ABNORMAL vaginal bleeding can catch a woman by surprise, especially when there are no obvious risk factors for any illnesses, and a doctor can’t immediately identify the cause. But it’s an issue that affects, and will affect, many women, and a lot of us suffer in silence.

The condition is defined as any vaginal bleeding, unrelated to your period, that may include spotting of small amounts of blood between periods — often seen on toilet tissue after wiping — or extremely heavy periods in which you soak a pad or tampon every one to two hours for two or more hours.

The Mayo Clinic says abnormal vaginal bleeding can relate to an issue with your reproductive system (a gynaecological condition) or to other medical problems or certain medications.

If you’re in menopause — generally defined as 12 months, give or take, without a menstrual period — any vaginal bleeding may be a cause for concern and should be evaluated.

Possible causes include:

Cancers and precancerous conditions

Cervical cancer

Endometrial cancer

Endometrial hyperplasia (when the lining of the uterus becomes too thick)

Ovarian cancer

Uterine sarcoma (malignant (cancer) cells form in the muscles of the uterus or other tissues that support the uterus)

Vaginal cancer.

Endocrine system factors

Hyperthyroidism (overactive thyroid)

Hypothyroidism (underactive thyroid)

Polycystic ovary syndrome (PCOS)

Stopping or changing birth control pills or menopausal hormone therapy.

Fertility and reproduction factors

Ectopic pregnancy

Fluctuating hormone levels

Miscarriage (before 20th week)

Pregnancy

Random ovulatory cycles

Sexual intercourse

Perimenopause

Vaginal atrophy (genitourinary syndrome of menopause).

Infections

Cervicitis

Chlamydia trachomatis

Endometritis

Gonorrhoea

Pelvic inflammatory disease Ureaplasma vaginitis

Vaginitis.

Medical conditions

Celiac disease

Severe systemic disease, such as kidney or liver disease

Von Willebrand disease (and other blood-clotting disorders).

Medications and devices

Forgotten (retained) tampon

Intrauterine device

Stopping or changing birth control pills or menopausal hormone therapy

Noncancerous growths and other uterine conditions

Adenomyosis

Cervical polyps

Endometrial polyps

Uterine fibroids, uterine polyps.

Trauma

Blunt trauma or penetrating injury to the vagina or cervix

Sexual abuse.

When to see a doctor

If you’re pregnant, contact your doctor immediately if you notice vaginal bleeding.

In general, anytime you experience unexpected vaginal bleeding, consult your doctor. Whether or not vaginal bleeding is normal depends on your age and the circumstances.

Contact your doctor in the following situations:

•Postmenopausal women not taking hormone therapy.

•Postmenopausal women taking cyclic hormone therapy may experience some vaginal bleeding. If you have bleeding other than expected withdrawal bleeding, contact your doctor.

•Postmenopausal women taking continuous hormone therapy may experience light, irregular bleeding for the first six months. If bleeding persists longer or heavy bleeding begins, see your doctor.

•Girls who don’t have any other signs of puberty or are younger than age eight should have any vaginal bleeding investigated.

The following situations are likely normal:

•Newborn girls may have some vaginal bleeding during the first month of life.

•Adolescent girls who have just begun having periods may experience irregular cycles during the first few years.

•Women starting birth control pills may experience occasional spotting the first few months.

•Women nearing menopause may experience increasingly heavy or irregular periods.