Should I be worried about spotting mid-cycle?

Naturopath, Herbalist and Yoga teacher (BA, Dip Nat, Dip Herb)
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12 October 2023

Spotting or mid-cycle bleeding is quite common, and often there is no need for concern. 10-30% of women experience spotting at ovulation for 1-3 days. Other causes for intermenstrual bleeding are hormonal imbalance, infection, perimenopause, polyps or fibroids, some medications and hormonal birth control, some infections including STIs, and a condition known as cervical ectropion.

Spotting or bleeding in the middle of the menstrual cycle, often occurring around the time of ovulation, is more common than most women believe. It is also often something that many women worry about when it does happen. While this occurrence can be unsettling, it's not always a cause for alarm. In this article, I'll explore three common reasons behind mid-cycle spotting and discuss when it's necessary to seek medical advice.

1. Ovulation:

The most common reason for spotting during the middle of your menstrual cycle is ovulation itself. In women who aren't taking oral contraceptives, mid-cycle bleeding is most likely ovulation bleeding. This typically occurs 7-20 days after your last period, is light, and often lasts somewhere between 12-72 hours. This actually occurs in approximately 10-30% of women, and is considered normal. What’s happening is that at ovulation you have a sudden surge in oestrogen which subsequently drops, causing destabilisation of the lining of your womb, which causes a short bleed.

This ovulation bleeding can also be accompanied by mild abdominal discomfort, known as mittelschmerz. You can learn more about this in my colleague Emma’s blog: Is it normal to have ovulation pain?

2. Hormonal Imbalances:

As you likely know, hormones play a crucial role in regulating the menstrual cycle, and there are some hormonal imbalances that can lead to mid-cycle spotting. This spotting, known as intermenstrual bleeding, occurs at any time between periods, not necessarily just at ovulation, and can be attributed to fluctuations in hormone levels. It can be associated with anovulation (failure to release an egg), polycystic ovary syndrome (PCOS), and irregular hormone production.

Ovulation bleeding which I mentioned above, can also be more likely to occur due to hormonal imbalance. For example, if oestrogen levels are higher, they can drop steeply post-ovulation, and the larger surge and drop can further destabilise the uterine lining, contributing to ovulation spotting.

3. Infections:

If you don’t regularly have mid-cycle spotting, but it starts all of a sudden, along with other symptoms like pain or fever, you may have an infection. This will need to be treated by a doctor. Infections of the reproductive organs, such as cervicitis or pelvic inflammatory disease (PID), can lead to spotting or abnormal vaginal bleeding. Some sexually-transmitted infections (STIs), if left untreated, can also cause such symptoms. If you suspect an infection or have been exposed to an STI, it's crucial to seek medical attention promptly.

4. Perimenopause:

Mid-cycle spotting can become a more common occurrence during perimenopause, the transitional phase leading up to menopause, when periods stop altogether. During perimenopause, oestrogen and progesterone levels can fluctuate a lot. These fluctuations can lead to the uterine lining not developing as consistently or predictably as it once did, causing mid-cycle spotting. Additionally, anovulatory cycles, where ovulation does not occur, become more frequent in perimenopause. In the absence of ovulation, the usual surge in progesterone does not take place, further contributing to changes in the uterine lining and increased susceptibility to spotting. While mid-cycle spotting can be bothersome, it's generally considered to be quite a normal part of the perimenopause.

5. Polyps or Fibroids:

Uterine polyps or fibroids are non-cancerous growths in the uterus that can sometimes cause irregular bleeding, including mid-cycle spotting. These growths can irritate the uterine lining, leading to spotting or heavier bleeding. If you have heavy bleeding as well as mid-cycle spotting, then it might be worth seeing your doctor. They can often refer you for a scan and other tests to diagnose the polyps or fibroids. If you are looking for natural support for polyps and fibroids, a naturopath or herbalist can often work alongside your doctor to support you in this.

6. Medications and Birth Control:

Certain medications, such as blood thinners or hormonal birth control methods like birth control pills, patches, implants, injections or intrauterine devices (IUDs), can sometimes lead to mid-cycle spotting, especially when you first start using them or if there's a change in your prescription. If you are taking medication or if you are using hormonal birth control, it is important to talk to your doctor to see if the mid-cycle spotting is a side effect of your medication.

7. Cervical Ectropion:

Cervical ectropion, also known as cervical erosion, is a condition where the cells from the cervical canal are present on the outer surface of the cervix. This can make the cervix more sensitive and prone to bleeding, especially during intercourse or when touched. While cervical ectropion is usually benign, it can cause mid-cycle spotting. If your spotting happens after sexual intercourse or after a cervical smear test, also known as a Pap smear, this could be something to look into.

Some of the other symptoms of cervical ectropion are increased vaginal discharge, which can be clear, white, or tinged with blood, as well as mild discomfort or a feeling of irritation in the vaginal area. If this is something you think you may have, then your doctor can diagnose this. Despite its complicated name, cervical ectropion is not typically a serious condition and often does not require treatment.

When to Be Concerned and Contact a Doctor:

While mid-cycle spotting is often benign and nothing to worry about, there are situations where it's crucial to seek medical advice:

Heavy or Prolonged Bleeding: If your mid-cycle spotting is accompanied by heavy or prolonged bleeding that soaks through your period products quickly, it may indicate a more serious issue. Excessive blood loss is never okay! It can lead to anaemia and is definitely worth getting checked out. If we were bleeding that much from any other part of the body, it would be a cause for concern. 

Severe Pain: If the spotting is accompanied by severe pelvic pain, it's important to consult a healthcare provider, as this could be a sign of a more significant problem.

Irregular Menstrual Cycles: If mid-cycle spotting becomes a regular occurrence or is accompanied by irregular menstrual cycles, it may be a sign of a hormonal imbalance or another underlying condition that requires evaluation. In this instance, it may be useful to see a naturopath or herbalist who specialises in menstrual health, as they will be able to help you get to the bottom of the hormonal imbalance and treat the root cause.

For peace of mind, and to rule out some other causes:

If you have ongoing spotting midcycle, and if it is worrying you, it can be helpful to see a doctor to rule out any other more severe underlying causes, like endometriosis, fibroids or polyps, or STIs, and to give yourself some peace of mind. Although relatively rare, uterine or cervical cancer can also sometimes cause mid-cycle spotting. It can be helpful to rule these things out with your doctor, especially if you are feeling worried about it. It is good to listen to our instincts. Our periods offer amazing insights into our health and it’s important not to dismiss our womb’s wisdom; so, if you feel like you need some medical tests to rule out some of these things, then book an appointment with your doctor.

However, it is worth stating that, once these are ruled out, and if a simple hormone imbalance is suspected, many doctors prescribe hormonal birth control, which only masks the symptoms. In this case, I would recommend seeing a naturopath or herbalist if you want to address the root cause of the hormonal imbalance.

In conclusion, spotting or bleeding in the middle of the menstrual cycle can be caused by various factors, most of which are benign. But while mid-cycle spotting can have numerous causes, it's not always easy to determine the exact reason without a medical evaluation. If you experience mid-cycle spotting that is persistent, severe, or accompanied by other concerning symptoms, don't hesitate to reach out to a healthcare provider. They can perform tests, conduct a physical examination, and consider your medical history to provide a proper diagnosis and appropriate treatment if needed. Regular gynaecological check-ups are also vital in maintaining reproductive health and addressing any issues early on, and there are many natural health practitioners who can help address these issues as part of a complimentary treatment model, as needed.

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