Pre-Menstrual Spotting

Dear Sara,

There are several reasons why you may be having the premenstrual bleeding. The most common one is resulting from polycystic ovarian syndrome. Women will have a range of symptoms and severity but commonly present with premenstrual spotting, abnormal cycling, anovulatory cycles, etc. It is highly associated with poor fertility, high blood pressure, diabetes, and uterine cancer.

From what you are describing, you are experiencing premenstrual bleeding which is associated with abnormal progesterone levels. You have had some hormone level tests but from my experience the majority of the tests are inaccurate because of the large range of “normal” or it was not known exactly where the level was drawn in relation to ovulation.

The best first step is to learn to chart your cycles which can only be taught by a certified NFP teacher. This is very low cost. Charting your cycles gives enormous medical information such as: the length of your cycles, the length and type of menstrual bleeding, the quality and length of the mucus cycle associated with ovulation, and how many days you are spotting and bleeding. The charts are accurate reflections of your body’s functioning such as hormone levels, follicle formation, ovulation, etc. And yes, some additional tests may be warranted.

After learning to chart, you would need to see a physician who is familiar with the charting. I would make sure about keeping up to date on PAP smears (cervical cancer screening) and checks for infections which can be a source of abnormal bleeding. There would be other things such as thyroid function that would need to be considered. This would also be the time to review whether you are experiencing premenstrual syndrome during this abnormal spotting and bleeding. There are certain criteria to be met but PMS is associated with abnormal progesterone levels.

The physician would review the chart with you. Ideally, estrogen levels could be drawn over several days prior to and right after ovulation. Additionally, several progesterone levels would be drawn during the post-ovulation phase. These all would need to be compared to levels that are standardized to the normals for those points in the cycle, not the broad levels found at most labs. Of course, this is the ideal.

What may appropriately be done is to have you take progesterone during the post-ovulatory phase only for several months. I imagine that the “progesterone only pill” that you took was the “mini-pill,” something that you took daily. This won’t correctly target the abnormal levels.

There are other reasons for the premenstrual bleeding which a physician would also consider. However, just putting you on the “pill” will not diagnose or treat any of the reasons. They may mask the bleeding if a “strong” enough pill were to be used.

I hope that this will help you find an answer to your situation. Please contact the CANFP for information about NFP teachers and physicians whom you might contact.

Gretchen V. Marsh, D.O