Abnormal Menstrual Bleeding

A definition of menstruation is the shedding of the lining of the uterus that occurs approximately every four weeks in nonpregnant women. There is a huge variation in normal when it comes to menstrual periods. Cycles are different from person to person and can change from year to year in the same person. Occasionally, there are changes that are not normal and cause concern, discomfort, inconvenience and sometimes embarrassment. There are several ways to manage these problems including medical options (medications), and surgical options, both relatively minor and major.

The amount of menstrual flow varies from individual to individual. Often it is hard to know if one's own experience is within normal limits. It is difficult even for health care providers to assess since one woman may describe her flow as heavy when objectively it is not. There are definitions that use volumes but it is not practical to measure the flow and this data is useful only in a research study setting. The best way to inform your provider of the severity of your flow is to describe the time it takes to soak a pad (side to side and front to back) or a tampon.

Abnormal menstruation occurs when cycles are irregular (too often or too scarce), the time of flow is long, flow is heavy, or when there is bleeding between periods. The normal length of a cycle (i.e. from the first day of bleeding until the first day again) ranges from 24 to 32 days, average 28, but if an occasional cycle is shorter or longer it does not necessarily mean there is an abnormality. If many cycles fall outside of this range, it is advisable to bring this to the attention of your health care provider and it is helpful to bring a calendar of cycles with you. Your provider will take a history, complete a physical examination and may order some blood tests to examine blood counts and hormone levels.

Another form of abnormal menstruation occurs when there is excessive blood flow. Heavy flow or prolonged flow (longer than seven days per cycle) can lead to anemia and can make completion of daily responsibilities difficult or even impossible for a woman. Once again, it is helpful to keep a calendar of dates and to take this to your provider. A history, physical exam, blood tests, and possibly a biopsy or an ultrasound examination will help her or him determine the cause of the heavy or prolonged bleeding.

Some of the options to manage this bleeding (depending on the cause discovered) may include non-steroidal anti-inflammatories (ibuprofen and naproxen, for example). Taking these medications can reduce the volume of flow for some women. Another option that may be considered is oral contraceptives. This is a good choice for women who also need birth control. An intrauterine contraceptive device (a specific type) also provides this benefit along with the management of heavy bleeding.

Surgical options include endometrial ablation and hysterectomy. Endometrial ablation is a technique whereby the lining of the uterus, which gives rise to the periodic bleeding, is destroyed, thus preventing it from regenerating each month. This is accomplished in an outpatient surgical setting or even in some doctors' offices. Hysterectomy is reserved for cases in which there are no other options or the other options have been exhausted with no relief.

Abnormal menstruation occurs on occasion for many women but when the abnormality is severe or persists for more than a cycle or two, it should be brought to the attention of your health care provider. The extent of the investigation and treatment will depend on the information you share with your provider. You may just need reassurance of the normal variation in cycles or there may be a need for some testing and management. There are many individual conditions that could be discovered during the investigations and the recommendations will vary depending on the findings and on the individual.

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