Ultrasound Shows Normal Uterus but Vaginal Bleeding Persists – What Could Be the Cause?
It's not uncommon for women to experience vaginal bleeding even when an ultrasound shows a perfectly normal uterus. While imaging tests like ultrasounds are valuable tools, they don't always reveal every underlying condition. Unexplained bleeding despite a structurally normal uterus can be caused by hormonal imbalances, ovulation-related changes, cervical conditions, or precancerous developments. Identifying the root cause is essential for effective treatment and long-term health.
Common Causes of Bleeding with a Normal Ultrasound
When no structural abnormalities are detected in the uterus, healthcare providers often turn their attention to functional and hormonal factors. Below are several potential explanations for persistent bleeding, even with a normal ultrasound result.
1. Hormonal Imbalance and Endocrine Disorders
Fluctuations in estrogen and progesterone levels can lead to irregular menstrual cycles and unexpected vaginal bleeding. This is especially common during perimenopause, after stopping birth control pills, or due to conditions like polycystic ovary syndrome (PCOS). A blood test measuring the six key reproductive hormones—often referred to as a "sex hormone panel"—can help pinpoint any imbalances.
Lifestyle adjustments play a supportive role in managing hormonal health. Maintaining good hygiene, practicing safe and moderate sexual activity, and eating a balanced diet rich in nutrients can improve overall well-being. It's also advisable to avoid spicy, greasy, or cold foods, which may worsen symptoms in some individuals.
2. Ovulation-Related Spotting
Some women experience light bleeding around mid-cycle, typically due to a temporary drop in estrogen during ovulation. This shedding of a small portion of the uterine lining results in brief spotting, often accompanied by mild pelvic discomfort or lower back tenderness.
To confirm ovulation timing, women can use at-home ovulation predictor kits or track basal body temperature daily. In cases where bleeding is frequent or disruptive, doctors may recommend short-term estrogen supplementation or hemostatic medications. Alternative approaches such as Traditional Chinese Medicine (TCM), including herbal formulations tailored to individual patterns, have also shown effectiveness for some patients.
3. Chronic Cervicitis (Cervical Inflammation)
Chronic inflammation of the cervix can cause intermittent bleeding, particularly after intercourse, along with symptoms like itching or irritation in the genital area. Although the uterus may appear normal on ultrasound, cervical issues require different diagnostic methods.
A colposcopy and Pap smear are commonly used to evaluate the cervix for signs of infection, dysplasia, or other abnormalities. Treatment options include physical therapies such as electrocautery, laser ablation, cryotherapy, or infrared coagulation. In milder cases, oral or topical herbal remedies may support healing under medical supervision.
4. Cervical Polyps
These benign growths on the cervix are a frequent yet often overlooked cause of abnormal bleeding. Women may notice spotting between periods, heavier menstruation, or post-coital bleeding. Some also report a dull ache in the lower back or pelvis.
Diagnosis usually involves hysteroscopy or colposcopy to visualize the cervical canal and remove the polyp if necessary. Procedures like polypectomy, electrocautery, or microwave therapy are effective and minimally invasive. Removed tissue should always be sent for biopsy to rule out malignancy.
5. Precancerous Cervical Lesions
Early cervical cell changes—known as cervical intraepithelial neoplasia (CIN)—may present with light, foul-smelling discharge or spotting. These changes are often linked to persistent HPV infection and require prompt evaluation.
Diagnostic steps include a Pap test, HPV testing, and colposcopic examination with biopsy. Mild cases may resolve on their own or be managed with antiviral treatments like interferon. More advanced lesions may require surgical intervention such as a loop electrosurgical excision procedure (LEEP) or cold knife conization to prevent progression to cervical cancer.
Other Possible Contributors to Abnormal Bleeding
While ultrasound is excellent at detecting many uterine issues, subtle endometrial abnormalities might not always be visible. Conditions like endometrial hyperplasia or small endometrial polyps can cause irregular bleeding without showing clear signs on standard imaging.
In such cases, further diagnostic tools are invaluable. An endometrial biopsy allows direct sampling of the uterine lining, while hysteroscopy provides real-time visualization inside the uterine cavity. These procedures enhance diagnostic accuracy and guide appropriate treatment decisions, especially in women over 40 or those with risk factors for endometrial cancer.
Ultimately, persistent bleeding—even with a normal ultrasound—should never be ignored. Seeking timely medical evaluation ensures that treatable conditions are identified early, promoting better reproductive health and peace of mind.