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Uterine Bleeding (Abnormal)

What is Uterine Bleeding (Abnormal)?

Abnormal uterine bleeding (AUB) refers to any change in the amount, frequency, or duration of menstrual bleeding that falls outside of the normal pattern for a woman’s age and reproductive status. It can be heavier, lighter, longer, shorter, or occur at unexpected times (e.g., between periods or after intercourse). While occasional variations are common, persistent AUB may signal an underlying health problem that requires evaluation.

The term “uterine bleeding” emphasizes that the source of the bleeding is the uterus, but some causes originate outside the uterus (e.g., hormonal imbalances, systemic disease). The condition is a frequent reason for gynecologic visits, affecting up to 30% of women of reproductive age at some point in their lives. [Mayo Clinic]

Common Causes

The reasons for AUB are diverse and can be grouped using the PALM‑COE mnemonic, which separates structural (PALM) from non‑structural (COE) causes.

• Polyp – Endometrial polyps are benign overgrowths that can cause spotting or heavy bleeding.
• Adenomyosis – Endometrial tissue grows into the uterine muscle, leading to painful, prolonged bleeding.
• Leiomyoma (Fibroids) – Benign muscle tumors often cause heavy or prolonged periods.
• Malignancy & hyperplasia – Endometrial cancer or precancerous hyperplasia can present with irregular bleeding.
• Coagulopathy – Blood‑clotting disorders (e.g., von Willebrand disease, platelet dysfunction) increase bleeding volume.
• Ovulatory dysfunction – Anovulation (often seen in PCOS, thyroid disease, or perimenopause) leads to irregular, sometimes heavy bleeding.
• Endometrial “disorder” – Primary endometrial insufficiency, where the lining does not respond appropriately to hormones.
• Medication‑induced – Hormonal contraceptives, intrauterine devices (IUDs), anticoagulants, and some herbal supplements can alter bleeding patterns.
• Pregnancy‑related – Implantation bleeding, miscarriage, ectopic pregnancy, or placental abnormalities.
• Infection / Inflammation – Pelvic inflammatory disease (PID) or uterine infections may cause spotting or bleeding.

Associated Symptoms

Abnormal uterine bleeding often occurs with other signs that can help pinpoint the cause:

• Pain or cramping (dysmenorrhea)
• Pelvic pressure or a feeling of fullness
• Clots larger than a quarter
• Spotting after intercourse
• Changes in menstrual cycle length (shortened or lengthened)
• Fatigue, shortness of breath, or dizziness (signs of anemia)
• Unexplained weight gain or loss
• Hot flashes or night sweats (possible hormonal cause)
• Skin changes, easy bruising, or prolonged bleeding from cuts (suggestive of clotting disorder)

When to See a Doctor

While occasional irregularities can be normal, you should contact a health‑care professional promptly if you notice any of the following:

• Bleeding that lasts longer than 7 days (or >8 weeks if you’re post‑menopausal)
• Very heavy flow that soaks through a pad or tampon every hour for several hours
• Passage of large clots (larger than a golf ball)
• Bleeding between periods, after intercourse, or after a negative pregnancy test
• Signs of anemia: fatigue, paleness, rapid heart beat, shortness of breath
• Pelvic pain that is new, worsening, or accompanied by fever
• History of uterine fibroids, polyps, or endometrial hyperplasia
• Any bleeding after menopause (any amount after age 45‑55)

Diagnosis

Evaluation of AUB is systematic, combining a detailed history, physical exam, and targeted investigations.

1. Medical History & Physical Exam

• Menstrual pattern, age of onset, and changes over time
• Medication list (including over‑the‑counter and herbal products)
• Sexual activity, contraception use, and pregnancy status
• Family history of bleeding disorders, fibroids, or cancer
• Pelvic exam to assess uterine size, tenderness, and any visible lesions

2. Laboratory Tests

• Complete blood count (CBC) – looks for anemia
• Thyroid‑stimulating hormone (TSH) – screens for thyroid disease
• Prolactin level – evaluates pituitary involvement
• Coagulation profile (PT/INR, aPTT) and von Willebrand factor if a bleeding disorder is suspected
• Pregnancy test (urine or serum β‑hCG) – essential for any reproductive‑age woman

3. Imaging & Direct Visualization

• Transvaginal ultrasound – first‑line imaging to detect fibroids, polyps, adenomyosis, and endometrial thickness.
• Sonohysterography – saline‑infused ultrasound that improves detection of intracavitary lesions.
• Hysteroscopy – direct view of the uterine cavity; allows biopsy or removal of polyps/fibroids.
• MRI – reserved for complex cases (e.g., extensive adenomyosis).
• Endometrial biopsy – performed when endometrial thickness is >4 mm in women over 45 or when cancer risk factors exist.

4. Additional Assessments

• Hormone panels (estradiol, progesterone) if ovulatory dysfunction is suspected.
• Referral to a hematologist for recurrent unexplained bleeding.

Treatment Options

Treatment is individualized based on the underlying cause, severity of bleeding, desire for fertility, and patient preferences.

Medical Management

• Hormonal therapies
  • Combined oral contraceptives (COCs) – regulate cycle and reduce flow.
  • Progestin‑only pills, injectable medroxyprogesterone, or levonorgestrel‑releasing intrauterine system (LNG‑IUS) – especially effective for anovulatory bleeding.
  • Cyclical oral progesterone (e.g., micronized progesterone) for perimenopausal women.
• Tranexamic acid – an antifibrinolytic taken during days of heavy flow (usually 1‑2 g three times daily). Reduces blood loss by up to 50 % in many studies. [CDC]
• Non‑steroidal anti‑inflammatory drugs (NSAIDs) – ibuprofen or naproxen can lessen menstrual bleeding and relieve cramping.
• Gonadotropin‑releasing hormone (GnRH) agonists/antagonists – temporarily shrink fibroids or suppress the endometrium; used short‑term due to side‑effects.
• Selective progesterone receptor modulators (SPRMs) – e.g., ulipristal acetate for fibroids (available in some countries).
• Iron supplementation – oral ferrous sulfate or IV iron for anemia, guided by CBC and ferritin levels.

Surgical & Procedural Options

• Polypectomy – hysteroscopic removal of polyps, often curative.
• Myomectomy – surgical excision of fibroids, preserving the uterus for future pregnancy.
• Endometrial ablation – destroys the uterine lining to control bleeding; suitable for women who do not desire future fertility.
• Uterine artery embolization (UAE) – interventional radiology technique that shrinks fibroids by cutting off blood supply.
• Hysterectomy – definitive treatment for refractory bleeding, especially when cancer or severe adenomyosis is present.

Home & Lifestyle Measures

• Track bleeding with a calendar or app to provide accurate information to your provider.
• Maintain adequate iron intake (red meat, legumes, fortified cereals) and vitamin C to improve absorption.
• Stay hydrated and avoid excessive alcohol or caffeine, which can worsen uterine cramps.
• Use high‑absorbency pads or tampons; change them frequently to reduce infection risk.

Prevention Tips

While many causes of AUB cannot be completely prevented, certain measures can lower risk or lessen severity:

• Keep a healthy weight – obesity is linked to hormonal imbalance and increased fibroid risk.
• Manage chronic conditions (diabetes, thyroid disease, hypertension) with regular medical follow‑up.
• Quit smoking – improves circulation to uterine tissue and reduces fibroid growth.
• Use hormonal contraception consistently if it has been effective for you.
• Screen for anemia annually if you have a history of heavy periods.
• Schedule routine gynecologic exams (including pelvic ultrasound when indicated) to catch polyps, fibroids, or hyperplasia early.

Emergency Warning Signs

Bottom Line

Abnormal uterine bleeding is a common but potentially serious symptom that warrants prompt evaluation, especially when heavy, prolonged, or accompanied by systemic signs such as fatigue or pain. A systematic approach—history, labs, imaging, and occasionally tissue sampling—helps identify the underlying cause, guiding treatment ranging from simple hormonal therapy to minimally invasive surgery or, in rare cases, hysterectomy. Early recognition and appropriate management can prevent complications like anemia, reduce the need for invasive procedures, and preserve reproductive health.

For personalized advice, talk with your primary care physician or a gynecologist. If you notice any of the emergency warning signs listed above, do not wait—seek care right away.

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