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Irregular menstruation; Heavy, prolonged, or irregular periods; Menorrhagia; Polymenorrhea; Metrorrhagia and other menstrual conditions; Abnormal menstrual periods; Abnormal uterine bleeding; Abnormal vaginal bleeding

The menstrual cycle is not the same for every woman. On average, menstrual flow occurs every 28 days (with most women having cycles between 24 and 34 days), and lasts about 4-7 days.

However, there is a wide variation in timing and duration that is still considered normal, especially if your periods began within the last few years.

A small percentage of women have periods more often than every 21 days or less often than every 35 days. These variations may be normal.

Some examples of abnormal bleeding include:

• Bleeding or spotting between periods
• Bleeding after sex
• Bleeding more heavily (passing large clots, needing to change protection during the night, soaking through a sanitary pad or tampon every hour for 2 - 3 hours in a row)
• Bleeding for more days than normal or for more than 7 days
• Menstrual cycle less than 28 days (more common) or more than 35 days apart
• Bleeding after you have gone through menopause

Often, if you are bleeding from the rectum or there is blood in your urine, you may think the blood is coming from the vagina. To know for certain, insert a tampon into the vagina to confirm that it's the source of your bleeding.

A change in hormone levels is a common cause of abnormal menstrual bleeding. This is called dysfunctional uterine bleeding.

Other causes of abnormal menstrual bleeding include:

• Endometrial hyperplasia (thickening/build-up of the lining of the uterus)
• Cancer of the uterus
• Uterine fibroids, uterine polyps (small noncancerous growths in the lining of the uterus), adenomyosis
• Medical conditions such as thyroid and pituitary disorders, diabetes, cirrhosis of the liver, and systemic lupus erythematosus
• Pregnancy complications -- such as miscarriage or ectopic pregnancy (when a fertilized egg implants somewhere other than the uterus)
• Changes in birth control pills or estrogens that you take
• Use of certain drugs such as steroids or blood thinners (for example, warfarin or Coumadin)
• Use of an intrauterine device (IUD) for birth control
• Recent trauma, surgery, or other uterine procedure
• Infection in the uterus (pelvic inflammatory disease)
• Bleeding disorders such as Von Willebrand disease
• Polycystic ovary syndrome
• Stress, change in diet or exercise routine, recent weight loss or weight gain, travel, or illness

Keep a record of your menstrual cycles and any other bleeding, including:

• When menstruation begins and ends
• How much flow you have (count numbers of pads and tampons used, noting whether they are soaked)
• Bleeding between periods and after sex
• Any other symptoms you experience

Tampons should be changed at least twice a day to avoid infection.

Because aspirin may prolong bleeding, it should be avoided. Ibuprofen is usually more effective than aspirin for relieving menstrual cramps. It also may reduce the amount of blood you lose during a period.

If you think you are or could be pregnant, talk to your doctor.

Call your doctor if:

• You have soaked through a pad or tampon every hour for 2 - 3 hours.
• Your bleeding has lasted longer than 1 week.
• You are pregnant or could be pregnant.
• You have severe pain, especially if you also have pain when not menstruating.
• Your periods have been heavy or prolonged for three or more cycles, compared to what is normal for you.
• You have a fever or abnormal vaginal discharge, especially if it has an odor.
• You have bleeding or spotting after menopause.
• You have bleeding or spotting between periods.
• You have nipple discharge, excessive hair growth, deepening voice, unintentional weight loss or gain, or new acne.

Your doctor will perform a physical examination, including a pelvic exam. Your doctor will ask questions like the following to determine the history of this symptom:

• What is your age?
• Have your last three menstrual periods been normal in timing and amount for you?
• How long do your periods usually last?
• How many days are there usually between your menstrual periods?
• How did this cycle (and others) differ from your usual menstruation?
• Have you passed blood clots?
• How many days has the bleeding lasted with these different or abnormal menstrual periods?
• How heavy have they been? How many pads and tampons have you been using per day?
• When was your last menstrual period?
• How old were you when had your first menstrual period?
• Do you use birth control pills? Do you use an IUD for birth control?
• Do you take an estrogen supplement?
• Do you take aspirin more than once per week?
• Do you take Coumadin, heparin, or other anticoagulants?
• Have you recently given birth, had surgery, or experienced trauma on or near the vagina or uterus?
• Have you recently had a vaginal or uterine infection?
• What other symptoms do you have? Abdominal or pelvic pain?
• Do you have nausea or vomiting?
• Are you pregnant or could you be pregnant?
• Have you noticed a growth, lump, or lesion on the genitals?
• Have you had blood in your stools?
• Do you bleed easily?

Diagnostic tests that may be performed include:

• Pap smear
• Endometrial biopsy
• Pelvic ultrasound
• Lab tests such as thyroid function tests, CBC, pregnancy test, and serum ferritin

For information about treatment, see:

• Dysfunctional uterine bleeding
• Ectopic pregnancy
• Hypothyroidism
• Pelvic inflammatory disease
• Polycystic ovary syndrome
• Uterine fibroids

Irregular menstruation; Heavy, prolonged, or irregular periods; Menorrhagia; Polymenorrhea; Metrorrhagia and other menstrual conditions; Abnormal menstrual periods; Abnormal uterine bleeding; Abnormal vaginal bleeding

Apgar BS, Kaufman AH, George-Nwogu U, Kittendorf A. Treatment of menorrhagia. Am Fam Physician. 2007;75:1813-1819.

Lobo RA. Abnormal uterine bleeding: Ovulatory and anovulatory dysfunctional uterine bleeding, management of acute and chronic excessive bleeding. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier;2007:chap 37.

Updated by: Susan Storck, MD, FACOG, Chief, Eastside Department of Obstetrics and Gynecology, Group Health Cooperative of Puget Sound, Redmond, Washington; Clinical Teaching Faculty, Department of Obstetrics and Gynecology, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.