QuestionQUESTION: Hi Dr. Ramirez,
I am 30 years old and have been trying to conceive for 8 cycles. Here's my story. Until last summer I had been on bcp for 12+ years. About eight years ago I started having bleeding (more than spotting, less than my normal period) about half way through my cycle. Dr. at the time tried several different bcp, nothing helped. Had a DNC, came back fine. Decided to get off the pill and see if that helped. It did. No LP bleeding for 8 months. Being off the pill caused moderate acne, so I got back on the pill at month 8 after deciding the bleeding wasn't a health issue and I'd rather deal with that than the acne. Stayed on the pill for the next 7 years or so until last summer when my husband and I decided we were ready to start a family. LP bleeding continued throughout this time.
I expected the bleeding during the LP to subside within a cycle or two after getting of the pill just like it had done a few years back. To my surprise, it actually got worse. A little heavier and lasted up until my period started. For six cycles it was pretty much exactly the same....within a day or two after ovulation, the bleeding would start. Heavier at first and then trail off to light bleeding that would continue until my period started. Everything checked out at my Gyno's office. CD3 blood work came back fine..FSH was at the very top of normal, but still within normal. Prog. level was at 15. Two sono's showed everything was normal. Colp came back normal.
The last two cycles have been a bit different. The first one I used vaginal antibiotics b/c of suspicion I might have had a bacterial infection. It did shorten the bleeding, which started the same....right after ovulation or at ovulation and continued for 7 days instead of 12 or up to my period. I also experienced this a year earlier. Antibiotic cream which shortened the bleeding for one month and then back to normal. I'm not sure if this information is entirely related b/c my Dr. feels that if an infection was causing the bleeding then it would be at various times of my cycle, and wouldn't always start at the same time (right after O). Last month I had an HSG which came back fine. Strangely enough, that month I didn't experience the bleeding after O. Only just the slightest amount of spotting. Nothing like the previous months. A bit more spotting came a few days before my period. But this was still a huge improvement.
This current cycle, I'm back to the same old bleeding after O. My concern is two part. One, a health concern that this could be something more serious. Two, could this kind of bleeding keep us from getting pregnant and if so, what needs to be done.
Thanks in advance for you help, it is much appreciated!
ANSWER: Hello Erica,
You certainly have a perplexing problem. Many women experience mid-cycle ovulatory bleeding but it is usually more spotting than actual bleeding. It is unusual to have bleeding like a period and for ovulatory bleeding to last so long. At this point, I cannot be sure exactly what is going on, especially in light of the past workup you had that was normal. I think this needs to be pursued prior to becoming pregnant, because any bleeding like this will prevent implantation of the embryo. Blood is toxic to the embryo and bleeding can flush the embryo out as well.
I think you need to have a hysteroscopy done. This is where a small cope is passed into the uterine cavity to examine it. There are abnromalities like endometrial polyps, fibroids and cancer that can cause abnormal bleeding like this. If that comes out normal, then the only other possibility is some type of weakness in your endometrial lining development.
I think that I would try a cycle of Femara (not Clomid) to see if you can go through an ovulatory cycle without the bleeding. I would also use progesterone supplementation in the luteal phase.
I hope this helps,
Edward J. Ramirez, M.D., FACOG
Exeutive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.
---------- FOLLOW-UP ----------
QUESTION: Thank you so much for your response. I can't tell you how much this has helped confirmed what I was already feeling. My Ob/Gyn feels I am too young for this to be cancer. She has stated that some women just have this type of unexplained bleeding. Also that some women can get pregnant with this type of bleeding. She seems to think it could be a hormonal imbalance occurring just at or right after ovulation and that with my prog. level good, the imbalance wouldn't prevent pregnancy. I am wondering what hormone(s) would be "off" right at/after ovulation that could cause this. Granted, even if the imbalance doesn't prevent pregnancy, based on what you've said it sounds as if the bleeding itself would probably prevent implantation and/or flush the embryo out. I have never felt 100% comfortable with the answers I've received from my Ob/Gyn, but certainly didn't want to go through invasive procedures if it wasn't necessary.
My Dr. wants to refer me to a fertility specialist, primarily for the infertility factor as she feels the bleeding isn't an issue. Would a fertility specialist treat abnormal bleeding? I just don't want to go from one Dr. to another without someone addressing the bleeding. Also, should I wait until I see the specialist to discuss the hysteroscopy or should that be performed by my regular Ob/Gyn? Also, I should try the Femara and Prog. supplementation prior to a Hysteroscopy, correct?
One final, somewhat unrelated, question is whether the prog supplement, Femara, etc... will cause my acne to worsen. It is pretty bothersome now that I have been off the pill for several months. On Yasmin, it was almost perfectly clear. Just trying to keep it from getting worse since I know there isn't much I can do to help it while trying to get pregnant. Between the abnormal bleeding, not getting pregnant, and the acne I'm sure I would be a good case study for stress management.
Again, thank you very much for your time.
AnswerHello again,
Thanks for the follow-up. I think it would be a good idea to see a fertility specialist. We are reproductive endocrinologist, which means that we specialize in reproductive hormonal disorders. This specialist should be able to help you with this problem.
I would defer any further testing or treatment to the fertility specialist and not pursue it any further with your general Ob/Gyn. He or She can address the bleeding issue since it is pertinent to your getting pregnant.
I'm sorry about the acne. I know how infuriating that is, since I suffered from it as a young man. However, you cannot take the Yasmin since you are getting pregnant. You should see a Dermatologist because there are other therapies you could go on and continue to try for pregnancy. Keep in mind, however, that pregnancy will probably worsen the problem. Again, because of the hormones elaborated by the pregnancy.
Good Luck,
Edward J. Ramire, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.
