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Uterine Bleeding Abnormalities

What is Uterine Bleeding Abnormalities?

Uterine bleeding abnormalities (also called abnormal uterine bleeding, AUB) refer to any deviation from a typical menstrual pattern in terms of frequency, duration, or amount of blood loss. “Typical” is usually defined as a predictable 24‑ to 38‑day cycle with 4–7 days of flow and total blood loss of about 30–80 mL per cycle. When bleeding is heavier, lasts longer, occurs at irregular intervals, or appears between periods, it is considered abnormal.

These irregularities are not a disease themselves; they are a symptom that can stem from hormonal imbalances, structural problems inside the uterus, systemic disorders, or even certain medications. Because the uterus plays a central role in reproduction, abnormal bleeding can affect fertility, quality of life, and, in severe cases, lead to anemia.

Sources: Mayo Clinic; American College of Obstetricians and Gynecologists (ACOG) <sup>1</sup>.

Common Causes

More than a dozen conditions can cause AUB, but the most frequently encountered are:

• Hormonal (Anovulatory) Dysfunction – Often seen in adolescents, perimenopausal women, or those with polycystic ovary syndrome (PCOS); estrogen stimulates the lining without the balancing effect of progesterone, leading to irregular shedding.
• Uterine Fibroids (Leiomyomas) – Benign smooth‑muscle tumors that can distort the uterine cavity and increase surface area of the endometrium.
• Endometrial Polyps – Small, overgrowths of the lining that bleed more easily.
• Adenomyosis – Endometrial tissue grows into the uterine muscle, causing a bulky, tender uterus and heavy bleeding.
• Endometrial Hyperplasia or Cancer – Excessive proliferation of the lining; can present as persistent spotting or heavy flow.
• Coagulation Disorders – Conditions like von von Gleitzen disease, platelet function defects, or use of anticoagulant medication (warfarin, DOACs).
• Thyroid Disorders – Both hypothyroidism and hyperthyroidism can disrupt the hormonal axis governing menstruation.
• Intrauterine Contraceptive Devices (IUDs) – Particularly copper IUDs may increase spotting; hormonal IUDs often cause initial irregular bleeding before stabilizing.
• Pregnancy‑Related Issues – Implantation bleeding, miscarriage, or ectopic pregnancy can mimic abnormal uterine bleeding.
• Medications & Substances – Antifibrinolytics, selective serotonin reuptake inhibitors (SSRIs), herbal supplements (e.g., ginger, ginkgo), and heavy alcohol use can influence clotting and hormone levels.

Sources: ACOG Practice Bulletin No. 141; National Institutes of Health (NIH) <sup>2</sup>.

Associated Symptoms

Depending on the underlying cause, abnormal uterine bleeding may be accompanied by:

• Pain or cramping (dysmenorrhea)
• Pelvic pressure or a feeling of fullness
• Spotting or bleeding between periods
• Unexplained weight gain or loss
• Breast tenderness
• Fatigue, shortness of breath, or dizziness (signs of anemia)
• Change in bowel or bladder habits (especially with large fibroids)
• Infertility or difficulty conceiving

Sources: Cleveland Clinic; WHO <sup>3</sup>.

When to See a Doctor

While occasional irregularities are common, you should schedule a medical evaluation if you notice any of the following:

• Bleeding that lasts longer than 7 days or is heavier than usual (soaking through one or more pads or tampons per hour).
• Bleeding after intercourse, between periods, or after menopause.
• Accompanying symptoms of anemia (persistent fatigue, pale skin, shortness of breath).
• Fever, chills, or foul‑smelling vaginal discharge (possible infection).
• Sudden, heavy bleeding that soaks a pad or tampon in under 2 minutes.
• Known risk factors: family history of uterine cancer, known clotting disorder, or use of anticoagulants.

Early evaluation helps identify treatable causes, prevents complications, and preserves reproductive health.

Diagnosis

Physicians use a stepwise approach that combines history, physical exam, and targeted testing.

1. Detailed Medical History

• Menstrual pattern (cycle length, flow, duration)
• Onset and progression of abnormal bleeding
• Medication and supplement use
• Family history of bleeding disorders, uterine fibroids, or cancer
• Reproductive history (pregnancies, miscarriages, contraception)

2. Physical & Pelvic Examination

• Abdominal and bimanual exam to assess uterine size, shape, and tenderness.
• Speculum exam to view the cervix and rule out cervical pathology.

3. Laboratory Tests

• Complete blood count (CBC) – evaluates anemia.
• Thyroid‑stimulating hormone (TSH) – screens for thyroid dysfunction.
• Coagulation profile (PT/INR, aPTT) and, if indicated, von Willebrand factor level.
• Pap smear & HPV testing – if cervical pathology is a concern.

4. Imaging

• Transvaginal ultrasound – first‑line to identify fibroids, polyps, adenomyosis, or thickened endometrium.
• Sonohysterography (saline infusion) – provides clearer view of the endometrial cavity.
• MRI – reserved for complex cases (e.g., extensive adenomyosis).

5. Endometrial Sampling

If the endometrial lining is >4 mm in a woman >35 years (or >45 years regardless of thickness), a biopsy (office pipelle or hysteroscopic directed) is performed to rule out hyperplasia or carcinoma.

6. Hysteroscopy (Diagnostic)

Direct visualization of the uterine cavity using a thin camera; enables targeted removal of polyps or submucosal fibroids during the same procedure.

Sources: ACOG Practice Bulletin No. 141; NIH Guidelines <sup>4</sup>.

Treatment Options

Treatment is individualized based on cause, severity, desire for fertility, age, and overall health. Options range from lifestyle modifications to surgical interventions.

1. Medical Management

• Tranexamic Acid – An antifibrinolytic taken during heavy days; reduces blood loss by 30‑50% (e.g., 1 g 3‑4 times daily) [5].
• Non‑steroidal anti‑inflammatory drugs (NSAIDs) – Ibuprofen or naproxen can lessen menstrual flow and relieve cramping.
• Combined Oral Contraceptives (COCs) – Regulate hormone cycles, reduce endometrial thickness, and often stop heavy bleeding.
• Progestin‑only therapies – Oral medroxyprogesterone acetate, levonorgestrel‑releasing intrauterine system (LNG‑IUS), or injectable depot medroxyprogesterone; especially useful for anovulatory cycles.
• Gonadotropin‑releasing hormone (GnRH) agonists/antagonists – Temporarily induce a hypo‑estrogenic state, shrinking fibroids and reducing flow; limited to short‑term use due to bone loss risk.
• Selective Progesterone Receptor Modulators (SPRMs) – Ulipristal acetate (approved in many countries) can control bleeding and reduce fibroid size.
• Iron supplementation – Oral ferrous sulfate or IV iron for anemia correction, guided by CBC.

2. Minimally Invasive Procedures

• Endometrial Ablation – Destruction of the uterine lining (thermal, radiofrequency, or cryo); effective for women who have completed childbearing.
• Hysteroscopic Polypectomy or Myomectomy – Removal of polyps or submucosal fibroids through the cervix.
• LNG‑IUS insertion – Releases levonorgestrel locally, often reducing bleeding by 80% within 6 months.

3. Surgical Options

• Myomectomy – Removal of fibroids while preserving the uterus; approaches include hysteroscopic, laparoscopic, or open abdominal.
• Hysterectomy – Definitive treatment that removes the uterus; considered when other therapies fail and the patient does not desire future fertility.

4. Home & Lifestyle Strategies

• Maintain a healthy weight – excess adipose tissue converts androstenedione to estrogen, potentially worsening AUB.
• Manage stress – chronic stress can disrupt the hypothalamic‑pituitary‑ovarian axis.
• Regular aerobic exercise – improves circulation and may reduce menstrual pain.
• Track cycles with a smartphone or paper diary to provide precise information to your provider.

Sources: Mayo Clinic; WHO; Cleveland Clinic <sup>5,6</sup>.

Prevention Tips

While not all causes are preventable, certain measures can reduce the risk or severity of abnormal uterine bleeding:

• Schedule regular well‑woman exams, including Pap smears and pelvic ultrasounds as recommended.
• Control chronic conditions such as thyroid disease, diabetes, and hypertension.
• Use hormonal contraception consistently if you have known anovulatory cycles.
• Avoid smoking and limit alcohol, both of which can affect liver metabolism of hormones.
• Discuss any family history of bleeding disorders with your physician before starting anticoagulant therapy.
• Stay active and maintain a BMI within the normal range (18.5–24.9 kg/m²).
• If you use an IUD, attend follow‑up visits to ensure proper placement and address early spotting.

Emergency Warning Signs

If you experience any of the following, seek immediate medical attention (call 911 or go to the nearest emergency department):

• Sudden, profuse bleeding that soaks a pad or tampon in less than 2 minutes.
• Bleeding accompanied by severe weakness, fainting, or a rapid heartbeat (possible severe anemia or hemorrhagic shock).
• Heavy bleeding with a fever > 38°C (100.4°F) or foul‑smelling discharge – may indicate a severe infection such as septic pelvic inflammatory disease.
• Rapidly enlarging pelvic mass that causes pain or pressure, suggesting torsion or necrosis of a fibroid.
• Pregnancy‑related bleeding accompanied by abdominal pain or shoulder pain, which could signal ectopic pregnancy or miscarriage complications.

Prompt evaluation can be lifesaving and prevent long‑term complications.

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References:

1. American College of Obstetricians and Gynecologists. Practice Bulletin No. 141: Abnormal Uterine Bleeding in Reproductive-Aged Women. Obstet Gynecol. 2014.
2. National Institutes of Health. Uterine Fibroids: Diagnosis and Management. 2022.
3. World Health Organization. Menstrual Health and Hygiene. 2021.
4. U.S. Preventive Services Task Force. Screening for Abnormal Uterine Bleeding. 2020.
5. Mayo Clinic. Tranexamic acid for heavy menstrual bleeding. 2023.
6. Cleveland Clinic. Abnormal Uterine Bleeding. Patient Education; updated 2024.

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