Can a Pessary Cause Bleeding?

Bleeding is one of the most commonly reported complications of pessary use, alongside vaginal discharge and tissue erosion. In most cases, the bleeding is minor and linked to friction or irritation of the vaginal walls rather than anything dangerous. But the sight of blood understandably alarms people, and the amount of information available on why it happens and what to do about it is surprisingly thin compared to how frequently it occurs. The picture gets more nuanced when you factor in hormonal status, how long the pessary stays in place, and how it is maintained.

Why a Pessary Can Cause Bleeding

A pessary is a firm device, usually made of silicone, that sits inside the vagina to support organs that have shifted due to pelvic organ prolapse or to help manage stress urinary incontinence. It works by physically propping things up. That means it presses against the vaginal walls constantly, and that sustained contact is the root cause of most pessary-related bleeding.

The vaginal lining is a mucosal tissue, and like other mucosal surfaces, it can be worn down by persistent pressure or friction. When the pessary rubs against the same spot over weeks or months, it can cause erosion, which is essentially an ulcer or raw patch on the vaginal wall. These erosions bleed. Sometimes the bleeding is just spotting on underwear or on the pessary itself when it is removed for cleaning. Other times, it can be more noticeable. A large integrative review of 61 studies found that vaginal discharge, erosion, and bleeding were the three most frequently reported pessary complications, and that these problems were linked to the pessary’s shape, the material it was made from, and how long it stayed in place between removals.¹

Discomfort, fecal impaction, and allergic reactions to pessary materials are also documented, but bleeding and erosion tend to be the complications that prompt patients to seek help or consider discontinuing pessary use.²

The Role of Vaginal Atrophy

The single biggest factor that determines whether a pessary will cause bleeding is the health of the vaginal tissue before and during use. After menopause, estrogen levels drop, and the vaginal lining thins, dries out, and becomes more fragile. This process, called vaginal atrophy, makes the tissue far more vulnerable to mechanical irritation from a pessary. A device that a premenopausal person tolerates with no problems can cause significant erosion and bleeding in someone whose vaginal walls have thinned.

A secondary analysis of a randomized controlled trial examined specific risk factors for vaginal epithelium-related adverse events in pessary users. The study found that longer time since menopause was an independent risk factor for these complications. For every additional year past menopause, the odds of developing tissue-related problems increased slightly but significantly. On the flip side, continuous estrogen use for 12 months or more was strongly protective, roughly cutting the odds of these problems in half compared to no estrogen use at all.³

This finding has practical weight. If you are postmenopausal and using a pessary, or considering one, the state of your vaginal tissue matters enormously. Estrogen therapy, whether applied locally as a cream or delivered through a vaginal ring, is one of the most evidence-backed strategies for reducing erosion and bleeding. A research group studying an estriol-eluting pessary described how estrogen creams and estrogen rings are often prescribed alongside standard pessaries specifically to counteract atrophy-related erosion.⁴ The concept of building hormone delivery directly into the pessary itself is an area of active development aimed at simplifying this dual-therapy approach.

How Pessary Shape and Duration Affect Bleeding Risk

Not all pessaries carry the same risk. There are two broad categories: support pessaries (like rings and dishes) and space-filling pessaries (like cubes and donuts). Support types rest against the vaginal walls more gently and are generally easier to insert and remove. Space-filling types exert more pressure over a larger area of tissue and tend to be used for more advanced prolapse. The integrative review that analyzed 61 studies found that complications including bleeding were related to pessary shape and material, with space-filling designs generally posing a higher risk of erosion.¹

Duration in situ, the amount of time the pessary stays inside without being removed, is also a significant factor. A pessary that is cleaned and reinserted every few days allows the vaginal tissue to recover. One that stays in place for months without removal gives erosion time to develop and deepen. This is the mechanism behind some of the more alarming case reports in the medical literature, where neglected pessaries left in for years caused severe tissue damage. These extreme cases are rare and almost always involve elderly or cognitively impaired patients who were lost to follow-up. But they illustrate the principle: the longer a pessary sits undisturbed against fragile tissue, the more likely erosion and bleeding become.

Self-Management Versus Clinic Visits

Traditionally, pessary care has been clinic-based. You visit your provider every few months, and they remove the pessary, inspect your vaginal walls for erosion, clean or replace the device, and reinsert it. This works, but it ties you to a schedule of regular appointments and means the pessary stays in place between visits.

A large randomized trial called TOPSY compared this clinic-based model with teaching patients to manage their own pessaries at home, meaning they learned to remove, clean, and reinsert the device themselves. The study found that self-management actually led to a lower percentage of pessary-related complications at 18 months, with a statistically meaningful difference favoring the self-management group.⁵

The likely explanation is straightforward. When you manage your own pessary, you remove it more frequently. You give your tissue regular breaks from the pressure. You are more attuned to early signs of irritation because you are the one inspecting the device and feeling any discomfort. By contrast, clinic-based care typically means the pessary stays in for weeks or months at a time, during which erosion can develop unnoticed. If you have the dexterity and willingness to learn self-care, it appears to reduce rather than increase your risk of complications including bleeding.

Self-management is not for everyone. Some people lack the hand strength or mobility to handle the device, and some pessary types, particularly larger space-filling models, are harder to remove and reinsert at home. Your provider can help you decide whether self-care is realistic for your situation.

When Bleeding Deserves Urgent Attention

Most pessary-related bleeding is a nuisance, not an emergency. Light spotting, pink-tinged discharge, or a small amount of blood on the pessary surface after removal usually points to minor erosion or friction. These problems typically improve with estrogen therapy, more frequent pessary removal, or switching to a different pessary type or size.

However, bleeding that is heavy, persistent, foul-smelling, or accompanied by pain warrants a prompt medical evaluation. The concern in these cases is not just about erosion. A pessary that has been neglected for a very long time can become embedded in the vaginal wall, causing tissue breakdown that extends beyond the surface. Case reports have documented fistulas, which are abnormal connections between the vagina and the bladder or rectum, resulting from severely neglected pessaries.² These are serious surgical complications, but they are almost exclusively tied to devices left in place for years without any medical follow-up.

There is also the question of what else might be causing the bleeding. Postmenopausal vaginal bleeding has a long list of possible causes unrelated to pessaries, including endometrial changes, polyps, and, more rarely, gynecological cancers. If you are using a pessary and notice new or worsening bleeding, your provider should examine you to rule out other causes rather than assuming the pessary is solely responsible. The pessary can sometimes mask other sources of bleeding by physically pressing against the tissue, or it can coexist with an unrelated condition. A thorough evaluation typically includes a visual inspection after pessary removal, and sometimes imaging or biopsy if the bleeding pattern is unusual.

Practical Steps to Reduce Bleeding

If you are using a pessary or about to start, several evidence-backed strategies can minimize your risk of bleeding and erosion:

Topical estrogen: If you are postmenopausal, vaginal estrogen cream or a vaginal estrogen ring is the most strongly supported intervention for preventing tissue erosion. The protective effect is substantial when used consistently for a year or more.³
Regular removal: Whether you manage the pessary yourself or visit a clinic, more frequent removal and reinsertion gives your tissue recovery time and allows early detection of irritation.
Proper sizing: A pessary that is too large puts excessive pressure on the vaginal walls. A pessary that is too small may shift and cause localized friction. Fitting is usually a process of trial and adjustment, not a one-time event.
Choosing the right type: If you are developing erosion with a space-filling pessary and your prolapse can be managed with a support type, switching may help. This is a conversation between you and your provider based on the degree of prolapse and your anatomy.
Moisturizers and lubricants: Water-based vaginal moisturizers used regularly can supplement estrogen therapy or provide some relief for people who cannot use hormones. These do not have the same level of evidence behind them as estrogen for preventing erosion, but they can reduce friction-related discomfort.

These strategies work best in combination. Estrogen alone helps, and regular removal alone helps, but doing both addresses different parts of the problem: estrogen strengthens the tissue, while regular removal reduces cumulative pressure.

Why Some People Bleed and Others Do Not

Individual variation in pessary tolerance is wide. Two people using the same size and type of ring pessary, both postmenopausal, both using estrogen cream, can have very different experiences. One may use the device for years with no issues, while the other develops erosion within months. Part of this comes down to anatomy, including the depth and width of the vaginal canal, the degree of prolapse, and how much the pelvic floor musculature has weakened. Part of it is tissue biology, which is the inherent resilience and vascularity of the vaginal epithelium, which varies between individuals even at similar hormone levels.

Immune status and general health also play a role. Conditions that impair wound healing, such as diabetes, chronic steroid use, or immunosuppression, can make the vaginal tissue less resilient to sustained pressure. Smoking affects blood flow to mucosal tissues and may slow the repair of minor abrasions. These are not well-studied in the specific context of pessary complications, but they are established risk factors for poor mucosal healing in other settings, and clinicians account for them when managing pessary patients.

The practical implication is that if you are experiencing pessary-related bleeding, it does not necessarily mean the pessary is wrong for you. It means something about the current setup needs adjustment, whether that is the type, the size, the removal schedule, or the hormone support. Many people who initially have trouble find a configuration that works after one or two changes.

Pessary Use During Pregnancy

Pessaries are occasionally used during pregnancy, most commonly cervical pessaries placed to reduce the risk of preterm birth in women with a short cervix. These are different devices from the ring or cube pessaries used for prolapse, and they sit around the cervix rather than supporting the vaginal walls. Bleeding with a cervical pessary in pregnancy raises different concerns, because vaginal bleeding in pregnancy can signal complications unrelated to the device. Any bleeding while using a cervical pessary should be reported to your obstetric provider immediately. The causes of pessary-related bleeding discussed in this article apply primarily to vaginal pessaries used for prolapse or incontinence, not to cervical pessaries in pregnancy, where the clinical context is entirely different.

When a Pessary Gets Forgotten

The most severe complications from pessaries happen when devices are left in place and forgotten about, sometimes for years or even decades. This scenario is more common than you might expect, particularly among elderly patients who may have cognitive decline, who may have changed healthcare providers, or who simply stopped attending follow-up appointments. Over time, vaginal tissue can grow over and around the device, essentially incorporating it into the vaginal wall. Removing an embedded pessary can require surgical intervention.

Neglected pessaries are associated with the full spectrum of severe complications: deep ulceration, heavy bleeding, fistula formation between the vagina and adjacent organs, and significant infections.² The good news is that these outcomes are almost entirely preventable with any reasonable level of follow-up. Whether you manage the pessary yourself at home or visit a clinic on a regular schedule, the simple act of periodically removing and inspecting the device is what separates a minor, manageable complication like light spotting from a serious surgical problem. If you are a caregiver for someone who uses a pessary and may not remember their follow-up schedule, keeping track of their appointments is one of the most important things you can do for their comfort and safety.