Vaginal haemorrhage refers to bleeding from the vaginal area that occurs outside of normal menstruation or is heavier than usual during a period. Managing this condition involves identifying the underlying cause and choosing appropriate treatments to control bleeding, restore quality of life, and prevent complications like anaemia.

Addressing vaginal bleeding: What matters most

When vaginal bleeding disrupts daily life, the main goal of treatment is to bring the bleeding under control and address the root cause behind it. Vaginal bleeding can range from light spotting between periods to very heavy flow that requires changing pads or tampons every hour. In some cases, it can occur after sex, after menopause, or during pregnancy. The severity and pattern of bleeding help guide which treatments will work best for each person.^[1]

Treatment depends heavily on the cause of bleeding, which could be hormonal imbalances, structural problems in the reproductive organs like polyps or fibroids, infections, or sometimes more serious conditions such as cancer. The age of the person and their plans for having children also play important roles in deciding what treatment path to follow. For example, a teenager with irregular bleeding due to hormonal fluctuations might need different care than a woman approaching menopause or someone who has already gone through it.^[2]

Because vaginal bleeding can interfere with work, exercise, social activities, and overall wellbeing, prompt evaluation and treatment are essential. Many people assume heavy or irregular bleeding is something they must accept, but effective treatments exist that can significantly improve quality of life. Medical societies have developed guidelines for managing abnormal vaginal bleeding, and researchers continue to study new approaches through clinical trials.^[1]

Standard approaches to treating vaginal bleeding

The first line of treatment for most cases of abnormal vaginal bleeding is medication. Medical management is preferred whenever possible because it tends to have fewer serious side effects than surgery, does not affect future fertility, and can be very effective for many women. The choice of medication depends on what is causing the bleeding, the person’s age, whether they want to have children in the future, and any other health conditions they may have.^[11]

Tranexamic acid is a medication that helps blood clot more effectively, which reduces bleeding. It comes as a tablet that is taken during menstrual periods when bleeding is occurring. Studies show it can reduce menstrual blood loss by about 40 percent. This medication works by preventing the breakdown of blood clots that naturally form to stop bleeding. It is particularly useful for women who have heavy periods but want to avoid hormonal treatments.^[17]

Non-steroidal anti-inflammatory drugs, commonly called NSAIDs, are another medication option taken during periods. These drugs reduce the amount of prostaglandin in the lining of the uterus (the endometrium). Prostaglandin is a substance that contributes to both heavy bleeding and menstrual cramps. NSAIDs can reduce bleeding by approximately 30 percent while also helping relieve period pain. However, some people experience stomach upset, nausea, or diarrhoea when taking these medications.^[17]

Hormonal treatments are widely used to control vaginal bleeding and work by regulating or stabilizing the lining of the uterus. Combined oral contraceptive pills contain substances that act like the natural hormones oestrogen and progesterone. These hormones prevent the uterine lining from becoming too thick, which reduces bleeding. The pill can be taken continuously to prevent periods altogether, or in a pattern that allows for a monthly period. It reduces bleeding by about 40 percent and also helps regulate irregular cycles. Side effects may include nausea, breast tenderness, headaches, and changes in sex drive.^[17]

The progestogen-only pill, sometimes called the mini-pill, works by preventing the uterine lining from building up and thickening. When taken throughout the menstrual cycle, it can reduce bleeding by about 85 percent. This medication works relatively quickly and can be used as a short-term treatment during particularly heavy periods or as long-term therapy. However, it may cause bloating, mood swings, breast soreness, and sometimes irregular spotting, especially when treatment first begins.^[17]

A hormone-releasing intrauterine device, or IUD, is a small plastic device placed inside the uterus that slowly releases progestogen. This device reduces bleeding by about 95 percent after at least three months of use, making it one of the most effective medical treatments available. The IUD also provides contraception and can remain in place for five years. In the first few months after insertion, irregular bleeding or spotting is common as the body adjusts. Some women experience acne, mood changes, or breast soreness. About one in five women request removal due to side effects, and in rare cases, the device may fall out or push through the uterine wall.^[17]

For women with certain types of bleeding, particularly those related to pregnancy complications like miscarriage, progesterone may be recommended. This hormone can help stop bleeding in early pregnancy and is usually taken twice daily until 16 weeks of pregnancy. It is only offered after a scan confirms pregnancy and if the person has experienced a previous miscarriage.^[7]

The duration of medical treatment varies. Some medications like tranexamic acid and NSAIDs are taken only during menstrual periods, while hormonal treatments typically require longer-term use to be effective. Healthcare providers work with each person to find a treatment approach that controls bleeding while minimizing side effects. Regular follow-up appointments help assess whether the chosen treatment is working or if adjustments are needed.^[11]

Surgical interventions when medication is not enough

When medical treatments do not adequately control bleeding, or when there are specific structural problems causing the bleeding, surgical options may be considered. Surgery might also be the first choice for women who are not medically stable, have severe bleeding that does not respond to medication, or have underlying conditions like large fibroids or cancer. The type of surgery recommended depends on what is causing the bleeding, the person’s desire for future fertility, and their overall health.^[11]

Endometrial ablation is a procedure that destroys the lining of the uterus using heat, freezing, microwave energy, electrical currents, or laser. A narrow lighted tube with a viewing device, called a hysteroscope, guides the procedure. This treatment dramatically reduces or stops menstrual bleeding in many women. However, it makes future pregnancy unlikely or unsafe, so it is only recommended for women who do not wish to have children in the future.^[8]

Uterine fibroid embolization is a minimally invasive procedure for women whose bleeding is caused by fibroids. During this procedure, a doctor uses an x-ray camera called a fluoroscope to guide a thin tube called a catheter into the arteries supplying blood to the fibroids. Tiny particles are injected through the catheter to block blood flow to the fibroids, causing them to shrink. This procedure preserves the uterus and may be an option for women who want to maintain their fertility.^[8]

Dilation and curettage, commonly called D&C, involves gently scraping or suctioning tissue from the lining of the uterus. This procedure can be both diagnostic (to obtain tissue samples for examination) and therapeutic (to remove tissue causing bleeding). It is performed under anaesthesia and may be done in conjunction with hysteroscopy to allow the doctor to see inside the uterus.^[8]

Myomectomy is the surgical removal of fibroids while leaving the uterus intact. This option is suitable for women who want to preserve their fertility but need treatment for fibroids that are causing heavy bleeding. The procedure can be performed through various approaches depending on the size and location of the fibroids.^[8]

Hysterectomy, the surgical removal of the uterus, is considered when other treatments have failed or are not appropriate. This is a definitive treatment that permanently stops menstrual bleeding but also means pregnancy is no longer possible. It is typically reserved for severe cases or when cancer is present. The decision to have a hysterectomy is significant and requires careful discussion with healthcare providers about the benefits, risks, and long-term implications.^[8]

After any surgical procedure for vaginal bleeding, recovery time varies depending on the type of surgery performed. Some minimally invasive procedures allow for quick return to normal activities, while more extensive surgeries require longer recovery periods. Once acute bleeding is controlled through medication or surgery, transitioning to long-term maintenance therapy is often recommended to prevent bleeding from recurring.^[11]

Innovative treatments being tested in research studies

While standard medical and surgical treatments effectively manage vaginal bleeding for many women, researchers continue to explore new approaches through clinical trials. These studies aim to find treatments that are more effective, have fewer side effects, or work better for specific causes of bleeding. Clinical trials test promising medications and procedures before they become widely available, and they play a crucial role in advancing medical care for women with vaginal bleeding.

Clinical trials typically progress through several phases. Phase I trials focus primarily on safety, testing a new treatment in a small group of people to evaluate side effects and determine safe dosages. Phase II trials expand the study to more participants to assess how well the treatment works and to continue monitoring safety. Phase III trials compare the new treatment with current standard treatments in large groups of people to confirm effectiveness, monitor side effects, and collect information that will allow the treatment to be used safely.

Women interested in participating in clinical trials for vaginal bleeding treatments can discuss options with their healthcare providers. Eligibility for trials depends on many factors, including the cause of bleeding, age, other medical conditions, and whether previous treatments have been tried. Trials are conducted in various locations, including hospitals and research centres in Europe, the United States, and other countries worldwide.

Participation in clinical trials is voluntary, and participants can withdraw at any time. These studies are carefully designed to protect participant safety, with oversight from ethics committees and regular monitoring of results. People who join trials may gain early access to new treatments that are not yet available to the general public, and they contribute valuable information that helps improve care for future patients.

Most common treatment methods

• Medical management with medications
  • Tranexamic acid tablets taken during periods to help blood clot and reduce bleeding by about 40 percent
  • Non-steroidal anti-inflammatory drugs (NSAIDs) taken during periods to reduce bleeding by approximately 30 percent and relieve menstrual pain
  • Combined oral contraceptive pills containing hormones that prevent the uterine lining from thickening excessively, reducing bleeding by about 40 percent
  • Progestogen-only pill (mini-pill) that prevents uterine lining build-up and can reduce bleeding by about 85 percent
  • Hormone-releasing intrauterine device (IUD) that releases progestogen to thin the uterine lining and reduces bleeding by about 95 percent after three months
  • Progesterone for bleeding in early pregnancy when miscarriage risk is present
• Minimally invasive surgical procedures
  • Endometrial ablation using heat, freezing, microwave, electrical currents, or laser to destroy the uterine lining
  • Uterine fibroid embolization that blocks blood flow to fibroids, causing them to shrink
  • Dilation and curettage (D&C) to scrape or suction tissue from the uterine lining
• Surgical removal procedures
  • Myomectomy to surgically remove fibroids while preserving the uterus and fertility
  • Hysterectomy to permanently remove the uterus when other treatments have failed or are not appropriate