I Was Bleeding Between Periods and Terrified. Here’s the Step-by-Step Investigation That Finally Gave Me Answers.

Part 1: The Red Flag No One Prepares You For

It happened on a Tuesday.

A completely unremarkable Tuesday, until it wasn’t.

I was at work, heading to the restroom between meetings, when I saw it: blood.

Not a lot, but enough to make my heart hammer against my ribs.

It was a bright, insistent red against the white tissue, a color that felt both familiar and alarmingly out of place.

My first thought was a jolt of pure confusion.

Is this my period? A quick mental calculation confirmed it couldn’t be.

My cycle, while not perfect, was predictable enough.

This was two weeks early.

My mind raced, trying to find a logical explanation.

Had I miscalculated? Was it just… a fluke?

But the bleeding didn’t stop.

It wasn’t heavy like a period, but it was persistent.

A ghostly reminder every time I went to the bathroom that something was off.

That night, I did what millions of us do when faced with a terrifying medical mystery: I turned to the internet.

The search bar glowed on my screen: “bleeding but no period.”

What I found was a firehose of information that managed to be both overwhelming and utterly unhelpful.

One link would calmly suggest “ovulation spotting” or “breakthrough bleeding” from birth control—harmless, normal things.¹

The very next would present a terrifying list of possibilities: fibroids, infections, polycystic ovary syndrome (PCOS), and the one word that makes everyone’s blood run cold—cancer.³

I clicked through forums where women shared stories of years-long battles with unexplained bleeding, of feeling dismissed by doctors, and of the constant, gnawing anxiety that came with not knowing.⁵

I felt my own anxiety spike.

Was I overreacting? Or was I not reacting enough?

This experience highlights a profound disconnect.

The medical world has neat, categorized lists of causes for what they call Abnormal Uterine Bleeding, or AUB.⁸

But for the person experiencing it, it’s not a neat list; it’s chaos.

It’s the fear of a ruined pair of pants, the dread before every trip to the bathroom, the feeling that your own body has become an unpredictable stranger.

The real struggle isn’t just the physical symptom; it’s the emotional and informational void between the sterile medical facts and our terrifying lived reality.

The doctors have a map, but we are lost in the woods without it.

It took me a few more weeks of this low-grade panic before I finally made an appointment.

I was convinced I was either dying or making a huge deal out of nothing.

What I learned, however, changed everything.

I learned that this bleeding wasn’t random chaos.

It was a signal.

My body was sending a message, and my job—with the help of a good doctor—was to learn how to decode it.

This guide is the decoder ring I wish I’d had.

It’s the map that can take you from a place of fear and confusion to one of understanding and empowerment.

Part 2: My Body’s Orchestra: Understanding the Hormonal Command Center

My turning point came in a small, quiet examination room.

I had expected my new gynecologist to run through the same checklist of possibilities I’d already found online.

Instead, she sat down, looked me in the eye, and said, “Before we talk about what could be wrong, let’s talk about how it’s supposed to work.

Think of your menstrual cycle as a symphony, conducted by your brain.”

That one sentence was my epiphany.

For the first time, someone wasn’t just listing problems; they were explaining the system.

And when you understand the system, the potential problems start to make sense.

This “symphony” is controlled by what’s known as the Hypothalamic-Pituitary-Ovarian (HPO) Axis.

It sounds complicated, but the orchestra analogy makes it beautifully simple.

It’s the intricate communication network that governs your entire reproductive cycle.¹⁰

• The Conductor (The Hypothalamus): Deep in your brain, the hypothalamus acts as the symphony’s conductor. It wields the baton, which is a hormone called Gonadotropin-releasing hormone (GnRH). Every 60 to 120 minutes, the conductor gives a precise flick of the wrist, releasing a pulse of GnRH.¹² This is the master signal that starts the music.
• The First Violins (The Pituitary Gland): The GnRH signal travels a short distance to the pituitary gland, the orchestra’s concertmasters or first violins. In response to the conductor’s cue, the pituitary plays two critical notes: Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH).¹³ These are the main melodies of your cycle.
• The Orchestra (The Ovaries): The melodies of FSH and LH travel through your bloodstream to the ovaries, your body’s full orchestra. FSH signals a group of follicles (each containing an egg) to start maturing. As they mature, they produce the first key hormone: estrogen. As estrogen levels rise, one follicle becomes dominant, continuing to grow while the others fall away.¹³
• The Crescendo and Finale (Ovulation and the Uterus): When estrogen reaches a high enough peak, it signals back to the pituitary to release a huge surge of LH. This is the symphony’s crescendo. This LH surge triggers the dominant follicle to rupture and release its egg—this is ovulation.¹³ The follicle that’s left behind transforms into a structure called the corpus luteum, which begins producing the second key hormone:
  progesterone. Progesterone’s job is to stabilize the uterine lining (the endometrium), which estrogen has been busy building up, making it a lush, welcoming place for a fertilized egg.¹³ If pregnancy doesn’t occur, the corpus luteum dissolves, progesterone levels plummet, and the unstable lining is shed. That is a normal, predictable period.

The Music Stops: What is Anovulatory Bleeding?

Now, what happens when the orchestra is out of sync? What if the conductor is stressed, or the first violins get a garbled message? This is where the problem of unexpected bleeding often begins.

Many cases of AUB are due to something called anovulatory bleeding, which means bleeding that happens in a cycle where you don’t ovulate.¹⁸

Without ovulation, the corpus luteum never forms, which means your body doesn’t produce progesterone.¹⁸

So, you have estrogen building up the uterine lining (the “unopposed estrogen” you might read about), but you’re missing the progesterone needed to make it stable.¹⁹

This overgrown, unstable lining becomes fragile.

It can’t hold itself together for a full cycle, so it starts to break down and shed unpredictably.

This isn’t a true period; it’s the result of a communication breakdown in the HPO axis.

This was a revelation for me.

“Hormonal imbalance,” a term I’d heard a thousand times, suddenly wasn’t a vague, dismissive catch-all phrase.²²

It was a specific disruption in a beautiful, complex system.

Conditions like Polycystic Ovary Syndrome (PCOS), thyroid disorders, significant stress, or extreme weight changes aren’t just random health issues; they are concrete factors that can interfere with the HPO “orchestra,” causing the communication to fail and leading to the confusing and frightening symptom of abnormal bleeding.³

Understanding this system was the first step.

The next was getting the map to investigate exactly where the breakdown was happening.

Part 3: The Investigator’s Map: A Guided Tour of the PALM-COEIN Framework

After explaining the HPO axis, my doctor turned her computer screen towards me.

“To figure out why your body’s signals are off,” she said, “we use a system.

It’s like an investigator’s map to make sure we check every possibility, from the most common to the most rare.

It’s called PALM-COEIN.”

Seeing my confused expression, she smiled.

“It’s just an acronym.

But it brings order to the chaos.”

The PALM-COEIN system, developed by the International Federation of Gynecology and Obstetrics (FIGO), is now the global standard for classifying the causes of abnormal uterine bleeding.⁹

It’s designed to replace vague, outdated terms like “dysfunctional uterine bleeding” with a clear, logical checklist.

It divides all potential causes into two main groups:

• PALM: These are structural causes. Think of them as problems with the physical “hardware” of your uterus—things that can often be seen with imaging like an ultrasound or identified in a tissue sample.²⁷
• COEIN: These are non-structural causes. Think of these as problems with the body’s “software” or “operating systems”—hormones, blood clotting, and other systemic functions.²⁷

Here is the entire map at a glance.

We’ll explore each territory in detail below.

Category	P.A.L.M. (Structural Causes)	C.O.E.I.N. (Non-Structural Causes)
P	Polyp: Benign growths in the uterus or on the cervix.	C
A	Adenomyosis: Uterine lining tissue grows into the muscular wall of the uterus.	O
L	Leiomyoma (Fibroids): Benign (non-cancerous) tumors in the uterine muscle.	E
M	Malignancy & Hyperplasia: Cancer or precancerous changes of the uterine lining.	I
		N

It’s important to remember that these causes are not mutually exclusive; a person can have more than one contributing factor to their AUB.²⁷

The PALM Group: Investigating the Physical Structure

The PALM causes are issues with the anatomy of your uterus.

Your doctor will often investigate these first with a physical exam and imaging tests.

P for Polyps

Think of polyps as small, soft, finger-like growths that can develop on the lining of the uterus (endometrial polyps) or the cervix (cervical polyps).³¹

They are essentially overgrowths of normal tissue.

While they are usually benign (non-cancerous), they can act like irritants inside the uterus, leading to bleeding between periods (intermenstrual bleeding) or spotting, especially after sex.⁸

Their prevalence increases with age, and while many are asymptomatic, they are a common finding in women who present with AUB.⁹

A for Adenomyosis

If the endometrium is the “wallpaper” of your uterus, adenomyosis is what happens when that wallpaper starts growing into the muscular wall (the myometrium).²⁷

This misplaced tissue still behaves like normal endometrial tissue—it thickens and bleeds with your cycle—but it does so within the muscle wall.

This can cause the uterus to become enlarged, boggy, and tender, and often leads to very heavy, painful periods and sometimes pain during intercourse.³

L for Leiomyomas (Fibroids)

Uterine fibroids, or leiomyomas, are extremely common non-cancerous tumors that grow from the smooth muscle cells of the uterus.²⁷

Up to 80% of women may have them by age 50, though many will never have symptoms.²⁷

Whether a fibroid causes bleeding depends heavily on its location ³⁷:

• Submucosal fibroids bulge into the uterine cavity and are the most likely type to cause heavy or abnormal bleeding because they distort the uterine lining.³⁷
• Intramural fibroids grow within the muscular wall of the uterus.
• Subserosal fibroids grow on the outside surface of the uterus.

Fibroid growth is often fueled by hormones, particularly estrogen, which is why they tend to shrink after menopause when estrogen levels drop.³⁷

M for Malignancy & Hyperplasia

This is the category that causes the most fear, so let’s address it directly and with perspective.

Malignancy (cancer) and hyperplasia (a precancerous overgrowth of cells in the uterine lining) are the most serious, but also among the least common, causes of AUB, particularly in premenopausal women.⁸

However, it is a critical diagnosis to rule O.T. Abnormal bleeding is the single most common warning sign of endometrial cancer.⁴

This is why

any bleeding after menopause is considered abnormal and requires immediate investigation.⁸

For premenopausal women, risk factors that increase suspicion include obesity, conditions that cause chronic anovulation like PCOS (which leads to the unopposed estrogen that can fuel abnormal cell growth), and a family history of certain cancers.³

As Tralisa Woods, an endometrial cancer survivor, shared, she had attributed her worsening bleeding to getting older and her known history of endometriosis and PCOS, highlighting how easy it can be to explain away this critical symptom when you have a history of irregular cycles.⁴

This is why a thorough investigation is so important.

The COEIN Group: Investigating System and Function

If the PALM causes are the hardware, the COEIN causes are the software and operating systems.

These are issues that won’t necessarily show up on an ultrasound but are just as important.

C for Coagulopathy

This refers to a systemic bleeding disorder, meaning the problem isn’t in your uterus but in your blood’s ability to clot properly.³

Conditions like von Willebrand disease or other platelet function disorders can cause heavy menstrual bleeding from a person’s very first period.²⁷

This is a particularly important consideration for adolescents presenting with severe, heavy periods.²⁷

The story of Maya, who endured years of debilitatingly heavy periods and worsening anemia, is a powerful example.⁴⁰

Her journey involved multiple misdiagnoses and doctors dismissing her symptoms as “normal” before she was finally diagnosed with both a bleeding disorder (hemophilia) and uterine fibroids.⁴⁰

Her story underscores the necessity of testing for coagulopathies when bleeding is severe and unexplained.

O for Ovulatory Dysfunction

This brings us right back to our HPO axis orchestra.

Ovulatory dysfunction (AUB-O) is the most common non-structural cause of AUB and refers to any condition that disrupts regular ovulation.²¹

When ovulation is infrequent or absent, the result is often the unpredictable, anovulatory bleeding we discussed earlier.¹⁸

This category is a broad umbrella for many common conditions ¹⁸:

• Polycystic Ovary Syndrome (PCOS): A common endocrine disorder characterized by hormonal imbalances that interfere with ovulation.³ Many women with PCOS, like Natalie Thibodeaux, first realize something is wrong when their cycles are irregular and heavy after stopping birth control.⁴¹
• Thyroid Disorders: Both an underactive (hypothyroidism) and overactive (hyperthyroidism) thyroid can disrupt the HPO axis and cause menstrual irregularities.³
• Hyperprolactinemia: High levels of the hormone prolactin can suppress the signals from the hypothalamus and pituitary, halting ovulation.¹⁰
• Extremes of Reproductive Age: It is very common for cycles to be anovulatory during the first few years after menarche (the first period) and during the perimenopausal transition, as the HPO axis is either still maturing or beginning to wind down.⁸
• Stress, Weight, and Exercise: Significant physical or emotional stress, extreme weight loss or gain, and excessive exercise can all signal to the hypothalamus that it’s not a safe time for reproduction, causing it to down-regulate the HPO axis.³

E for Endometrial

This is a “diagnosis of exclusion,” meaning it’s considered when all other PALM and COEIN causes have been ruled O.T.³⁰

This category suggests there’s a primary problem with the endometrium itself.

The hormonal signals might be fine, and there are no structural issues, but the uterine lining has a localized problem with its own mechanisms for stopping bleeding (hemostasis).³⁰

This could be related to a low-grade, chronic infection (endometritis) or issues with the local blood vessels.³

I for Iatrogenic

“Iatrogenic” is a medical term that simply means “caused by medical treatment”.²⁷

Unscheduled “breakthrough bleeding” is a very common side effect when starting or inconsistently using hormonal contraception, including pills, patches, rings, injections, implants, and hormonal IUDs.¹

A non-hormonal copper IUD is also a well-known cause of heavier periods.³⁶

Other medications can also be responsible, including blood thinners (anticoagulants), aspirin and NSAIDs, tamoxifen, and certain antidepressants or antipsychotics.¹

N for Not Otherwise Classified

This is a catch-all category for rare or poorly defined causes that don’t fit neatly elsewhere.

This includes things like arteriovenous malformations (an abnormal tangle of blood vessels in the uterus) or an “isthmocele,” which is a niche or defect in the uterine wall at the site of a previous Cesarean section scar that can collect blood and cause post-menstrual spotting.²⁷

Other Critical Causes to Rule Out First

Before diving deep into the PALM-COEIN map, there are two crucial possibilities that any doctor will investigate immediately.

Pregnancy

This is always the first thing to rule out, no matter your age or circumstances.³

Bleeding in early pregnancy is common and can sometimes be harmless “implantation spotting,” which occurs when the embryo embeds in the uterine wall.²

However, it can also be the first sign of a serious problem like a miscarriage or an ectopic pregnancy (a dangerous condition where the embryo implants outside the uterus, usually in a fallopian tube).³⁶

Infections

Infections of the reproductive tract can cause inflammation and irritation that leads to abnormal bleeding, especially bleeding between periods or after sex.¹

Pelvic Inflammatory Disease (PID) is a serious infection of the uterus, fallopian tubes, or ovaries, often resulting from untreated sexually transmitted infections (STIs) like chlamydia or gonorrhea.⁴⁷

Other infections of the cervix (cervicitis) or vagina (vaginitis) can also be culprits.³

Part 4: Building Your Case: How to Become the Lead Investigator of Your Health

Learning about the HPO axis and the PALM-COEIN framework was like being handed a compass and a map.

The forest of my symptoms was still dense and scary, but for the first time, I had the tools to navigate it.

I realized I didn’t have to be a passive, frightened patient waiting for a verdict.

I could become an active partner in my own care—the lead investigator, gathering evidence for my case.

This shift in mindset is the most powerful tool you have.

Your doctor is the expert on medicine, but you are the world’s foremost expert on your own body.

By systematically gathering your own data, you can bridge the communication gap and ensure your concerns are taken seriously.

Step 1: Gather Your Intelligence – The Power of Symptom Tracking

A detailed symptom diary is your single most important piece of evidence.⁴⁹

In the face of a doctor’s skepticism or limited time, a written record of objective data is incredibly difficult to dismiss.⁵¹

It transforms a vague, subjective complaint like “I’ve been bleeding a lot” into a concrete, factual report: “For the past two cycles, starting on day 14, I’ve had spotting that required two panty liners per day, and on day 2 of my period, I passed three quarter-sized clots and had to change my super-plus tampon every 90 minutes for six hours.” That is the kind of specific, high-quality data that helps a clinician make an accurate diagnosis.⁵²

You can print the table below and keep it by your bed, filling it out each evening.

Tracking for at least two full cycles provides the most valuable information.⁵⁴

My Menstrual Health Diary (Printable)

Date	Cycle Day (Day 1 = first day of period)	Bleeding (S=Spotting, L=Light, M=Medium, H=Heavy)	# of Pads/Tampons Used (Note saturation)	Clots? (Yes/No & Size)	Pain Score (1-10)	Pain Location (e.g., Pelvic, Back)	Other Physical Symptoms (e.g., Bloating, Acne, Breast Tenderness)	Mood/Emotional Symptoms (e.g., Anxiety, Irritability, Fatigue)	Notes (e.g., Bled after sex, Took Ibuprofen)

This diary is a tool for personal tracking and to facilitate discussion with a healthcare provider.

It is based on common symptom tracking recommendations.⁴⁹

Step 2: The Doctor’s Briefing – What to Expect at Your Appointment

Walking into your appointment armed with your symptom diary can dramatically reduce anxiety because you are prepared.

Here’s a general rundown of what to expect so there are no surprises.

• The History: The first and most important part of the visit is the conversation. Your doctor will ask a series of detailed questions about your bleeding pattern, your menstrual history, your sexual and reproductive history, and any associated symptoms.⁹ This is where your diary becomes your superpower. You can provide precise answers about cycle length, duration of bleeding, heaviness, and timing.
• The Physical Exam: Your doctor will likely perform a pelvic exam. This can be a source of anxiety for many, but knowing what’s happening can help. You will be asked to lie on an exam table with your feet in supports (stirrups).⁵⁹ The exam typically has two parts:

1. Speculum Exam: A device called a speculum is gently inserted into the vagina to allow the doctor to visually inspect your vaginal walls and cervix for any obvious abnormalities, like polyps, lesions, or signs of infection.⁵⁹ They will likely perform a Pap test at this time if you are due for one.
2. Bimanual Exam: The doctor will insert two gloved fingers into the vagina while gently pressing on your lower abdomen with their other hand. This allows them to feel the size, shape, and mobility of your uterus and ovaries and check for any tenderness or masses.⁸

Step 3: The Diagnostic Toolkit – Understanding the Tests

Based on your history and physical exam, your doctor will decide which tests are needed to investigate the potential causes on the PALM-COEIN map.

• Blood Tests: A simple blood draw can reveal a wealth of information. A Complete Blood Count (CBC) will check for anemia, which is common with heavy or chronic bleeding.⁵⁸ Other tests can measure hormone levels to check for thyroid disorders, high prolactin, or the androgen excess seen in PCOS, as well as screen for bleeding disorders.⁸
• Pelvic Ultrasound: This is a cornerstone of AUB diagnosis. It uses sound waves to create images of your pelvic organs.⁶² It often involves two parts: a transabdominal ultrasound (where the probe is moved over your abdomen) and a transvaginal ultrasound (where a thin, wand-like probe is inserted into the vagina). The transvaginal approach provides a much clearer, more detailed view of the uterus and ovaries, making it excellent for identifying structural issues like fibroids, adenomyosis, and significant polyps.⁸
• Sonohysterogram: If a standard ultrasound isn’t clear enough, your doctor might recommend this enhanced version. A sterile saline solution is gently infused into your uterus through a tiny catheter. The fluid expands the uterine cavity, allowing the ultrasound to create a very sharp image of the uterine lining, making it highly effective for detecting small polyps or submucosal fibroids that might otherwise be missed.³
• Endometrial Biopsy: To investigate the “M” in PALM, your doctor may need to take a small tissue sample from your uterine lining (endometrium). This is often done in the office using a thin, flexible tube that suctions a tiny piece of tissue. The sample is then sent to a lab to be examined for any abnormal, precancerous, or cancerous cells.³
• Hysteroscopy: This procedure allows your doctor to look directly inside your uterus with a thin, lighted camera called a hysteroscope, which is inserted through the vagina and cervix.⁶² It’s a powerful tool because it can be both diagnostic and therapeutic; if a polyp or small fibroid is found, it can often be removed during the same procedure.³

Step 4: Mastering Self-Advocacy – How to Make Sure You’re Heard

The sad reality is that many women, particularly those with menstrual health issues, report feeling dismissed by healthcare professionals.⁶

Their pain is normalized, their symptoms are minimized, and they leave appointments feeling frustrated and unheard.

This is why learning to advocate for yourself is not just helpful; it is essential.

Self-advocacy is not about being aggressive or confrontational.

It is about being prepared, clear, and confident.

It’s about transforming the power dynamic from a passive patient to an active partner in your healthcare.⁶⁷

Here are concrete strategies to ensure you are heard:

1. Come Prepared: Walk in with your symptom diary, a written list of your top 3-4 most pressing questions, and a list of all medications and supplements you take.⁶⁷ Handing a copy of your questions and a summary of your diary to your doctor can be incredibly effective, especially in a time-crunched appointment.
2. Bring a Supporter: Ask a trusted friend or family member to come with you. They can act as a second set of ears, take notes, and provide moral support. They can also speak up for you if they see you becoming flustered or feeling dismissed.⁶⁷
3. Use Clear, Assertive Language: Use “I” statements to describe your experience. “I am concerned about the amount of bleeding,” or “I feel that this is impacting my ability to work.”.⁷³ If you don’t understand something, say so. “Can you explain that in simpler terms?” or “Can you draw me a picture of what that means?”.⁶⁷
4. Know What to Do If You Feel Dismissed: This is the hardest part, but you have options.

• Voice It Calmly: “I’m feeling like my concerns aren’t being fully heard. It’s really important to me that we figure this out.”.⁶⁶
• Ask for Documentation: “Could you please document in my chart that I reported these symptoms and that we have decided not to pursue testing at this time?” This simple request can sometimes change the course of the conversation, as it creates an official record.⁷²
• Request a Second Opinion: You always have the right to a second opinion. A good doctor will not be offended by this request. You can say, “Thank you for your input. I would feel more comfortable getting a second opinion before we decide on a course of action.”.⁵⁰
• Ask for a Referral: If you feel your issue is complex, you can ask for a referral to a specialist, like a gynecologist who focuses on AUB or a reproductive endocrinologist.⁶⁶

Part 5: Conclusion – The Relief of an Answer

My own journey through the diagnostic maze took several months.

After the exams, the blood tests, and the ultrasounds, my “investigation” led to a two-part diagnosis.

The COEIN culprit was Ovulatory Dysfunction (AUB-O)—my symptom diary clearly showed irregular cycles, and bloodwork confirmed the hormonal markers of Polycystic Ovary Syndrome (PCOS), a condition I never knew I had.

The PALM culprit was a small submucosal Leiomyoma (fibroid), clearly visible on the sonohysterogram, that was likely contributing to the heaviness of the bleeding when it did occur.

The moment I got the answer, the primary emotion wasn’t fear or sadness.

It was profound, bone-deep relief.

The monster under the bed finally had a name.

Two names, in fact.

The chaos resolved into a clear picture.

The bleeding wasn’t a random, terrifying betrayal by my body.

It was a logical consequence of a specific hormonal disruption and a small, benign growth.

My fear of the unknown was replaced by the clarity of a diagnosis and, most importantly, a plan.

A plan that involved lifestyle changes to help manage the PCOS, and a discussion about options for the fibroid if it continued to cause problems.

My body was no longer a source of mystery and anxiety; it was a complex system that I could finally begin to understand and support.

If you are reading this because you, too, saw that unexpected and frightening red flag, please know this: your experience is valid.

Your concerns are legitimate.

And a path to answers exists.

You are not powerless in this process.

The journey from fear to understanding begins with a single step.

Start your symptom diary today.

Make that appointment.

Walk into that office armed with your data, your questions, and the knowledge that you are your own best and most powerful advocate.

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