During the menstrual cycle, two hormones, estrogen and progesterone, are made by the ovaries. Each month, these hormones cause the endometrium (lining of the womb) to grow in preparation for a possible pregnancy.
About 12–14 days before the start of the period, an egg is released from one of the ovaries. This is called ovulation. The egg then moves into one of the fallopian tubes. There it can be fertilized by a sperm. If it is not, pregnancy does not occur. The levels of hormones decrease. This decrease is a signal for the uterus to shed its lining. This shedding is the menstrual period.
The cycle begins with the first day of bleeding of one period and ends with the first day of the next. In most women, this cycle lasts about 28 days. Cycles that are shorter or longer by up to 7 days are normal. For most women, the period lasts for 4-7 days.
What is a normal
Bleeding in any of the following situations is abnormal:
Bleeding between periods
Bleeding after sex
Spotting anytime in the menstrual cycle
Bleeding heavier or for more days than normal
Any bleeding after menopause
What is considered
The average cycle length is about 28 days. Menstrual cycles that are longer than 35 days or shorter than 21 days are abnormal. The lack of periods for 3-6 months (amenorrhea) is not normal. Either of these patterns should be evaluated by your doctor. Abnormal bleeding may occur at any age.
At certain times in a woman’s life it is common for periods to be somewhat irregular. They may not occur on schedule in the first few years after a girl has her first period (around 9-16 years of age). Typically, it takes about 2 years for the period to normalize. On the other end, cycle length may get shorter starting at age 35. It will get shorter as a woman approaches menopause (the average age is 51). During these transitional years, it is common for a woman to skips periods or for bleeding to get lighter or slightly heavier.
Abnormal bleeding can have many causes. Your provider will start by checking for problems most common in your age group. Some are not serious and are easy to treat. Others may be more serious but all should be evaluated. For some women, it may be as simple as too much or not enough of a certain hormone leading to abnormal or heavy bleeding. The imbalance may also be caused by other medical conditions such as thyroid or clotting disorders or by some unrelated medications.
Pregnancy, miscarriage or an abnormal pregnancy
Problems linked to birth control methods such as an IUD or OCP
Infection of the uterus or cervix
Fibroids or endometrial polyps
Problems with blood clotting
Chronic medical conditions such as thyroid disorders, diabetes
Certain cancers particularly cancers of the uterus, cervix or vagina
what are potential causes of
how is the cause diagnosed?
To find the cause of your bleeding, your provider will ask about your personal and family health history. You may be asked about the following issues:
your medical history (past and present illnesses)
use of medications
use of birth control
weight, eating and exercise habits
level of stress
your menstrual cycle
blood work may be ordered to rule out pregnancy, test for anemia, evaluate relevant hormones, and possibly check for clotting disorders
sound waves (via a probe) are used to create a picture of the pelvic organs. This can be done with a transabdominal probe (on your belly) or a transvaginal probe (placed through the vagina). A transvaginal probe gets closer to the pelvic organs and is the preferred approach for gynecology or early pregnancy.
sterile saline (salt water) is placed in the uterus through a thin tube a small catheter (straw-like tube) to move the walls of the uterus apart. Ultrasound images are then made of the uterus to evaluate the inside of the cavity for submucosal fibroids or endometrial polyps.
dye is injected into the uterus and fallopian tubes as an X-ray is taken. This test evaluates both the inside of the uterus for the presence of endometrial polyps or fibroids and also checks if the fallopian tubes are open. This test is more commonly performed as part of a fertility work-up.
using a small catheter (or straw-like tube), a tissue sample is taken from the uterine cavity and looked at by pathologist under a microscope. This test will test for any cancerous or precancerous changes of the uterus. It will not identify endometrial polyps or fibroids.
a catheter is attached to what looks like an iPhone. Sterile Salt water is instilled into the uterus pushing the walls apart for a direct viusal inspection of the inside of the uterus. If there is a polyp or fibroid present an option would be to have an operative hysteroscopy under anesthesia to remove it, otherwise there would be no need to undergo an operative procedure.
dilation & curettage
a procedure performed in an outpatient setting. The opening of the cervix is enlarged and the entire contents of the uterine lining is gently scraped. It is then examined under a microscope by a pathologist. The endometrial biopsy is an office version of uterine sampling that is a representative sample of the cavity. Typically, when a D&C is done for abnormal bleeding, a hysteroscopy is done at the same time.
a thin stick-like device with a camera is inserted though the vagina into the uterus for a direct visual inspection of the uterine cavity. Endometrial polyps or fibroids may be identified with this visual procedure. If there is a polyp or fibroid present an option would be to have an operative hysteroscopy under anesthesia to remove it, otherwise there would be no need to undergo an operative procedure.
this procedure is performed in an operating room under general anesthesia. A thin device (like a telescope) is inserted through a small cut just below or through the belly button. Your doctor can then view the inside of the abdomen. Diagnostic laparoscopy is simply looking at all the organs in the pelvis (as well as the upper abdomen). When procedures such as biopsies or removal of ovarian cysts and even the uterus (hysterectomy), this is referred to operative laparoscopy.
Once a diagnosis is made then treatment options can be discussed. The two most important causes of abnormal bleeding are due to pregnancy or cancer. These need to be ruled out and treated accordingly. Treatment for other causes depend on many factors including the cause of bleeding, your age, your desire for future child bearing, to name a few. Treatment falls into 3 general categories: observation, medical treatments and procedural or surgical options.
As long as pregnancy-related bleeding and cancer have been ruled out, you might choose to simply monitor your symptoms. During this time continue to keep a Menstrual Diary.
This is also a good opportunity to track the food you are eating. Processed sugary foods will increase insulin and play havoc on the female hormones leading to bleeding irregularities. Adopt a whole foods plant rich diet. Also sleep can affect our hormones. Try to get 7-8 hours of restorative sleep a night. Incorporate exercise into your regimen but do not over exercise as that may increase your stress hormones. Excess stress can also cause bleeding irregularities. Try some meditative breathing practices.
These are known to decrease prostaglandins (the hormone released by the uterus during our periods causing both pain as well a bleeding). Motrin, Advil, Aleve. Aspirin not as helpful nor is acetaminophen (Tylenol). Of note, Omega-3 fatty acids found in oily fish, flax and chia seeds also have anti-prostaglandin action. If taking as a supplement, take 3,000 mg daily and fish-based supplements are more effective
Birth control pills, hormonal IUDs or depo-provera injection are known to reduce period flow when simply used for contraception. Since they are contraceptives, they should have no cost under the Affordable Care Act regardless of their intended use.
tranexamic acid (Lysteda)
(Lysteda). This drug prevents enzymes in the body from breaking down blood clots and is used to treat heavy menstrual bleeding. Unlike contraception, this is only taken with heavy bleeding (up to 5 days each cycle).
This was released over a year ago as an oral treatment for endometriosis. Recent studies have looked at its effectiveness in treating bleeding from fibroids.