Abnormal Periods:
What’s Happening and What You Must Do About It

Let's first establish what is normal. Remember that we measure a menstrual cycle by counting from the first day of one period to the fist day of the next. A textbook normal menstrual cycle is 28 days. It is normal for cycle length to be as short as 21 days or as long as 35 days, and it may vary a bit every month. The average length of bleeding is 3 – 7 days. This duration is usually constant for a given woman. For example, one woman may always have a 3 – 4 day period, while another always has a 6 – 7 day period.

So what is considered abnormal?
  • A cycle that is shorter than 21 days or longer than 35 days
  • Bleeding between periods – even light bleeding known as spotting
  • Bleeding that is longer or heavier than normal
  • Bleeding after sex
  • Bleeding after menopause

Let’s review what happens in a normal monthly cycle. Day 1 is the first day you bleed. Estrogen and Progesterone (the 2 main female hormones) are both low. Estrogen rises, causing the uterine lining to thicken in preparation for a possible pregnancy. It peaks in the middle of the cycle (about day 14). Progesterone also rises, but more slowly than Estrogen. It functions to stabilize the lining that has been growing. When Estrogen peaks and Progesterone is rising (about day 14) the egg is released from the ovary. We call this ovulation. Ovulation causes the Progesterone level to rise further and peak on day 21. If pregnancy does not occur, both hormone levels will drop. The drop in Progesterone now destabilizes the uterine lining and allows “shedding” to occur, which is a period.

Abnormal bleeding may occur at any age, but it is most common at the beginning and end of the reproductive years. Interestingly, the cause of irregular or abnormal bleeding may be the same in these 2 groups. In young women who are just beginning to menstruate, ovulation doesn’t always occur. It usually takes about 2 years for young women to ovulate regularly. This unpredictable ovulation will affect the rise and fall of Progesterone and therefore the timing of the periods will be “off” or irregular. In women who are approaching menopause the same thing happens, but for different reasons. In these women, the egg supply is decreasing and ovulation doesn’t always occur. Again this affects the rise and fall of Progesterone and causes irregular bleeding. So cycles without ovulation (annovulatory cycles) are the number one cause of irregular bleeding.

Other Causes for Abnormal Uterine Bleeding

Pregnancy or miscarriage is a common cause of abnormal bleeding in women in their reproductive years. Birth control regimens are used to treat irregular bleeding, but they may also cause irregular bleeding in some patients, particularly if a dose is missed. An intrauterine device or IUD sometimes causes irregular or heavy bleeding. Changing birth control methods or removing an IUD is sometimes required. Abnormal thyroid function can also affect menstrual bleeding.

Benign growths in the uterus may also cause irregular or heavy bleeding at any age. These growths are polyps or fibroids. If bleeding is especially heavy or bothersome these growths may need to be removed.

Any bleeding after menopause is abnormal and needs to be investigated – even light spotting. The cause may be hormonal or uterine growths as described above. In some cases the uterine lining has become thickened. This may be due to a precancer or cancer of the uterus.

Anyone over the age of 35 (ACOG recommendation), and certainly anyone after menopause, who has irregular bleeding should have an endometrial biopsy. This is a simple office procedure, which samples are taken cells from the uterine lining. These cells are then viewed in a laboratory to look for abnormal cells. A pelvic ultrasound uses sound waves to produce a picture of what’s inside. It will show growths in the uterus or a thick lining and may be helpful identifying a mass, but abnormal cells or cancer can only be diagnosed with an office biopsy or a surgical procedure.

Treatment of abnormal uterine bleeding depends on the cause, the age of the patient, and her desires for future pregnancy. It falls into 3 categories.
  • Observation. We do nothing. We just watch and wait, because many times it will resolve on its own.
  • Medical management. This is usually hormonal treatment. Progesterone may be added to stabilize the uterine lining and decrease the thickness. Birth control pills are a common and effective treatment option in some patients. Anti-inflammatory medications have been shown to reduce bleeding in some cases.
  • Surgical management. Polyps or fibroids that are causing irregular bleeding often need to be removed. This can usually be accomplished simply by removing the growth. It is sometimes necessary to remove the entire uterus (a hysterectomy). This is only done when other treatments have failed or are not an option.

If you have abnormal bleeding, it is important to see your doctor. Persistent, heavy or prolonged bleeding may result in excessive blood loss or anemia. There are many causes and treatment options. The most common causes are benign, but uterine cancer must always be addressed and ruled out in patients over the age of 35.