Vaginal Bleeding

Is this your child's symptom?

• Vaginal bleeding before puberty OR abnormal bleeding after puberty
• Heavy menstrual bleeding after puberty
• Light breakthrough bleeding or spotting in between menstrual cycles after puberty

Causes

• Newborn Vaginal Bleeding. Baby girls can have some minor vaginal bleeding. It can start any time from 2-10 days of life. This is normal and called false menses. The cause is the sudden drop-off in the mother's estrogen (a hormone) after birth. The blood-tinged or pink discharge should not last more than 3 or 4 days.
• Before Puberty. Vaginal bleeding (other than newborn) is not normal. Bleeding in this age group needs an exam.
• First Menstrual Period. If over 8 and has signs of puberty, this most likely is her first period. Signs of puberty are breast changes or pubic hair. Most girls do not have their first period until 2 years after puberty begins. Some girls do start during the first stage of puberty.
• After Puberty. Vaginal bleeding is abnormal if it occurs between regular periods. Heavy bleeding is also not normal. Bleeding that is severe or lasts over 7 days should be seen. Bleeding along with signs of severe anemia (such as pale skin, weakness) should also be seen. Teens may have abnormal bleeding during the year after their periods start. This can be normal. It usually doesn't need an urgent exam unless it's heavy or severe.
• Sexually Transmitted Infections (STIs). May cause spotting or blood-tinged discharge.
• Birth Control. Some birth control medicines can cause breakthrough or abnormal bleeding. This most often occurs for the first few months on the medicines.
• Pregnancy. Vaginal bleeding can be a sign of pregnancy. Teens that are having sex should keep this in mind. In early pregnancy, vaginal bleeding can be a sign of serious problems. Causes include miscarriage or an ectopic pregnancy. If in doubt, always do a pregnancy test.

Excessive Menstrual Bleeding

Menstrual bleeding can be defined as too much with any of the below:

• More than 7 days (1 week) of bleeding (8 days is prolonged)
• More than 6 well-soaked pads or tampons per day
• Periods happen more often than every 21 days
• Any bleeding or spotting between regular periods
• If bleeding is felt to be more than normal, the teen should be seen.

Vaginal Bleeding Severity is defined as:

• Spotting: pinkish/brownish mucus discharge, less than 1 pad total per day
• Mild: less than 1 pad per hour; like menstrual bleeding
• Moderate: 1-2 pads/hour; small blood clots (pea, grape, small coin)
• Severe: soaking more than 2 pads/hour. Bleeding not contained by pads with large amount of red blood from vagina. Can also have large blood clots (golf ball, large coin).

When to Call for Vaginal Bleeding

Call 911 Now

• Passed out (fainted)
• Very weak (can't stand)
• You think your child has a life-threatening emergency

Call Doctor or Seek Care Now

• Could have been caused by sexual abuse
• Moderate vaginal bleeding (soaking 1 pad or tampon per hour for 6 or more hours)
• Pale skin and new onset
• Skin bruises, nosebleed, or other bleeding not caused by an injury
• Vaginal bleeding of unknown cause before puberty. (Not a newborn less than 2 weeks OR first menstrual period)
• Your child looks or acts very sick
• You think your child needs to be seen, and the problem is urgent

Contact Doctor Within 24 Hours

• Yellow, green, or gray vaginal discharge
• Bleeding is heavy (6 or more soaked pads or tampons per day)
• You think your child needs to be seen, but the problem is not urgent

Contact Doctor During Office Hours

• Bleeding lasts for more than 7 days
• Bleeding or spotting happens between normal periods
• Irregular bleeding happens more than 2 cycles (2 months) and using birth control medicines. Birth control includes pills, patches, shots, implant, or vaginal ring.
• Taking birth control pills and has missed 2 or more active pills in a pack. Note: use a back-up method of birth control.
• You are worried about a sexually transmitted infection (STI)
• You have other questions or concerns

Self Care at Home

• Signs of puberty and bleeding for the first time
• Mild vaginal bleeding after puberty
• Irregular bleeding on birth control medicine
• Taking birth control pills and missed dose
• Newborn vaginal bleeding

Care Advice

First Menstrual Period

1. What You Should Know About First Menstrual Periods:
   • If over 8 and has signs of puberty, this most likely is her first period. This is normal.
   • Don't be surprised if she skips a period or 2 after the first one.
   • During the first year after periods begin, there are often no menstrual cramps.
2. Use Pads or Tampons:
   • It's safe to use either pads or tampons, but change them often.
3. Call Your Doctor If:
   • Bleeding becomes worse
   • Bleeding with first period lasts over 6 days

Mild Vaginal Bleeding After Puberty

1. What You Should Know About Vaginal Bleeding:
   • A teen should talk to her doctor if she is bleeding more than normal. This means using 2 or more tampons or pads than she normally uses per day. Periods that last 3 or more days longer than normal should also be discussed.
   • Birth control can also cause spotting or abnormal bleeding. (See the next section on Irregular Bleeding on Birth Control)
2. Iron and Anemia:
   • Heavy periods can cause anemia (low red blood count). This is caused from not enough iron. It is one of the most common causes of anemia in women.
   • Women with heavy periods should eat foods rich in iron. They can also take a daily vitamin pill with iron.
3. Mild Spotting Causes - Normal:
   • There are some common causes of mild vaginal bleeding (spotting) outside of normal periods.
   • Spotting can happen after a doctor's exam.
   • It can also happen the first time you have sex.
   • Some women spot when they ovulate (mid-cycle on about day 14.) This spotting can be normal.
   • Bleeding from these causes should not last longer than 2 days.
4. Pregnancy Test, When in Doubt:
   • If there is a chance that you are pregnant, use a urine pregnancy test.
   • You can buy a pregnancy test at any drugstore.
   • It works best if you test your first urine in the morning.
   • Follow all package directions.
5. Call Your Doctor If:
   • Pregnancy test is positive
   • Your teen has trouble with the at-home pregnancy test
   • Bleeding becomes worse
   • Spotting (mild irregular bleeding) lasts more than 2 days or happens again
   • You think your teen needs to be seen
   • Your teen gets worse

Irregular Bleeding on Birth Control Medicine

1. What You Should Know About Irregular Bleeding on Birth Control:
   • Mild breakthrough bleeding or spotting is common with types of hormonal birth control.
   • This is especially true the first few months after you start birth control.
   • It usually will get better as your body adjusts to the hormones.
   • Here is some care advice that should help.
2. Spotting Between Periods and Taking Birth Control Pills:
   • This is common.
   • You may have breakthrough bleeding or spotting with most of these pills.
   • It is likely to happen during the first three pill pack cycles.
   • Missing a pill may also cause breakthrough bleeding or spotting. (See the next section on Taking Birth Control and Missing Doses.)
3. Irregular Bleeding and Using Birth Control Implant or Shot:
   • This is common for the first several months.
   • Irregular bleeding may be heavier or lighter than normal.
   • It may also be more or less frequent bleeding than your normal period.
   • Bleeding and spotting usually decrease over time.
4. Irregular Bleeding and Using the Birth Control Patch:
   • This is common.
   • You may have breakthrough bleeding or spotting with these patches.
   • This is likely to happen during the first 3 cycles (months).
5. Irregular Bleeding and Using the Vaginal Ring (NuvaRing):
   • This is not common.
   • Most women don't have breakthrough bleeding or spotting with NuvaRing.
   • But, it can happen during the first 1-2 months of use (first 2 cycles).
6. Keep a Record of Bleeding:
   • Keep a record of the days you have any bleeding or spotting.
7. Call Your Doctor If:
   • Irregular bleeding happens more than 2 cycles (2 months)
   • Bleeding becomes worse
   • You think your teen needs to be seen
   • Your teen gets worse

Taking Birth Control Pills and Missed Doses

1. What You Should Know About Missed or Late Doses of Birth Control Pills:
   • Almost everyone misses a dose of their birth control pill at times.
   • Try to remember to take them the same time every day. Many take them with a meal. Some women use an alarm to remind themselves.
   • Missing a pill is also a common cause of breakthrough bleeding or spotting. This is normal.
   • Here is some care advice that should help.
2. Missed Placebo Pills:
   • Follow these directions if you missed 1 or more placebo pills (reminder pills).
   • Throw away the missed pill or pills.
   • Keep taking the rest of the pills on the usual day.
   • You are not at higher risk for pregnancy.
   • You do not need to use a back-up form of birth control.
   • Example: Missed pill(s) during days 22-28 of a 28-day of combination pill pack.
3. Late Taking 1 Active Pill (Less than 24 Hours Since a Pill Should Have been Taken):
   • Follow these directions if you are late taking an active hormone pill (not placebo pills).
   • Take the late pill as soon as possible.
   • Take the next pill at the normal time. This means you may need to take 2 pills at one time. This may also mean taking 2 pills on the same day.
   • Taking 2 pills may make you feel a little nauseated, but this is normal. It should pass in a day.
   • There is little or no risk of getting pregnant with 1 late pill. (Exception: progestin-only pills. See Care Advice #6)
   • You do not need to use a back-up method of birth control.
4. Missed 1 Active Pill (24-48 Hours Since a Pill Should Have been Taken):
   • Follow these directions if you missed 1 active hormone pill (not placebo pills).
   • Take the missed pill as soon as possible. Take the next pill at the normal time. This means you may need to take 2 pills at one time. This may also mean taking 2 pills on the same day.
   • Taking 2 pills may make you feel a little nauseated, but this is normal. It should pass in a day.
   • There is little or no risk of getting pregnant with 1 missed pill. (Exception: progestin-only pills. See care advice #6.)
   • You do not need to use a back-up method of birth control.
5. Missed 2 Active Pills (2 or more):
   • Follow these directions if you missed 2 or more active hormone pills (not placebo pills).
   • Take one of the missed pills (most recently missed) as soon as possible.
   • Throw away other missed pills. Take the next pill at the normal time. This means you may need to take 2 pills at one time. This may also mean taking 2 pills on the same day.
   • Taking 2 pills may make you feel a little nauseated, but this is normal. It should pass in a day.
   • Call your doctor for further instructions during office hours.
   • Use a back-up birth control method until you speak with your doctor. You can also avoid having sex until you talk with your doctor. Ask your doctor how long you need to use back-up birth control.
   • Consider emergency contraception if you've had unprotected sex in the past 5 days.
6. Progestin-Only Pills - Missing Doses or Taking Dosages Late:
   • These pills need to be taken at the same time daily to work the best. This is very important. Reason: Pregnancy is possible if you take your dosage more than 3 hours past the normal time.
   • Follow these directions if you miss a pill or take a pill more than 3 hours late.
   • Take the missed or late pill as soon as possible. Keep taking the rest of your pills at your normal time every day. This means you may need to take 2 at one time. This may also mean taking 2 pills on the same day.
   • Use a backup method (such as condom and foam) after taking the late pill. You will need to do this for 48 hours.
   • If you had sex before you realized you missed pills, consider emergency contraception.
7. Lost 1 Pill:
   • Take the next pill in the pack today.
   • As a result, you will finish the birth control pill pack one day sooner.
   • Start your next pill pack one day earlier. Reason: Most pregnancies on the pill (with regular use) happen with late starts of the pill pack. (Even just 1 or 2 days late as you may ovulate early).
8. Emergency Contraceptive Pills (ECP) - When to Consider:
   • Emergency contraception pills (ECPs) can be used by any teen who is worried she might become pregnant. No prescription is needed.
   • ECPs should be taken as soon as possible within 5 days after unprotected sex.
   • The sooner ECPs are taken, the better they work.
9. Pregnancy Test, When in Doubt:
   • If there is a chance that you are pregnant, use a urine pregnancy test.
   • You can buy a pregnancy test at any drugstore.
   • It works best if you test your first urine in the morning.
   • Follow all package directions.
10. Call Your Doctor If:
    • Pregnancy test is positive
    • Your teen has more than mild bleeding or spotting
    • You think your teen needs to be seen
    • Your teen becomes worse

And remember, contact your doctor if your child develops any of the 'Call Your Doctor' symptoms.

Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.

Last Reviewed: 10/11/2023

Last Revised: 12/30/2022

Copyright 2000-2023. Schmitt Pediatric Guidelines LLC.