spotting can render a woman niddah. Thus, bleeding that has little medical significance can lead to great emotional stress if it causes long periods niddah, during which all physical contact between husband and wife is prohibited. Therefore, women may turn to health care professionals for assistance in treating this phenomenon. As not all spotting causes niddah, a physician should suggest that couple consult with a halachic authority prior to undertaking medical intervention.

Careful history taking, supplemented at times with ultrasound or measurement of hormone levels, is important for identification of the abnormal bleeding pattern. Accurate diagnosis is essential to devising an appropriate solution. Bleeding patterns include:

Menorrhagia: Prolonged heavy bleeding

Consequences:  The woman may have to wait for 10-14 days before she can begin the process of exiting the niddah status. Because she needs to wait one week from that point until she can immerse in the mikveh, she can remain in the niddah status for as long as three weeks. If this is paired with short cycles, not uncommon as women enter the perimenopause, she can be left with a very short time frame for a physical relationship with her husband. Sometimes she may not even be able to immerse in the mikveh before her next menses begin.

Diagnosis: A bimanual examination and/or ultrasound can often reveal a potentially treatable cause [3]. These can include fibroids or polyps.

Treatment: Benign growths of the uterus, such as fibroids (leiomyomas) or polyps, can be sometimes treated by embolization [4] or operative hysteroscopy [5] respectively. For women past childbearing, hysterectomy may also be indicated. Prolonged bleeding from other causes can be reduced by hormonal contraception [6], progesterone secreting IUD [7]and, for those who have finished with childbearing [8], endometrial ablation [9] (various methods of destroying the uterine lining while leaving the rest of the uterus intact).

Long periods: light bleeding that does not end

Consequences: The woman has difficulty exiting the niddah status, as the prolonged light bleeding invalidates the internal self examinations that she is required to perform. Although she feels as if all bleeding has ceased, stains will continue to be seen on her undergarments or internal self examinations. The potential consequences are similar to those of menorrhagia in that she can be niddah for 18, 19 or more days. If this is paired with short cycles she can be left with a very short time frame for a physical relationship with her husband.

Diagnosis: The cause can be indicated by the finding on ultrasound. A thick endometrium suggests some form of anovulation. A thin endometrium suggests that the woman is most likely perimenopausal [10].

Treatment: In the case of a thick endometrium, giving external progesterone and then withdrawing it can lead to improvement at least for a number of months [11], after which the intervention can be repeated. In the case of a thin endometrium, estrogens can be given to replace the low estrogen status that has lead to the condition [11].

Ovulation bleeding

Consequences: Even short episodes of halachically significant spotting prior to mikveh immersioncan can require a couple to wait an additional week before resuming their physical relationship. It is easier to find halachic solutions to this situation if the bleeding occurs after mikveh use.

Diagnosis: This explanation of mid-cycle bleeding is generally obvious from history alone and can be confirmed by tests of ovulation timing. The diagnosis is further suggested when the blood is mixed in the cervical mucous, typical in this condition [12].

Treatment: One can take a number of medical approaches to treating this condition. One approach is to simply push off ovulation by a few days by giving estrogen at the beginning of the menstrual cycle. In this way, this minimal bleeding will be delayed until after mikveh immersion when the woman no longer has to do internal self examinations and can wear colored underwear, so that mild spotting would not render her a niddah.  If the woman is not trying to get pregnant, it is possible to suppress ovulation by the use of hormonal contraceptives. Another approach is to support the uterine lining at the time of ovulation with the use of high dose clomiphene citrate [13]. For women who wish to avoid medicinal intervention, halachic interventions may some times be of help. A woman should consult with a halachic authority.

Pre-menstrual spotting

Consequences: If the discharge is of a color that makes a woman niddah, this will prolong the time unavailable for the couple to have a physical relationship. Even if the discharge does not make her niddah, anticipation of oncoming menses may also have halachic consequences. If a woman has a consistent premenstrual symptom (in this case spotting), there may be a halachic prohibition on intercourse, although non intimate contact would be permitted.

Diagnosis: The timing of the problem generally makes the diagnosis obvious. This condition is particularly common in women entering the perimenopause. As not all colored discharge will render a woman niddah, consultation with a halachic authority is strongly advised.

Treatment: Supporting the uterine lining at the end of the menstrual cycle by the use of progestins is often helpful [14].

Intermittent spotting

Consequences: This form of spotting can lead to constantly repeating the seven days, so that the woman may not be able to immerse in the mikveh until the next cycle's menses have begun.

Diagnosis:  Anovulation is a likely cause of this situation. The probable cause of the lack of ovulation can generally be found by history, estrogen levels and ultrasound [15].

Cases where high estrogen is found are most likely polycystic ovarian syndrom [16]. Low estrogen is associated with a number of conditions, many of which are obvious from history alone. These include lactation, perimenopause and side effects of various hormonal treatments.

Treatment:  In cases of high estrogen levels, administration of progesterone followed by withdrawal can often help [17]. In low estrogen cases, supplemental estrogen may help [17].

Implications for Patient Care:  Any spotting or bleeding outside of a normal menstrual cycle can have significant implications for the marital life of a couple. Physicians can assist women with these conditions by attempting to diagnose and treat the underlying condition. Problems arising from minimal bleeding can sometimes be resolved halachically. Therefore, prior to beginning medical intervention, it is best to encourage the woman to consult with a halachic authority to assure that this intervention is necessary.

Medical References

[1] Datey S, Gaur LN, Saxena BN. Vaginal bleeding patterns of women using different contraceptive methods (implants, injectables, IUDs, oral pills) - an Indian experience. An ICMR Task Force Study. Indian Council of Medical Research. Contraception 1995 Mar;51(3):155-65.

[2] Speroff L, Glass RH, Kase NG. Clinical gynecologic endocrinology and infertility. 6th ed. Baltimore: Lippincott Williams & Wilkins, 1999;201-38,499,575-9.

[3] Munro MG. Dysfunctional uterine bleeding: advances in diagnosis and treatment. Curr Opin Obstet Gynecol 2001;13:475-489.

[4] Gupta JK, Sinha AS, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev 2006 Jan 25;(1):CD005073.

[5] Lefebvre G, Vilos G, Allaire C, et al. The management of uterine leiomyomas. J Obstet Gynaecol Can 2003 May;25(5):396-418; quiz 419-22.

[6] Iyer V, Farquhar C, Jepson R. Oral contraceptive pills for heavy menstrual bleeding. Cochrane Database Syst Rev 2000;(2):CD000154.

[7] Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2000;(2):CD002126.

[8] Cook JR, Seman EI. Pregnancy following endometrial ablation: case history and literature review. Obstet Gynecol Surv 2003;58(8): 551-556.

[9] Lethaby A, Hickey M. Endometrial destruction techniques for heavy menstrual bleeding. Cochrane Database Syst Rev 2002;(2):CD001501.

[10] Goldstein SR, Zeltser I, Horan CK, et al. Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding. Am J Obstet Gynecol 1997;177:102.

[11] Chuong CJ, Brenner PF. Management of abnormal uterine bleeding. Am J Obstet Gynecol 1996;175(3 Pt 2):787-92.

[12] Oriel KA, Schrager S. Abnormal Uterine Bleeding. Am Fam Physician 60(5):1371-1382.

[13] Eden JA, Place J, Carter GD, Jones J, Alaghband-Zadeh J, Pawson ME. The effect of clomiphene citrate on follicular phase increase in endometrial thickness and uterine volume. Obstet Gynecol 73 (1989);187-190.

[14] Walden MS. Primary care management of dysfunctional uterine bleeding. JAAPA 2006 Feb;19(2):32-9; quiz 47-8.

[15] Munro MG. Dysfunctional uterine bleeding: advances in diagnosis and treatment. Curr Opin Obstet Gynecol 2001;13:475-489.

[16] Speroff L, Fritz MA. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Baltimore: Lippincott Williams & Wilkins, 2005;470-74.

[17] Speroff L, Fritz MA. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Baltimore: Lippincott Williams & Wilkins, 2005;557-60.

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