Fadi Yahya, M.D.
Obstetrics & Gynecology (OB-GYN)
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Menstrual cycle irregularities are common among women. The causes of abnormal bleeding depend on the age of the woman. For example, cancers are more common among postmenopausal women, while pregnancy-related bleeding is more common among reproductive-age women.
In this article, we’ll review the causes of abnormal bleeding among reproductive-age women (15-49 years). There are three common bleeding patterns, and each pattern is associated with a number of causes. It’s always a priority to exclude pregnancy before considering other causes.
The three most common bleeding patterns are as follows:
Heavy menstrual bleeding (HMB) is when the cycles are regular but the bleeding is heavy or prolonged. The bleeding is considered heavy when there is a need to change a pad or tampon every one to two or hours because it’s completely soaked or there’s passage of large clots. On the other hand, the bleeding is considered prolonged if it lasts more than eight days.
The most common causes of HMB are:
- Fibroids. A fibroid is an abnormal growth of the muscles of the uterus. Approximately 80 percent of women will have fibroids during their lifetime, although not all of these women have bothersome fibroid symptoms.
- Adenomyosis. This happens when the cells that normally line the inner walls of the uterus start invading the muscles of the uterus. This condition often causes heavy and painful periods.
- Bleeding disorder. This is condition that affects the way the blood normally clots. A bleeding disorder is likely if heavy or prolonged menses began at menarche (first menstruation), if there is family history of bleeding issues, if there are signs of a bleeding problem — such as easy bruising — or if taking medications that can prevent normal clotting.
Intermenstrual bleeding (IMB) refers to vaginal bleeding at any time during the menstrual cycle other than during normal menstruation.
The most common causes of IMB include:
- Polyps. A polyp is an overgrowth of cells around a small blood vessel and can arise inside the uterus or on the cervix.
- Contraceptive methods. Many of the contraceptive methods used can cause intermenstrual and irregular bleeding, especially in the first few months after starting the method.
- Cancer or pre-cancer. A cancer or pre-cancer growth on the uterus or cervix can cause intermenstrual bleeding. This is more likely if a woman had previous abnormal pap smears or if there are other risk factors, such as obesity, family history of uterine cancer or bleeding that has been going on for a long time without evaluation.
- Pelvic infections. Intermenstrual bleeding can be a sign of an infection in the uterus or on the cervix. Women who have infection usually experience pelvic pain or increased vaginal discharge in addition to the bleeding. Pelvic infections are more common in women who are exposed to sexually transmitted infections or in women who recently had a child or a surgery on their uterus or cervix.
- Cesarean scar defect. Two-thirds of women who have had one or, in particular, multiple cesarean births may have a cesarean scar defect. Approximately one-third of women with this condition experience bleeding that starts just after the end of their regular menstruation.
Irregular bleeding is when a woman goes through phases of no bleeding that may last for two or more months and other phases with either spotting or episodes of heavy bleeding. Irregular bleeding is most commonly related to abnormal ovulation or what’s more commonly known as polycystic ovarian syndrome.
All women with menstrual irregularities should have an evaluation to uncover the cause of their problem. The evaluation is usually based on a physical and pelvic exam, as well as other tests that could include a urine pregnancy test, an ultrasound, a biopsy called endometrial biopsy and a pap smear. Once the cause of the bleeding is determined, then a treatment plan could be developed to manage the problematic bleeding pattern.
For those women who are experiencing menstrual cycle irregularities, there is help available so you don’t have to suffer through another painful period.Fadi Yahya, M.D., is an obstetrician and gynecologist at Mayo Clinic Health System in Albert Lea.