(introduction...)

How to use this chapter:

Most of the causes of the bleeding problems in this chapter are described in other parts of this book. If you have a bleeding problem, look it up here and then turn to the numbered page listed for more information. If the problem is not covered in this book, see a health worker trained to do pelvic exams,

Figure

It is normal for monthly bleeding to change from time to time because of illness, stress, pregnancy, breastfeeding, a long journey, overwork, or a change in diet. But if a change in monthly bleeding happens suddenly, lasts more than a few months, or if it comes with other problems, it may be a sign of a more serious problem.

¨ If monthly bleeding suddenly changes, always think about the possibility of pregnancy - even if a family planning method is being used.

Danger signs If a woman has any of these danger signs, she may need medical help right away. Turn to the numbered page listed for more information. · bleeding and pain in the abdomen when regular monthly bleeding has been missed · bleeding in late pregnancy · heavy bleeding after childbirth, miscarriage, or abortion

Figure

Figure

Heavy monthly bleeding, or bleeding that lasts a long time

· Monthly bleeding is heavy if a pad or cloth is soaked through in less than one hour

· Monthly bleeding is long if it lasts for more than 8 days.

· Blood clots (soft, dark red, shiny lumps in the blood that look like liver) are also a sign of heavy bleeding,

· Heavy bleeding that goes on for many weeks, months or years can cause weak blood (anemia).

Causes: · The hormones may be out of balance so the ovary does not release an egg. This is common for women under 20 and women over 40 years of age. · An intra-uterine device (IUD) may be making monthly bleeding more heavy. Figure · Miscarriage, even if you did not think you were pregnant. Figure · If you have pain in the abdomen with bleeding, you may have a pregnancy outside the womb in the tube. URGENT. Go to a hospital right away. Figure · You may have a problem with the thyroid gland. · You may have growths (fibroids or polyps) or cancer in your womb. Figure

IMPORTANT
See a health worker trained to do pelvic exams if you have heavy bleeding and:

· blood gushes from your vagina.
· monthly bleeding has been heavy and long for 3 months.
· you think you might be pregnant.
· you have severe pain with the bleeding.

Light monthly bleeding

Light bleeding each month is not a health problem.

Figure

Causes:

· Some family planning methods - like injections, implants, and the pill - can make you bleed less after you have been using them for some time.

· Your ovaries may not have released an egg.

Monthly bleeding that comes too often, or bleeding at other times

Something may be wrong if monthly bleeding comes more often than every 3 weeks, or if it comes and goes without a regular pattern.

Causes:

· The ovary may not have released an egg.

· There may be growths (fibroids or polyps) or cancer in the womb, especially if monthly bleeding is heavy and not regular.

· Taking the medicine called estrogen after menopause.

Figure

· Some family planning methods - like the pill, implants, and injections - can cause you to bleed more often.

Figure

¨ Hormonal family planning methods such as pills, implants, or injections, can change monthly bleeding.

When monthly bleedings come too far apart, or have stopped

Monthly bleeding usually comes about every 21 to 35 days. It may be normal to have an even longer time between bleeding. But something may be wrong, or you may be pregnant, if your monthly bleeding does not come at all.

¨ If you are over 18 and have never had a monthly period, get medical help.

Causes:

· You may be pregnant.
· You may be pregnant and having a miscarriage.
· The ovary may not have released an egg.
· You may have a serious illness - like malaria, tuberculosis or AIDS.
· If you are over 40 or 45, you may be nearing menopause.
· Some family planning methods - like the pill, injections, and implants - can make monthly bleedings come far apart.

When a woman grows older, her monthly cycle changes.

Bleeding during pregnancy or after childbirth

Bleeding problem	May be caused by	What to do
Bleeding during the first 3 months with constant pain or pain that comes and goes	pregnancy in the tube	URGENT! Go to a hospital right away.
Bleeding during the last 3 months of pregnancy	the afterbirth (placenta) is coming off the wall of the womb Figure the placenta is covering the cervix	URGENT! Go to a hospital right away.
Bleeding during the first 6 months of pregnancy	Figure may be a miscarriage (especially if you also have cramping pains like birth pains)	Watch and wait. If bleeding becomes heavy, go to a hospital.
Heavy bleeding during or just after childbirth	pieces of the placenta are left in the womb Figure the womb is too tired to squeeze or tighten	URGENT! See a midwife or go to a hospital if bleeding is heavy.
Light, pink bleeding during the first 3 months of pregnancy without pain	this can be normal, or it may be a sign of early miscarriage	See ‘bleeding early in pregnancy’.
Spotting or light bleeding instead of your normal monthly bleeding	the developing baby (fetus) is attaching to the wall of the womb (implantation). This is normal. Figure	See the chapter on “Pregnancy and Childbirth.”

Bleeding after an abortion or miscarriage

Bleeding problem	May be caused by	What to do
Heavy bleeding, or bleeding that lasts longer than 15 days, or bleeding with pain or fever	pieces of the pregnancy may still be in the womb Figure infection in the womb	Go to a hospital or clinic right away.
Bleeding like a normal monthly bleeding, but lasting 5 to 15 days, getting lighter and lighter	this is normal Figure	See ‘what to expect after an abortion’.

Bleeding after sex

Bleeding problem	May be caused by	What to do
Bleeding during or after sex	sexually transmitted disease (STD)	See ‘gonorrhea and chlamydia’.
	pelvic inflammatory disease	See’PID’.
	forced sex	See “Rape.”
	growths or cancer of the cervix or womb	See ‘cancer of the cervix’ and ‘problems of the womb’.

Bleeding after menopause

Bleeding problem	May be caused by	What to do
Bleeding that begins 12 months or more after menopause	growths or cancer of the womb Figure	See a health worker trained to do a pelvic exam.
	growths or cancer of the cervix	You may need to have a Pap test or a D and C.