Lochia that lasts too long, or stops and comes back

Your lochia stopped a week ago, and now you see blood again. Or it has been nearly two months and you are still spotting. Family members say "there is still bad lochia left, take something to get it all out", others say "your period must be back". Either could be right, and you cannot tell them apart just by looking at the blood.

A little bleeding coming back is usually nothing to worry about

Bleeding again is not, in itself, an illness. As the previous article in this series explained, quite a few mothers have times when the lochia (postpartum vaginal discharge) turns red again, or stops for a few days and then starts again. Among breastfeeding mothers, the World Health Organization’s multi-country study recorded 20.3% (about 1 in 5 mothers) having an episode of bleeding around day 40.

So if there is only light spotting for a day or two and then it stops, and you feel well, there is no need to rush. Write down the days you bled so you can tell your doctor at your follow-up visit.

Causes to tell apart

When the bleeding comes back heavily, or keeps trickling without fading, there are several possibilities.

The first is your period returning. Mothers who are not breastfeeding can get their period back from 5–6 weeks after birth; in one study, no one ovulated before day 25 after birth. Mothers who breastfeed exclusively usually get their period back much later. The classical Vietnamese physician Hai Thuong Lan Ong wrote that going half a year to a year without a period while breastfeeding "is normal". Whether you breastfeed or not, two thirds of women ovulate before their first period, so you can get pregnant even before your period comes back. If bleeding returns after 4–6 weeks and it is unclear whether it is a period or lochia, a home pregnancy test is a simple step worth taking.

The second group is retained placental tissue, poor healing of the placental site (it has not shrunk and closed over well), or endometritis (inflammation of the uterine lining): the three most common causes of late bleeding after birth. Endometritis usually comes with fever, lower belly pain and foul-smelling lochia. An ultrasound is the first step to see whether anything is left in the uterus.

If you have had a C-section, there is another possibility: an ultrasound may show a small "niche" at the scar on the uterus. One study found this niche in 64.5% of women (about 2 in 3) on ultrasound with gel instillation, far more than the number who actually have spotting; in other words, having a niche does not necessarily mean it bleeds. Once periods return, women with a niche often have brown spotting for many days after each period. This symptom can be treated.

Another cause that is often missed is progestin-only contraception (progestin is a type of hormone). The mini-pill made for breastfeeding mothers, the implant, the injection and the hormonal IUD are safe while breastfeeding, but they often cause light, irregular spotting in the first few months.

Finally, there is gestational trophoblastic neoplasia, a disease caused by abnormal growth of placental cells. It is very rare, about 1 in 50,000 births, but it often shows up as prolonged bleeding. The Royal College of Obstetricians and Gynaecologists (UK) advises: if bleeding is persistent or abnormal beyond 8 weeks after birth, do a urine pregnancy test and see a doctor. The test at this point is there so nothing gets missed; most results are negative. If the disease is present and found early, it can almost always be cured.

Traditional medicine books also say: rule things out first

In traditional medicine, prolonged lochia is called "lochia that does not stop" (恶露不绝 / 惡露不絕, è lù bù jué). Books set different cut-offs for calling it prolonged, from more than 10–15 days to 3 weeks or 1 month, but all of them count only the time when red bleeding continues.

Xia Guicheng’s gynecology book only uses this name after retained placenta, retained membranes, infection, tumors, trophoblastic disease and clotting disorders have been ruled out. The book lists an ultrasound to see whether anything is left in the uterus, whether there are fibroids and whether a C-section scar has healed, plus blood tests, clotting tests and HCG (the pregnancy hormone that a pregnancy test measures). Retained placenta must be removed by curettage: "one must not rely on medicine alone".

If placental tissue is still left and blood-moving herbs (herbs that make blood flow more strongly) are used, bleeding can get heavier; if there is inflammation, antibiotics are needed. If it turns out to be just a period, no treatment is needed at all.

Once these are ruled out, how traditional medicine helps

When ultrasound and tests show nothing that needs intervention, traditional medicine treats according to the pattern the physician identifies at the examination. With prolonged lochia, a common pattern is qi deficiency (here meaning qi, the body’s strength, is weak): spotting that goes on for a long time drains qi, and qi can no longer hold the blood in, so treatment aims to strengthen qi so that the bleeding stops by itself. If you have heat inside or still have blood stasis (stale blood still pooled), the treatment is quite different, which is why you need an examination rather than one formula for everyone. Maciocia, author of an English-language textbook on obstetrics and gynecology in Chinese medicine, notes that with the right herbs, change is usually seen within about a week. No improvement after that time is a reason to come back for a check. Herbs people may recommend to you, such as Yi mu cao (Leonurus japonicus herb, motherwort), are also for the physician to decide on.

If you are breastfeeding, tell the physician clearly. In the books we consulted, there is no data showing that these formulas are safe while breastfeeding.

When to watch and when to see a doctor

If bleeding soaks a large pad every hour for two hours in a row, or you feel faint or pass out, go to the emergency department right away (see the article "Warning signs after birth that need care right away").

Watch, and mention it at your follow-up visit:

• Lochia lasting up to 6–8 weeks but getting lighter, with no foul smell, no fever and no worsening belly pain;
• Lochia that stops, then returns lightly for a few days and fades on its own;
• Spotting after starting progestin pills, an implant or a hormonal IUD; if it goes on or bothers you, tell the place that fitted or prescribed it.

See an obstetrician the same day:

• Bleeding comes back as heavy as in the first days, or keeps trickling without fading after 2–3 weeks;
• Fever of 38°C or higher, foul-smelling lochia, lower belly pain that is getting worse;
• Passing a clot the size of a golf ball or larger.

Book an appointment within a few days, with an ultrasound:

• Light spotting that has faded in color but has not stopped after more than 6 weeks, or bleeding that returns several times when it is unclear whether it is a period (do a pregnancy test first);
• You have had a C-section, your periods have returned, and every cycle you have brown spotting for many days after the period ends;
• Persistent bleeding beyond 8 weeks after birth: do a urine pregnancy test before your visit.

References

Sources in Vietnamese

• Hạ Quế Thành. Sổ tay chẩn đoán điều trị phụ khoa (bản dịch tiếng Việt).
• Hạ Quế Thành. Thực dụng Trung y phụ khoa học (bản dịch tiếng Việt của BS. Tâm).
• Hải Thượng Lãn Ông. Hải Thượng y tông tâm lĩnh. Hà Nội: NXB Y học.

Sources in English

• Bij de Vaate AJ, van der Voet LF, Naji O, Witmer M, Veersema S, Brölmann HA, et al. 2014. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. Ultrasound Obstet Gynecol. 43(4):372-82. doi:10.1002/uog.13199. PMID: 23996650.
• Campbell OM, Gray RH. 1993. Characteristics and determinants of postpartum ovarian function in women in the United States. Am J Obstet Gynecol. 169(1):55-60. doi:10.1016/0002-9378(93)90131-2. PMID: 8333476.
• De Winter J, De Raedemaecker H, Muys J, Jacquemyn Y. 2017. The value of postpartum ultrasound for the diagnosis of retained products of conception: A systematic review. Facts Views Vis Obgyn. 9(4):207-216. PMID: 30250654.
• Gray RH, Campbell OM, Zacur HA, Labbok MH, MacRae SL. 1987. Postpartum return of ovarian activity in nonbreastfeeding women monitored by urinary assays. J Clin Endocrinol Metab. 64(4):645-50. doi:10.1210/jcem-64-4-645. PMID: 3818896.
• Maciocia G. Obstetrics and Gynecology in Chinese Medicine. Chapter 47.
• Mayo Clinic. Mayo Clinic Guide to a Healthy Pregnancy. 2nd ed.
• Ngan HYS, Seckl MJ, Berkowitz RS, Xiang Y, Golfier F, Sekharan PK, et al. 2021. Diagnosis and management of gestational trophoblastic disease: 2021 update. Int J Gynaecol Obstet. 155 Suppl 1(Suppl 1):86-93. doi:10.1002/ijgo.13877. PMID: 34669197.
• NHS. Your body after the birth [Internet]. Available from: https://www.nhs.uk/pregnancy/labour-and-birth/after-the-birth/your-body/.
• Royal College of Obstetricians and Gynaecologists (RCOG). 2020. Management of Gestational Trophoblastic Disease. Green-top Guideline No. 38.
• Sherman D, Lurie S, Frenkel E, Kurzweil Y, Bukovsky I, Arieli S. 1999. Characteristics of normal lochia. Am J Perinatol. 16(8):399-402. doi:10.1055/s-1999-6818. PMID: 10772198.
• van der Voet LF, Bij de Vaate AM, Veersema S, Brölmann HA, Huirne JA. 2014. Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 121(2):236-44. doi:10.1111/1471-0528.12542. PMID: 24373597.
• Visness CM, Kennedy KI, Ramos R. 1997. The duration and character of postpartum bleeding among breast-feeding women. Obstet Gynecol. 89(2):159-63. doi:10.1016/S0029-7844(96)00482-6. PMID: 9015013.
• World Health Organization (WHO) Task Force on Methods for the Natural Regulation of Fertility. 1999. The World Health Organization multinational study of breast-feeding and lactational amenorrhea. IV. Postpartum bleeding and lochia in breast-feeding women. World Health Organization Task Force on Methods for the Natural Regulation of Fertility. Fertil Steril. 72(3):441-7. doi:10.1016/s0015-0282(99)00273-3. PMID: 10519614.

Sources in Chinese

• 钟赣生, 主编. 中药学.