Abnormal Uterine Bleeding and Irregular Periods: Causes and Treatment
Intermenstrual bleeding, heavy periods and irregular cycles: the limits of a normal period, PALM-COEIN causes, investigations, and medical and hysteroscopic treatment.
Op. Dr. Sadık Kükrer, MD
Obstetrician & Gynecologist · Adana, Türkiye
Abnormal uterine bleeding describes bleeding whose frequency, duration, regularity or volume falls outside normal limits, or that occurs between periods. Around one in three women of reproductive age experiences it at some point. Most causes are benign and treatable, but accurate diagnosis requires a systematic assessment.
The limits of a normal period
- Cycle length: 24–38 days
- Duration of bleeding: fewer than eight days
- Cycle-to-cycle variation: generally less than seven to nine days
- Volume: not interfering with daily life or work
Causes: the PALM-COEIN classification
The International Federation of Gynecology and Obstetrics (FIGO) divides causes into two groups:
- Structural (PALM): endometrial polyp, adenomyosis, fibroids, and malignancy or hyperplasia.
- Non-structural (COEIN): coagulopathy, ovulatory dysfunction (PCOS, thyroid disease, raised prolactin, marked weight change, stress), endometrial causes, iatrogenic causes such as medication or an intrauterine device, and those not yet classified.
Common causes by age
- Adolescence: immaturity of the ovulatory axis, bleeding disorders.
- Reproductive years: pregnancy and its complications, polyps, fibroids, PCOS, hormonal medication.
- Menopausal transition: irregular ovulation, polyps, fibroids, endometrial hyperplasia.
- After the menopause: atrophy and polyps; endometrial cancer must always be excluded.
Investigations
Assessment begins with a pregnancy test. A detailed history and examination are followed by transvaginal ultrasound, a full blood count and ferritin, with thyroid, prolactin and clotting tests as required. Endometrial biopsy is advised for women over 45, those with risk factors such as obesity or PCOS, and those who do not respond to treatment. When a polyp or submucous fibroid is suspected, hysteroscopy provides both diagnosis and treatment.
Treatment options
- Non-hormonal medication: tranexamic acid and non-steroidal anti-inflammatory drugs reduce blood loss.
- Hormonal treatment: the combined pill, progestogens and the levonorgestrel intrauterine system, which reduces bleeding by up to 90%.
- Hysteroscopic surgery: incision-free removal of polyps and submucous fibroids.
- Endometrial ablation or hysterectomy: for selected women who have completed their families and in whom other treatments have failed.
- Iron replacement is added where there is iron deficiency.
When to seek urgent care
Bleeding that soaks a pad every hour or more often, dizziness or feeling faint, bleeding when pregnancy is possible and severe pelvic pain require urgent assessment. For bleeding during pregnancy, see our article on bleeding in pregnancy.
Op. Dr. Sadık Kükrer, MD diagnoses and treats abnormal uterine bleeding, including hysteroscopic surgery, in Adana, Türkiye.
Frequently asked questions
What counts as abnormal bleeding?+
Cycles shorter than 24 or longer than 38 days, bleeding lasting more than eight days, variation of more than seven to nine days between cycles, bleeding between periods or after intercourse, bleeding that requires hourly pad changes or produces large clots, and any bleeding after the menopause.
What are the commonest causes?+
The FIGO PALM-COEIN classification lists structural causes (polyps, adenomyosis, fibroids, and malignancy or hyperplasia) and non-structural causes (coagulopathy, ovulatory dysfunction such as PCOS, thyroid disease, raised prolactin or stress, endometrial causes, iatrogenic causes such as medication or an intrauterine device, and those not yet classified).
Which investigations are needed?+
Pregnancy is excluded first. Examination, transvaginal ultrasound, a full blood count and iron studies follow, with thyroid, prolactin and clotting tests where indicated. Endometrial biopsy is advised for women over 45, those with risk factors and those who do not respond to treatment; hysteroscopy is recommended when a polyp or submucous fibroid is suspected.
Can heavy periods cause anaemia?+
Yes. Prolonged heavy bleeding is one of the commonest causes of iron-deficiency anaemia, leading to fatigue, palpitations, hair loss and poor concentration. Iron replacement is added to treatment.
What treatments are available?+
Treatment depends on the cause. Non-hormonal options include tranexamic acid and non-steroidal anti-inflammatory drugs; hormonal options include the combined pill, progestogens and the levonorgestrel intrauterine system. Polyps and submucous fibroids are removed hysteroscopically. Endometrial ablation or hysterectomy may be considered when other treatments fail.
Is postmenopausal bleeding dangerous?+
Most postmenopausal bleeding has a benign cause such as endometrial atrophy or a polyp, but because it is the principal symptom of endometrial cancer, every episode should be assessed with ultrasound and, where indicated, biopsy.
When should I seek urgent care?+
Bleeding that soaks a pad every hour or more often, dizziness or feeling faint, bleeding when pregnancy is possible and severe pelvic pain all require urgent assessment.
Would you like to book a consultation?
For pregnancy monitoring, women's health, and gynecologic surgery in Adana, get in touch with Op. Dr. Sadık Kükrer.
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