Abnormal Uterine Bleeding

What is abnormal uterine bleeding (menometrorrhagia)?

Abnormal uterine bleeding (formerly called menometrorrhagia) is when you bleed between your monthly periods or when your periods are extremely heavy and/or prolonged. Normal menstrual flow typically lasts about five days and occurs every 21 to 35 days.

Your provider should know about any abnormal bleeding you’re experiencing. What’s causing your bleeding may be harmless. But your bleeding may be a sign of cancer or conditions that may negatively impact your fertility.

What is the difference between menorrhagia and menometrorrhagia?

Menometrorrhagia was once an umbrella term for two different conditions that sound nearly the same:

• Menorrhagia: excessive and/or prolonged menstruation.
• Metrorrhagia: excessive, prolonged and/or irregular bleeding unrelated to menstruation.

In 2011, the International Federation of Gynecology and Obstetrics (FIGO) changed the names to prevent confusion. Menorrhagia is now called heavy menstrual bleeding. Menometrorrhagia is now called abnormal uterine bleeding.

Who does it affect?

The term “abnormal uterine bleeding” primarily describes bleeding in non-pregnant people in their reproductive years. But this doesn’t mean that irregular bleeding won’t affect you if you’re post-menopausal or pregnant.

If you’re bleeding and have experienced menopause, contact your provider. Bleeding after menopause is never normal. Blood may be red, pink, brown or even rust-like in appearance.

You should also contact your provider if you’re bleeding during pregnancy. Some causes are harmless, but others require medical attention, especially if the bleeding happens late in your pregnancy.

How common is abnormal uterine bleeding?

Not everyone who experiences abnormal uterine bleeding reports their symptoms. As a result, 10% to 35% of women worldwide may have abnormal uterine bleeding. But the numbers may be higher. It’s most common during menarche (when menstruation begins) and perimenopause (the years leading up to menopause).

Hormone imbalances are often to blame for abnormal uterine bleeding. They’re most common among people whose periods are just beginning or near ending.

What are the signs and symptoms of abnormal uterine bleeding?

The signs of abnormal uterine bleeding can vary. Some signs that your bleeding may be abnormal include:

• Heavy menstrual bleeding (formerly called menorrhagia).
• Bleeding at unusual times (between periods, after intercourse).
• Unusually long periods (seven days or longer).
• Inconsistent menstrual cycles.

What causes abnormal uterine bleeding?

Abnormal uterine bleeding can have many causes, including a variety of medical conditions and even stress:

Hormone imbalances

• Anovulation.
• Thyroid disease.
• Polycystic ovary syndrome (PCOS).

Weighing more than your ideal body weight can lead to hormone imbalances that may cause abnormal uterine bleeding, too.

Structural abnormalities in your uterus

• Polyps.
• Fibroids.
• Adenomyosis.

Precancer and cancer

• Uterine cancer.
• Cervical cancer.
• Vaginal cancer.
• Ovarian cancer.
• Endometrial hyperplasia.

Infections

• Trichomoniasis.
• Cervicitis.
• Chlamydia.
• Gonorrhea.
• Endometritis.
• Vaginitis.

Other medical conditions

• Von Willebrand disease.
• Liver disease.
• Kidney disease.
• Pelvic inflammatory disease (PID).
• Leukemia or platelet disorders.

Medications

• Blood thinners and aspirin.
• Hormone replacement therapy.
• Tamoxifen (breast cancer drug).
• Intrauterine devices (IUDs).
• Birth control pills and injectables (NuvaRing®, Depo-Provera®, Implanon®).

Retained foreign bodies and trauma

Forgetting to remove an IUD can lead to infection and abnormal bleeding. Trauma to your uterus, caused by an injury, can also cause bleeding.

How is abnormal uterine bleeding diagnosed?

Your healthcare provider will ask you several questions when working to diagnose abnormal uterine bleeding. These questions may include:

• What brings on the bleeding?
• What other symptoms are you experiencing?
• Are you pregnant?

Your healthcare provider will then do a physical exam, including:

• A pelvic exam.
• A cervical exam.
• A Pap smear (Pap test).

What tests will be done to diagnose this condition?

Your healthcare provider may order several tests or procedures when diagnosing abnormal uterine bleeding. These tests may include:

• A pregnancy test. A miscarriage causes heavy bleeding. You can test positive on a pregnancy test up to 35 days after a miscarriage. Light bleeding is also common in the early stages of pregnancy.
• Blood tests. Your provider can check how your blood clots and do a complete blood count.
• A thyroid test. Problems with your thyroid function may be a sign that there is also a problem with your ovary function that could be causing your bleeding.
• Hormone levels test. Hormone imbalances may be causing your abnormal bleeding, or they may be a sign of a condition causing your bleeding.
• A hysteroscopic exam of your uterus lining (endometrium). This test checks for fibroids, polyps or signs of cancer.
• A pelvic ultrasound. Imaging allows your provider to check for any growths in your reproductive organs that may be causing your bleeding. A sonohysterogram, also called saline-infusion sonography, is a highly sensitive imaging procedure that can help your provider identify abnormal structures in your uterus, like polpys or fibroids.
• A biopsy of your endometrium. Your provider can collect tissue samples from your uterus lining and check for signs of cancer or pre-cancer cells.

How is abnormal uterine bleeding treated?

Your treatment depends on what’s causing your bleeding. Medications and surgical options are available to manage your bleeding or treat what’s causing it.

Medications

Medications used to treat abnormal uterine bleeding include:

• Birth control pills.
• Progestin (can be given by a shot, implant or device placed in your uterus called an IUD).
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil®, Motrin®).
• Gonadotropin-releasing hormone (GnRH) agonists can temporarily stop or reduce bleeding by preventing ovulation.
• Gonadotropin-releasing hormone (GnRH) antagonists (elagolix®) can manage heavy period bleeding related to fibroids.

Surgery

There are several procedures available to treat abnormal uterine bleeding. Ask your provider about how often they perform a given procedure. Seeing a provider who frequently performs a procedure often leads to faster recovery with fewer complications.

• Hysteroscopy. A procedure where your provider removes atypical structures in your uterus, like fibroids and polyps.
• Uterine artery embolization. Stops blood flow to fibroids, causing them to shrink.
• Myomectomy. Removes fibroids while keeping your uterus intact and preserving your ability to get pregnant and have children.
• Endometrial ablation. Destroys your uterus lining through the use of a laser, heat, electricity, microwave energy or freezing. You shouldn't have this procedure if you want to get pregnant and have children.
• Hysterectomy. Removes your uterus. Hysterectomy is often used to treat cancer or cancerous changes in your endometrium. Advanced stages of cancer may need radiation or chemotherapy.

How can I reduce my risk?

You can’t prevent many causes of abnormal uterine bleeding. But you can reduce your risk of certain conditions that lead to abnormal bleeding. For instance, maintaining a healthy weight plays a potential role in keeping your hormones balanced. Avoiding diets that contain a high amount of animal fat can reduce your risk of some cancers. Practicing safer sex can reduce your risk of certain sexually transmitted infections (STIs) that can cause abnormal uterine bleeding.

What can I expect if I have this condition?

Your process for diagnosis and your options for treatment depend on what’s causing your bleeding. When making a diagnosis, your provider will consider multiple factors, including your age, symptoms, and risk factors for certain conditions that cause abnormal bleeding.

Your provider can individualize your care path – including diagnostic options and treatment — based on your physical exam and medical history.

When should I see my healthcare provider?

Schedule an appointment with your provider if you’re noticing abnormal uterine bleeding so that they can address the underlying cause.

Symptoms to watch out for include:

• Passing blood clots that are the size of a quarter or larger.
• Changing menstrual products less than every two hours.
• Bleeding in between periods or for longer than a week.
• Symptoms of anemia, like feeling fatigued, weak, or short of breath.
• Symptoms of pica, which include hair loss, pale skin and the urge to eat non-food items (paper, hair, dirt, etc.)

If abnormal bleeding interferes with your quality of life, see your provider. You shouldn’t have to double up on menstrual products to manage your blood flow. You shouldn’t have to skip activities you enjoy or avoid going out in public because of heavy or unpredictable bleeding.

What questions should I ask my provider?

• Do I have heavy menstrual bleeding?
• Does my blood loss put me at risk for developing other health conditions?
• Am I bleeding so much that I’m at risk of developing anemia?
• What are the pros and cons of the treatment options available to me?
• What are the best treatment options available if I wish to get pregnant in the future?
• Will you administer my treatment alone, or will it involve a care team?
• What surgical experience do you have in treating abnormal uterine bleeding? Is this a routine part of your practice?

A note from Cleveland Clinic

You’re the best judge of what's normal for you — how long your periods usually last and how heavy your bleeding is. If your periods are especially heavy or lasting longer than usual, or if you’re bleeding outside your menstrual cycle, speak to your provider. You should never suffer in silence or be embarrassed. Many non-invasive treatment options are available to you that can provide relief from your bleeding.