Bleeding and periods after ectopic pregnancy

The vaginal bleeding you have after surgery, after treatment with methotrexate, or if you are managed expectantly, is not actually classed as your first period after the ectopic pregnancy. This is your body expelling the thickened lining of the uterus because you are, sadly, no longer pregnant.

Once the beta hCG levels (pregnancy hormones) in your body have dropped, the chemical signals to retain the thickened uterine lining that has built up in early pregnancy, are no longer being produced and so the lining of the uterus is shed. This is part of the pregnancy tissue. The process involves vaginal bleeding and the material may be clotty, heavy, dark in appearance or appear just like one of your normal menstrual period bleeds.

The length of time anyone bleeds varies greatly, as the vaginal bleeding is from the lining of the womb and is hormonally controlled. It will probably last a week or two, changing in colour from red to brown and diminishing. Some women report bleeding and spotting on and off for up to six weeks.

Provided you are not soaking a pad in less than an hour or the abdominal pain is so severe you can’t manage it with over-the-counter pain relief, such as paracetamol, you should try not to worry. If the amount of bleeding worries you or you have any concerns, you should seek medical advice and a reassessment.

The bleeding that follows an ectopic pregnancy, particularly when treated with methotrexate, can be very heavy and clotty and result in the passing of what we call a decidual cast. This decidual cast can cause confusion and worry and it can often be mistaken for the tissue of their baby.

The lining of the uterus when we are pregnant, other than that which is taken up by the placenta, is called the decidua. The appearance of the normal lining of the uterus by the presence and action of progesterone (hormone that prepares the uterus for a fertilised egg) becomes decidualised. When an area of the decidua is shed we call it a decidual cast. It is thought to occur as a result of the lack of stability of the integrity of the lining and this lack of stability is because the hormones aren’t functioning properly in an ectopic pregnancy.

The sudden drop in hormones can cause the pregnancy tissue inside the uterus to be shed in layers and the material that is passed can be grey, pink or white as well as appear like a clot or dark or frank red blood.

It is common to begin bleeding a few days following injection with methotrexate and this bleeding may persist anywhere between a few days to up to six weeks.

Not experiencing vaginal bleeding after being treated with methotrexate is not something you have to be too worried about. Some will not experience bleeding as a side effect with this medical treatment option.

To check that the treatment is working, it is important to attend regular appointments with your healthcare professionals to have your hCG levels monitored.

Your menstrual periods after an ectopic pregnancy can take a while to re-establish.

They can restart any time between four and ten weeks after treatment. Most find that their first period arrives sometime around week six or seven after surgery, or, if treated without surgery, at some time in the four weeks after their hCG levels have fallen to below 100 mIU/mL. According to a study for women who had methotrexate treatment for an ectopic pregnancy in a Fallopian tube, periods generally return to normal after an average of 24 days (range of 24–38 days) from the pregnancy ending. 

Before you can have a period, ovulation needs to occur. It is perfectly possible to ovulate 14 days after surgical treatment and almost as soon with methotrexate treatment. It is important to be aware that it is possible to become pregnant even without having the first period if you are not using some form of contraception when having sexual intercourse.

The first period may be more painful or less so than usual, heavier or lighter, and last for longer or shorter than usual – there really is no set pattern. You should be able to manage the discomfort with over-the-counter (OTC) pain relief medications and should not be soaking a pad in less than an hour. If this is not the case, you should seek medical advice.

One of the symptoms of endometriosis is heavy bleeding and so if you have this condition it is worth remaining extra vigilant.

Before, they were 25/26 days but this time it has been 30 days. I have taken a pregnancy test and am not pregnant. Is my changed menstrual cycle length ok?

The first period can occur up to ten weeks after the ectopic pregnancy although it may not be like your normal menstrual period. It might be heavier or lighter and it may be more painful than expected. The period after that is usually more like your usual pattern. However, although there is no medical reason for it, women do very often report some irregularity in their cycle for several months after an ectopic pregnancy.

Broadly speaking, doctors consider menstrual period cycles of between 23 to 42 days to be within normal parameters. If the first day of your last period was more than 42 days ago, make an appointment with your doctor to discuss the possible reasons for this. Your doctors may also discuss periods returning at a follow-up appointment.

You will continue to have normal periods every month after the removal of one or both Fallopian tubes (salpingectomy), following tubal pregnancy. The menstrual cycle is controlled by hormones produced in different sites in the body, predominantly in the ovaries, and a period is the shedding of the lining of the womb. The Fallopian tubes play no part in controlling your period cycle. Periods usually continue normally even in the very rare cases when one of the ovaries is removed as part of the surgical process, whether by laparoscopy or laparotomy.

Additionally, during surgical treatment for ectopic pregnancy in a Fallopian tube, the ovaries are typically not removed and remain intact. This means it is possible to have a regular menstrual cycle with ovulation and periods making it possible to conceive again in most cases.

After surgery for an ectopic pregnancy, you may have some adhesions in the abdominal cavity which might cause some pelvic pain, abdominal pain during sexual intercourse and pain at ovulation, but this usually settles with time. Some women do report that they can feel themselves ovulate, often because there is more awareness of sensations within our bodies after suffering an ectopic pregnancy. However, this is not usually cause for worry, as in most cases, these feelings can reduce or stop after a few cycles.

Sometimes, pain around the pelvic area can be due to an underlying condition including one called pelvic inflammatory disease or PID. If you have symptoms and are worried, you can visit your doctors and they can discuss tests and investigations. You can read more about symptoms of PID and diagnosis and treatment here:

https://www.nhs.uk/conditions/pelvic-inflammatory-disease-pid/

There is no evidence that an ectopic pregnancy affects or changes the timing of menopause. However, if it was necessary to undertake surgery on the ovary or remove one of the ovaries, this can result in menopause developing slightly earlier although the impact does not appear to be significant. If the ectopic pregnancy is treated with surgery where one of the ovaries is removed, soon after the surgery the remaining ovary overtakes the function for producing hormones that control the menstrual cycle, so it is unlikely that menopause will start earlier.

It is unlikely that your periods will change following the removal of your ovary, whether by keyhole surgery or open surgery. Typically, the remaining ovary compensates and produces sufficient hormones to control the menstrual cycle so your periods are likely to settle into a regular cycle over the next few months even though one of your ovaries has been removed.