Spotting & Cramping After a Missed Period: Causes & What to Do

Differential for Spotting + Cramping After Missed Period

1. Early Pregnancy (Most Common)

• Implantation bleeding: 6–12 DPO, light pink/brown, few hours–2 days, mild cramping.
• Threatened miscarriage: Bleeding + cramping, closed cervix, viable fetus on US.
• Ectopic pregnancy: Unilateral pain, vaginal bleeding, shoulder tip pain (diaphragmatic irritation), hemodynamic instability — EMERGENCY.
• Molar pregnancy: Bleeding, hyperemesis, uterine size >dates, high hCG.

2. Hormonal / Cycle Variation

• Anovulatory cycle (PCOS, stress, weight change, thyroid, hyperprolactinemia) → irregular shedding.
• Ovulation bleeding (mid-cycle) mistaken for late period.
• Perimenopause (erratic cycles, spotting).

3. Structural / Gynecologic

• Endometrial polyp, submucosal fibroid.
• Adenomyosis, endometriosis.
• Cervical ectropion / polyp (postcoital spotting).
• IUD (copper: heavier/spotting; hormonal: irregular spotting 3–6 mo).

4. Medication / Systemic

• Anticoagulants, hormonal contraceptives (breakthrough bleeding).
• Thyroid dysfunction, coagulopathy.

Immediate Steps

1. Urine hCG test (first morning urine). If positive → OB/GYN.
2. If negative & bleeding heavy/pain severe → ER (rule out ectopic).
3. If negative & mild → repeat test in 48 hrs; track cycle; see clinician if persists/recurs.

Red Flags

• Soaking pad/hr, passing clots >quarter
• Severe unilateral pain, dizziness, shoulder pain
• Fever, foul discharge
• Known bleeding disorder / anticoagulation