Full transcript
0:00Picture this. You go to the bathroom and you see a little bit of pink, a little bit of brown,
0:04spotting, nowhere near your expected period. I can guess in about four minutes,
0:10you're going to be googling or looking up on ChhatBT midcycle spotting. What does
0:15it mean? Is there something wrong with my uterus? Does this mean that I can't
0:18get pregnant this month? Is it cancer? These are real questions that my patients ask me
0:25every day. and we are going to learn all about midcycle spotting today.
0:36I'm Dr. Laura Shaheen. I'm a double board certified OBGYn and reproductive endocrinologist
0:41helping women and people learn about their bodies for over 20 years. And today we're going to learn
0:48all about what could cause spotting between periods. If this is your first time finding
0:53my channel, welcome. I am so glad you are here. Be sure and subscribe so you don't miss any of my
0:59educational content. And if you're coming back because you have found information valuable,
1:05thank you. That is such an incredible compliment. And there are other ways to stay in touch and
1:10to learn from me. You can sign up for my newsletter in the description below. And
1:14you can listen to my Brave and Curious podcast anywhere you listen to podcasts. Apple podcast,
1:19Spotify. You can watch in-depth discussions and interviews here on my YouTube channel. But today,
1:26we're going to learn all about midcycle spotting and what it means. We're going to go over five
1:31important topics. Topic number one, we're going to learn exactly what midcycle spotting is and how
1:36common it is. Number two, we're going to go over causes. Number three, testing to figure out what
1:42is going on. Number four, treatment options that are available. And finally, number five, we'll do
1:49a recap and I'll give you specific questions to ask your doctor about your personal situation.
1:55Topic number one, let's make sure we're on the same page and we're talking about the same thing.
1:59Midcycle spotting is really called intermenstrual spotting. So, spotting between your periods. So,
2:06older terms that you might hear and and some people might use are menia, menometaria, or
2:13dysfunctional uterine bleeding. What we're talking about is spotting right around ovulation. So,
2:18right in the middle of menstrual cycles and timing is key. And I'm going to talk a lot about how
2:25important it is to track the timing and exactly what symptoms you're having because it can help
2:30us figure out what's going on. But if you have approximately 28 day menstrual cycles for from
2:36the onset of cycle day one, first day of bleeding to the next onset of the next cycle day one is at
2:42about 28 to 30 days. you are probably ovulating in the middle there right around cycle day 14,
2:4715, 16. And so spotting in that window, I'm talking about midcycle spotting. So
2:54how common is it? It might be less common than you think. True midcycle spotting was seen in
3:01one study looking at prospective design. About 200 women said they had true midcycle spotting about
3:084.8% of the time. Another large study, Apple Women's Health Study, looked at almost 20,000
3:14participants and any intermen menstrual spotting, not necessarily right around ovulation, but any
3:21spotting between periods occurred about 6.1% of the time. As we age, when we get into our 40s,
3:27it actually becomes even more common. One study quoted about 24% of women after the age of 40 will
3:33have incidence of spotting between periods. Topic number two, causes of this midcycle spotting. So,
3:40I think of this in five main categories, and I'm going to go through each one. Category number one,
3:46side effects from birth control. So, a lot of different types of birth control, whether it's
3:51the pills, the IED, um implants, uh shots, a lot of them can be associated with spotting,
3:57especially in the first 3 months of use. One study actually said 30 to 50% of women starting
4:04the birth control pill will talk about irregular and unexpected spotting within the first 3 months.
4:09It's really common. Copper IUD is notorious for some spotting and heavier menstrual flow. And
4:16the hormonal IUD that can be famous for actually decreasing flow and even stopping menstrual cycles
4:23from a thin endometrial lining. In the first few months, you can have some irregular spotting. So,
4:28when you're starting birth control or a new method, expect some irregular bleeding for the
4:34first three, maybe even up to 6 months. But talk to your doctor. There are alternatives
4:39and get your questions answered. The second category I think about with irregular bleeding
4:44or spotting between periods, pregnancy. So even if you think it is impossible, it can't happen,
4:51you're contracepting, take a pregnancy test because bleeding in pregnancy can sometimes
4:56be associated with miscarriage or even something more urgent, an ectopic pregnancy. You really want
5:01to get this evaluated. The next big category is anatomic causes. And I think about this as
5:08cervical causes and uterine causes. I can think of three main reasons that people can have spotting
5:13or bleeding from their cervix between periods. Number one, cervical polyps. This is a benign
5:19polip. It's typically no abnormal cells. It can grow on the cervix for one reason or another, and
5:25it can cause spotting between periods. This can be diagnosed with a simple speculum exam, and often
5:30removed in the office. The second cervical issue that could cause spotting or bleeding is regular
5:36anatomy. Sometimes people have the glandular part of cervical anatomy on the outside of the cervix.
5:43This is called a cervical ectropion and this is common when we have high levels of estrogen
5:48especially in uh adolescence and in pregnancy and if we're using estrogen containing contraception.
5:56So this glandular tissue is a little bit more fryable. This tropion can be easier to
6:02uh bleed and be kind of irritated especially with intercourse or things like tampons in the vagina
6:08and it rarely needs treatment. The third cervical thing I think of causing bleeding or irritation
6:14uh and intermenstrual spotting is infection. And this could be an STI. It could be gorrhea. It
6:21could be chlamydia. And this needs to be diagnosed and treated with antibiotics right away. Something
6:26that's important to talk about with the cervix is bleeding after intercourse. That can be a little
6:32red flag for me as a gynecologist helping people for years that we really should look for abnormal
6:37cells. So, a little warning sign or worrisome sign of cervical cancer or abnormal cervical cells can
6:45be bleeding after intercourse. Of course, there can be other reasons. I just mentioned them,
6:49but make sure that you are up to date with your papsmear. Think about screening for HPV,
6:54human papilloma virus, because some strains can be associated with abnormal cervical cells. Uh, talk
7:01to your doctor and just know that bleeding after intercourse on a regular basis is something that
7:06should be checked out. While we're talking about anatomy, I also think about uterine anatomical
7:11causes of bleeding or intermenstrual spotting. This I think about in five categories. I think
7:16about uterine polyps. So polyps just like they can grow on the cervix, which is on the outside of the
7:22uterine cavity, polyps can grow on the inside of the uterine cavity and lead to spotting. This can
7:27be diagnosed with imaging and it can be treated with a simple hysteroscopy, a little camera
7:32inside the uterus to grab the polip, bring it out, send it to the pathologist to make sure there's
7:37no abnormal cells. They're almost always benign. Another anatomical issue within the uterine cavity
7:43that can cause spotting are fibroids. So fibroids are benign muscle tumors. I know it has the word
7:50tumor, but they're benign that can grow in any part of the uterus. Sometimes they're in the wall
7:56of the uterus, sometimes they're on top of the uterus. But if they're growing inside the uterine
8:00cavity, a submucosal fibroid, that can cause symptoms like spotting or bleeding and it can be
8:06associated with increased risk of miscarriage and even fertility issues. So if that is discovered
8:12on imaging, it's something to talk to your doctor about maybe getting treated. Three more things to
8:17talk about for the uterus and bleeding. Number one is endometriosis or adnomiiosis. Endometriosis is
8:24a chronic inflammatory condition that is estrogen dependent. It is typically associated with painful
8:30periods, pain with intercourse, and sometimes difficulty getting pregnant. It can present in
8:36these ways. It's basically these lesions and tissue that looks like it should belong on
8:43the lining of the uterus, but it's found outside of the uterus, like along the pelvic side walls,
8:48on top of the uterus, within the ovaries, along the fallopian tubes, and other parts of the body.
8:54Now, endometriosis, if it's inside the wall of the uterus, it's called adnomiiosis. So adnomiiosis I
9:02think of as a type of endometriosis but it's just this lesions this tissue is kind of growing in the
9:08wall of the uterus. It can make the uterus look bulky um and irregular on some imaging. It can be
9:15associated with painful periods and intramenstrual spotting. So it's something to think about um as
9:22one of the causes of spotting between periods. I also think about chronic endometritis. So,
9:29this is a chronic infection that's within the lining of the uterus that is typically associated
9:35with recurrent miscarriage or recurrent uterine um instrumentation like procedures that sort of
9:42lead to these chronic inflammatory cells that uh line the uterine cavity. It can be associated with
9:49infertility. can be associated with miscarriages, not necessarily, but it's diagnosed with
9:54an endometrial biopsy and it's treated with antibiotics. And one of the presentations can
10:00be irregular spotting throughout your cycle. The final uterine issue that I think of anatomically
10:05that can be associated with spotting or sort of discharge between periods is a C-section scar. And
10:11the medical term for that is not everybody that has a C-section is going to get an ismile. Um,
10:19sometimes I'll do imaging on somebody that's had a C-section and I cannot even tell that they ever
10:24had delivered a baby that way. I mean, the uterus is just absolutely amazing. But some people do get
10:30a little scar, a little triangle, a little area where fluid and blood can kind of get trapped
10:36in the wall of the uterus. And this can come out at different times in the cycle. This is called
10:41an ismasil. I have a whole video here on YouTube that's really describing this uh unique situation
10:49that could explain intrammenstrual spotting. So, it's something to just ask your doctor about if
10:54you've had a C-section. Say, "Hey, could this be an ismosil?" And let's do some imaging to figure
11:00out if that's what's going on. Um the fourth group of causes of intermenstrual or midcycle splatting
11:07are hormonal causes. I know that sounds like a big category. It could be something like thyroid
11:13disease or prolactin issues that are leading to irregular ovulation. When you're not ovulating on
11:20a regular basis, that can make it confusing to track your cycles and it can seem like there's
11:25intramenstrual spotting. So, it's something to look at, think about. It's not the actual
11:31thyroid disease that's causing the spotting or the high prolactin level that's causing the spotting.
11:36It is the irregular ovulation that results from these hormone imbalances. So, it's something to
11:42think about if you're also having irregular and unpredictable menstrual cycles. You might want to
11:46ask to get your thyroid checked and your prolactin check. But when I really think about hormonal
11:51issues, and this is really one of the most common causes of midcycle spotting is a little dip in
11:58estrogen levels. So, remember the menstrual cycle. For the first two weeks, your ovaries
12:03are making estrogen, and that estrogen is talking to the uterine lining to build it up and get nice
12:07and thick and ready for an embryo to implant. After ovulation, your body makes progesterone to
12:13stabilize that lining. If you are not pregnant, about 2 weeks after ovulation, the ovaries stop
12:19making estrogen and progesterone. Those hormone levels drop and that signals the shedding of the
12:25lining of the uterus. So the uterine lining is very sensitive to drops in estrogen levels. And
12:32sometimes when people ovulate in the middle of the cycle, they release the egg from that follicle,
12:37that structure in your ovary. And with it, the ovary just temporarily stops making or just dips
12:44the amount of estrogen that it's making. And that little dip, if someone's uterine lining
12:48is sensitive to that, it'll just shed a little bit. So when you think about hormonal causes
12:53that is one of the most common causes you have to think about these anatomic reasons these
12:59um other reasons like infection or chronic endritis things that we've talked about today
13:03but if you rule out these other things um this can be a cause if you're really tracking and
13:09it's really happening exactly with ovulation this is something to think about. And the final
13:15kind of group of things that could cause irregular bleeding is what we are the most terrified about,
13:20but it's also one of the most rare and that is cancer. So yes, some cancers like cervical cancer
13:27can present with postcoidal bleeding or after sex bleeding. Some uterine cancers can present with
13:33irregular and unpredictable bleeding. This is very rare for people pre-menopause. But if anyone has
13:41bleeding after menopause, it should be evaluated. You should have your little red flag up to make
13:46sure we don't have any abnormal cells. We already talked about keeping up to date with your papsmear
13:50and your cervical cancer screening. Thankfully, cervical cancer is very slow growing. So,
13:56if you are keeping up to date, seeing your doctor, getting your screening tests, if it happens,
14:01you're going to find those abnormal cells early and it'll be treatable. So, I hope this
14:06is helpful. I don't want to talk about something that makes you really nervous. It's really rare,
14:10but if you are worried, you need to talk to your doctor about it and figure out the tests. They're
14:14going to help you feel more comfortable that this is not the issue. So, topic number three,
14:19let's talk about the testing. What will you talk to your doctor about? Like, how are you going to
14:23figure out what is causing this midcycle spotting? Step one, your history. Tracking is so important.
14:30tracking when your period starts, when the next period starts, the day of your cycle that you get
14:36spotting, uh whether you're ovulating. So, if you're tracking basil body temperatures,
14:41whether you're doing ovulation predictor kits, whether it's just the middle of the cycle,
14:45uh that's really important. A lot of people will get spotting a couple of days before their period
14:50starts. And that's really different from this midcycle spotting that we're talking about,
14:54but it's still spotting between your periods. But if you track, you know, and it can help
14:59you differentiate exactly what's going on. Step two, exam and kind of the basic test. Number one,
15:05a pregnancy test. When you go to the doctor, they're probably going to do a physical exam.
15:10They're going to do a speculum exam and a bmananual exam. Most likely, the speculum
15:14exam is placing a speculum into the vagina to see the cervix to look and see, is there a polip
15:20that could be causing this spotting? um are there any warning signs of an active infection? They're
15:26going to be looking for that. They might also do a bimanual exam. This is where the provider has
15:32one hand on the abdomen and um some fingers in the vagina to feel the uterus to feel and
15:38see if it's bulky. Are there fibroids? Feel both ovaries. Are there cysts? Um it's really helpful.
15:46even feeling for some areas that could be signs of endometriosis or if the uterus is bulky could be a
15:52sign of adnomiiosis. So those physical exams can be very helpful. It might be time for you to get
15:59a updated papsmear that could be done during the speculum exam. If there's worries about infection,
16:04they might be able to take a sample to screen for STI like gorrhea and chlamydia. Another test that
16:10might be offered is a CBC or a blood count to rule out anemia. It depends on how much bleeding you're
16:15describing. Lab tests that are not automatic but might be signaled based on your history and your
16:22cycle, you know, regularity, etc. You might check your thyroid function. You might check prolactin.
16:27Remember talking about that? Sometimes people ask for a big hormonal panel. They say, "Doctor,
16:32like check all my hormones." And it's not that the doctor doesn't want to check these hormones.
16:40It's just it totally depends on where you are in your cycle, whether it makes sense to check an
16:45estrogen level, a progesterone level, a follical stimulating hormone, etc. So ask about what tests
16:50are being done and understand, you know, hey, I read this on Instagram and I feel like I should
16:55really get this test done. Do you recommend it or why not? And this is an important point. A
17:01single progesterone level is not going to be very helpful to figure out why you're having
17:05intermenal spotting. And if it did, I would order it on all of my patients. But let me explain cuz
17:12patients always ask for a progesterone level. And if it's doesn't make sense, it's it's not
17:17going to be helpful. It can honestly just be more confusing. So you've got to understand, remember,
17:22progesterone is not made by the ovaries until after ovulation or in the LEO phase. And it's
17:27produced in a very pulsatile fashion. So one blood test at 10:00 a.m. on a Thursday could
17:35be four. and you could think, "Oh my gosh, this is too low. This is not supporting my
17:40uterine lining." Or it could be 24 and you could say, "Oh, everything's perfect. No problems
17:45there." The progesterone and the ludal phase can be helpful to tell you if you've ovulated. That's
17:51the best use for that test. If it's o and in most labs, if it's over three nanogs per deciliter,
17:57that means that you have ovulated. But just tech checking it to figure out if you need progesterone
18:04or not. Important to talk to your doctor about it because the raw number doesn't dictate whether I
18:10think someone needs progesterone in the leal phase. I do it based on clinical symptoms and
18:15a discussion. So ask your doctor about it. Make sure you understand what the results mean. Step
18:20three is imaging. So it's probably going to start with a transvaginal ultrasound. This is an amazing
18:26view of the uterus and the overall shape. You can find fibroids that way. You can look for signs
18:31of adnomiiosis. You can also peek at the ovaries and look at your antroal follicle count if you're
18:36thinking about fertility. You can look for ovarian cysts. It's a really good checkup. Now, it can
18:42miss things that are inside the uterine cavity. It can also miss a cervical polip, but it could
18:48miss an endometrial or a uterine polip or some small fibroids in the uterine cavity. So in order
18:54to get a really good cavity evaluation, you need something other than just a regular transvaginal
18:59ultrasound, you probably need a saline infusion sonogram where a little bit of salt water is
19:04placed in the cavity and it distends the cavity so you can see a filling defect like a little polip
19:09or fibroid. Or it could be a hysterosalpingogram that gives a window into the uterine cavity and
19:15it's also flushing the fallopian tubes in case you are thinking about fertility and you want to
19:20make sure that those fallopian tubes are open and you also get a window into the uterine cavity. Uh
19:24the gold standard for diagnosing a uterine cavity pathology is a hysteroscopy that usually requires
19:31sedation. It usually requires um often being done in a procedure room whereas the other tests
19:37are usually done in the clinic and are easier to schedule. Step number four, you might be talking
19:42to your doctor about an endometrial biopsy, not necessarily. Not everyone needs this test
19:47for midcycle spotting, but if there's a worry about chronic endometritis, sampling the uterus
19:52and sending it to a pathologist or a special lab looking for that can be important. And of course,
19:57if you're worried about abnormal cells or endometrial cancer because you're having
20:01the symptoms that we talked about earlier, doing an endometrial biopsy will send that lining to a
20:07pathologist to look for any abnormal cells. So, those are the tests. And now, topic number four,
20:14treatment. Treatment totally depends on what is found. So, if you happen to have irregular cycles
20:20due to a thyroid issue, you're going to treat the thyroid issue. If you have a cervical polip,
20:24that is usually something that can be diagnosed with a specul exam in the clinic and removed right
20:29then and there. If you have a sub mucosal fibroid in the uterine cavity that's causing symptoms,
20:35uh then that would be treated most likely with an operative hysteroscopy. So that little camera
20:41going inside the uterine cavity and removing that fibroid under sedation. Uh if you have chronic
20:48endometritis, it could be antibiotics. If you have an STI like gonorrhea and chlamydia that could be
20:53antibiotics. So really the treatment depends on the findings. Now what if all of the tests
21:01are normal? You don't have a cervical polip. You don't have a sub mucosal fibroid. You don't have
21:07any infections or inflammation or any hormonal issue that you can tell is causing this midcycle
21:14spotting. Well, it could just be that little dip in estrogen. So the question is if it's just this
21:21little spotting right around ovulation, does that affect your fertility? And there is a study that
21:27was designed to look at this. It's from 2016. It was published in fertility and sterility. And the
21:32lead author is a dear friend of mine and someone I'm sure that you know does a lot of education
21:37on YouTube and she has her own podcast. It's Dr. Natalie Crawford. This study followed 549 women
21:43who were trying to conceive across over 1,500 cycles and cycles with intermenstrual bleeding
21:51which they actually included across like right around ovulation or leading kind of even up to
21:57uh the period. So bleeding any time between like cycle day ones uh was associated with a slightly
22:03lower chance of conceiving in that cycle but it did not predict fundability or the ability
22:10to get pregnant in subsequent cycles. So the worry that it must be treated or it's going
22:16to predict your fertility long term this study is actually very reassuring. So really bottom line,
22:23there is no evidence that just, you know, occasional little midcycle dip in estrogen,
22:28midcycle spotting right around ovulation is going to affect your fertility. All right,
22:33last topic. Let's do a recap and I will leave you with questions to ask your doctor. So here's the
22:39recap. Spotting between your periods has a name, intramenstrual bleeding. It can
22:44occur anywhere from 4 to 6% of cycles when women are self-reporting. The most common causes are
22:51benign. It could be right around ovulation and that little dip in estrogen. It could be side
22:57effects from birth control methods and it could be issues with the cervix or anatomy that is not
23:04cancer but something that can be addressed and taken care of. The evaluation is mostly low tech
23:10and a lot of it is tracking uh on your own. So you can really have a thorough discussion with your
23:15doctor. Then it can be some tests in the clinic. and bees physical exam and some imaging treatment
23:21absolutely depends on what is found and what's causing the spotting. But if nothing is found,
23:27there's reassuring information that isolated a little bit of spotting around ovulation does
23:34not impact your fertility. I hope you find this reassuring. I'm so glad you stuck around to the
23:39end of the discussion because I want to leave you with three important questions to ask your doctor.
23:44Number one, based on symptoms and tracking and the data that I'm giving you, what do you think
23:49is going on? Number two, what tests are we going to order? And if those are normal, what further
23:55testing are we going to figure out? And number three, how do I get my questions answered? How
24:00do I get the test done? When am I going to get the results? When do I talk to you again? So,
24:05I hope you found this information valuable. I hope you learned something today. Like this video if
24:11you learned something. Comment with questions that you have. Be sure and subscribe to this channel
24:15so you don't miss this educational material. And until next time, stay brave and curious.