Ovulatory bleeding is followed by menstrual flow. Ovulatory bleeding is caused by a transient drop in estrogen levels that accompanies ovulation, which manifests as a localized exfoliation of the endometrium. Ovulatory bleeding is a diagnosis of exclusion, and organic lesions, including cervical lesions, endometrial lesions and hormonal changes due to ovarian factors, must be excluded before ovulatory bleeding can be considered. After the appearance of midmenstrual bleeding, the first step is to perform a gynecological examination to determine the site of the bleeding and to determine whether it is bleeding from the cervix or from within the cervical canal. Diagnostic scraping is required to rule out endometrial lesions if necessary, and ultrasonography is also necessary. Ovulatory bleeding does not interfere with normal menstruation afterwards. Vaginal bleeding occurs when there is ovulation.