More Common Causes Of Irregular Bleeding In Greater Detail


Serum concentration of oestrogen fluctuates during a normal menstrual cycle. There is a large rise during the follicular phase, followed by a precipitate fall for 2 to 3 days at the time of ovulation. In some women, this fall can be so great that the endometrium loses its hormonal support in the same way as at menstruation. Desquamation commences, but stops when oestrogen and progesterone from the corpus luteum stimulate the endometrium. This is one reason why consistent mid-cycle intermenstrual bleeding is a normal phenomenon in some young women.


The cervix is composed of two types of epithelium. Columnar epithelium is generally inside the cervical canal, and therefore not seen. This epithelial cell is translucent, and therefore underlying blood vessels are visible if they migrate to the extracervical area. Squamous epithelium covers the intravaginal portion of the cervix, and is generally seen. Its appearance is opaque and dull to the eye. Where the two types of epithelium meet is the squamo-columnar junction (S-C J). This junction moves up and down the cervix as the epithelia change from one type to another. These changes occur during exposure to high oestrogen levels, for example at puberty, during the use of oral contraceptives, and during pregnancy. An eversion occurs when the S-C J moves down the cervix.

The main problems caused by the columnar epithelium becoming intravaginal are that it can increase vaginal discharge, or, because the epithelium is fragile, it can become traumatised during intercourse and bleed. Eversions do not require treatment unless a cervical smear is abnormal. However, some women may require symptomatic relief with treatments such as cryotherapy or cautery.


The combined oral contraceptive pill maintains the integrity of the endometrium during the three weeks for which it is taken. Some women may have a pharmacodynamic reason as to why they do not absorb a particular oestrogen or progestogen efficiently, or their endometrium may not respond adequately to those compounds. If this is so, the endometrium will shed and the woman will experience intermenstrual bleeding. This is common during the first few months of starting a new pill. If it does not resolve it is worth considering changing to a pill with different doses of progestogen and oestrogen. It is also worthwhile considering sexual health screening and cervical cytology, to rule out any possible underlying pathology.

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