Condition Overview

Is this topic for you?

What is abnormal uterine bleeding?

Abnormal uterine bleeding (AUB) is irregular bleeding from the uterus that is longer or heavier than usual or does not occur at your regular time. For example, you may have heavy bleeding during your period or in between periods.

Bleeding during pregnancy is a different problem. If you are pregnant and have any amount of bleeding from the vagina, be sure to tell your doctor.

What causes abnormal uterine bleeding?

Abnormal uterine bleeding has many causes. It is sometimes caused by changes in hormone levels. It can also be caused by problems such as growths in the uterus or clotting problems.

In some cases the cause of the bleeding isn't known.

What are the symptoms?

You may have abnormal uterine bleeding if you have one or more of the following symptoms:

• You get your period more often than every 21 days or farther apart than 35 days. A normal adult menstrual cycle is 21 to 35 days long. A normal teen cycle is 21 to 45 days.
• Your period lasts longer than 7 days (normally 4 to 6 days).
• Your bleeding is heavier than normal. If you are passing blood clots and soaking through your usual pads or tampons each hour for 2 or more hours, your bleeding is considered severe and you should call your doctor.

How is abnormal uterine bleeding diagnosed?

Before your doctor finds the cause of abnormal uterine bleeding, he or she must first make sure it's not vaginal bleeding from pregnancy or miscarriage.

Your doctor will ask how often, how long, and how much you have been bleeding. You may also have a pelvic examination, urine test, blood tests, and possibly an ultrasound. These tests will help your doctor check for other causes of your symptoms. He or she may also take a tiny sample (biopsy) of tissue from your uterus for testing.

How is it treated?

Let your doctor know if you have abnormal uterine bleeding. There are many ways to help treat it. Some are meant to return the menstrual cycle to normal. Others are used to reduce bleeding or to stop monthly periods. Each treatment works for some women but not others. Treatments include:

• Hormones, such as a progestin pill or daily birth control pill (progestin and estrogen). These hormones help control the menstrual cycle and reduce bleeding and cramping.
• Use of the levonorgestrel IUD, which releases a progesterone-like hormone into the uterus. This reduces bleeding while preventing pregnancy.
• Hysteroscopy, to remove polyps or fibroids.
• Surgery, such as endometrial ablation or hysterectomy, when other treatments do not work.

If you also have menstrual pain or heavy bleeding, you can take regular doses of a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen.

In some cases, doctors use watchful waiting, or a wait-and-see approach. It may be okay for a teen or for a woman nearing menopause. Some teens have times of irregular vaginal bleeding. This usually gets better over time as hormone levels even out. Women in menopause can expect their periods to stop. They may choose to wait and see if this happens before they try other treatments.

Cause

Abnormal uterine bleeding has many causes. These include:

• Growths or problems in or around the uterus.
• Blood-clotting problems.
• Changes in hormone levels.

In some cases the cause can't be found.

Symptoms

Symptoms of abnormal uterine bleeding include:

• Vaginal bleeding that occurs more often than every 21 days or farther apart than 35 days (a normal teen menstrual cycle can last up to 45 days).
• Vaginal bleeding that lasts longer than 7 days (normally lasts 4 to 6 days).
• Blood loss of more than 80 mL (3 fl oz) each menstrual cycle [normally about 30 mL (1 fl oz)]. If you are passing blood clots and soaking through your usual pads or tampons each hour for 2 or more hours, your bleeding is considered severe.

What Happens

Abnormal uterine bleeding often occurs before age 20 and after age 40.

• Teen years. Some teens have times of irregular vaginal bleeding. This usually gets better over time as hormone levels even out and the menstrual cycle becomes more regular. If you need treatment, your doctor may give you hormones to help regulate your menstrual cycle. He or she may also prescribe medicine to reduce bleeding.
• Reproductive years. Some women in their 20s and 30s have abnormal uterine bleeding. Sometimes it's because of changes in hormone levels or growths in the uterus such as fibroids or polyps. And sometimes the reason is not known. Your treatment may depend on whether you are planning to have children.
• After age 40: Perimenopausal and menopausal years. After age 40, women tend to have changing hormone levels. During this time before your period stops (perimenopause), you may not always ovulate. This can lead to irregular vaginal bleeding. You can expect this bleeding to go away on its own when menopause is complete. Your treatment options depend on your child-bearing plans and how much your symptoms affect your daily life. Your doctor may recommend a wait-and-see approach, hormones, or a surgical procedure.

No matter what your age, see your doctor if you have irregular vaginal bleeding.

What Increases Your Risk

Risk factors (things that increase your risk) for abnormal uterine bleeding include:

• Your age. Abnormal uterine bleeding is more common in teens, at the beginning of the reproductive years, and in perimenopausal women at the end of their reproductive years.
• Your weight. Overweight women more commonly develop abnormal uterine bleeding.^{footnote 1}

Some women have abnormal uterine bleeding even though they have no risk factors.

When To Call

Any big change in menstrual pattern or amount of bleeding that affects your daily life requires evaluation by a doctor. This includes menstrual bleeding for three or more menstrual cycles that:

• Occurs more frequently than every 21 days or farther apart than 35 days (a normal teen menstrual cycle can last up to 45 days).
• Lasts longer than 7 days.
• Consists of more than 80 mL (3 fl oz) of blood lost or involves passing blood clots and soaking through your usual pads or tampons each hour for 2 or more hours.

Watchful waiting

Watchful waiting is a wait-and-see approach. If you have been diagnosed with abnormal uterine bleeding, you may consider watchful waiting when:

• A careful examination has revealed no other physical problem or disease.
• Blood loss is not severe enough to cause anemia.
• You prefer to wait and see if your symptoms get better on their own. If you are a teen, you can expect your cycles to even out with time. If you are nearing the age of menopause, you can expect menstrual cycles to stop sometime soon.

Talk to your doctor if you have not had a menstrual period for more than 3 months.

Who to see

Your family doctor or general practitioner can do an initial evaluation of a vaginal bleeding problem. For treatment of abnormal uterine bleeding, you may be referred to a specialist, such as a gynecologist.

Examinations and Tests

Your doctor looks for a number of possible causes of your bleeding.

First tests

First, your doctor will:

• Review your history of symptoms and menstrual periods. (If possible, bring with you a record of the days you had your period, how heavy or light the flow was, and how you felt each day.)
• Do a pelvic examination.
• Find out whether you are ovulating regularly. This is done using one or more of the following:
  • A daily record of your symptoms (menstrual calendar)
  • A daily basal body temperature chart, if you have been keeping track at home. This charts your at-rest temperature.
  • A progesterone test, because low levels during the third week of a menstrual cycle suggest an ovulation problem
  • An endometrial biopsy for women age 40 and older, because abnormal endometrial tissue is common in this age group. It may be needed at an earlier age for some conditions. The endometrial tissue is the lining of the uterus.

Other tests

If your symptoms are severe, your doctor suspects a serious medical problem, or you are considering a certain treatment, you may also have one or more other tests, such as:

• Blood tests, which may include:
  • Pregnancy test (human chorionic gonadotropin, or hCG).
  • Complete blood count (CBC), to check for signs of disease, infection, and anemia.
  • Thyroid-stimulating hormone (TSH) to check for a thyroid gland problem, which can cause menstrual irregularity.
  • Serum prolactin level, to check for a pituitary gland problem, which can interfere with or stop the menstrual cycle.
  • Serum ferritin, to check for anemia, a symptom of heavy blood loss.
• Pap smear and cultures to check for infection or abnormal cervical cells.
• Urine test to screen for infection, disease, and other signs of poor health.
• Transvaginal pelvic ultrasound, to check for any abnormalities in the pelvic area. After the pelvic examination, a transvaginal ultrasound is often the next step in diagnosing a vaginal bleeding problem. If a pelvic mass is found, ultrasound results are useful for making further testing and treatment decisions.
• Sonohysterogram, which uses ultrasound to monitor the movement of a salt solution (saline), which is injected into the uterus. This test may be done to look for uterine polyps or fibroids.
• Hysteroscopy, if no cause is apparent but a problem condition is suspected; to check for and treat a suspected condition, such as uterine fibroids; or if bleeding continues despite treatment.

Early Detection

Endometrial cancer risk increases with age. This cancer is also known as uterine cancer. It's most common in women over age 50, after menopause. But endometrial cancer can also develop earlier, during perimenopause or in women who have had abnormal bleeding.

• If you have heavy or unusual vaginal bleeding after menopause, your doctor will do tests to look for cancerous cell changes. These tests often include ultrasound or endometrial biopsy.
• If you are perimenopausal, have not responded to other treatment for uterine bleeding, or have other risks for endometrial cancer, your doctor may recommend an endometrial biopsy.

Treatment Overview

It's important to let your doctor know if you have abnormal uterine bleeding. There are many ways to help treat it. Bleeding can usually be managed with medicine to reduce bleeding and/or hormone therapy to either stop or regulate menstrual periods. Surgical treatment is reserved for bleeding that can't be controlled with medicine or hormone therapy.

Acute, severe uterine bleeding

Severe uterine bleeding is usually treated on an emergency basis with a short course of high-dose estrogen therapy. If that isn't effective in rare cases, a dilation and curettage (D&C) may be done to clear the uterus of tissue. When needed, a blood transfusion is used to quickly restore needed blood volume.

If you are treated for severe uterine bleeding, you and your doctor can then choose a treatment that is safe for the longer term.

Ongoing uterine bleeding

Your age, the cause of your condition, and any future plans for pregnancy will impact the treatment choices available to you.

• If you are a teen, you can expect your periods to become more regular as your body matures. You may choose to wait and see if your periods become more regular. If you need treatment, your doctor may prescribe progestin or birth control pills to regulate your cycle.
• If you are not ovulating regularly, it's difficult to predict how long your abnormal bleeding will last until you stop having periods completely (menopause). If you need treatment, your doctor may give you hormone therapy (such as birth control pills or a hormonal IUD) to regulate your cycle. If you have no future child-bearing plans and have severe symptoms, you can opt for surgical treatment to remove your uterus (hysterectomy) or to destroy the uterine lining (endometrial ablation).
• If you are ovulating regularly, have abnormal bleeding, and plan to become pregnant in the future, talk to your doctor about your treatment options. Depending on the cause of your bleeding, he or she may recommend treatments such as progestin or birth control pills or a hysteroscopy to remove polyps or fibroids. If you have no future pregnancy plans, you can consider endometrial ablation or hysterectomy if other treatment doesn't help.

Gonadotropin-releasing hormone analogues (GnRH-As) are rarely used now. These drugs reduce estrogen production, making your body think it is in menopause. This reduces or stops menstrual periods for as long as you take the medicine. After you stop taking the medicine, your symptoms will come back unless you are close to menopause. Side effects with GnRH-As are common.

A medicine called tranexamic acid (such as Cyklokapron) is sometimes used for women who have bleeding that is heavier than normal. This medicine is not a hormone. It prevents bleeding by helping blood to clot. Talk to your doctor to find out if this option is right for you.

For more information about treatment options, see:

• Abnormal Uterine Bleeding: Should I Use Hormone Therapy?

What to think about

If you are thinking of getting treatment for abnormal uterine bleeding, evaluate the following:

• Has irregular menstrual bleeding caused a significant change in your lifestyle?
• Do you plan to become pregnant in the future?
• Do you have anemia caused by irregular menstrual bleeding?
• Do you want a treatment that will also provide birth control?
• Do you prefer to avoid medical treatment if possible?
• Will you be starting menopause soon? If you are approaching menopause, you can expect uterine bleeding to naturally stop without treatment.

The answers to these questions will help you and your doctor select the treatment plan that is best for you.

Prevention

Sometimes hormonal changes cause abnormal uterine bleeding, so it can't be prevented. But being overweight can affect your hormone production, which increases your risk for irregular menstrual bleeding. If you are overweight, losing weight may help prevent abnormal uterine bleeding.

Self-Care

You can use home treatment for some problems related to abnormal uterine bleeding.

For menstrual pain and heavy bleeding, you can use a non-steroidal anti-inflammatory drug (NSAID), such as over-the-counter ibuprofen. This type of medicine lowers prostaglandins, which cause menstrual pain, and reduces bleeding during your period. An NSAID works best when you start taking it 1 to 2 days before you expect pain to start. If you don't know when your period will start next, take your first dose of an NSAID as soon as bleeding or premenstrual pain starts. Be safe with medicines, and follow your doctor's instructions.

Irregular menstrual bleeding can lead to low levels of iron in the blood. This condition is known as anemia. You can prevent anemia by increasing the amount of iron in your diet.

Medicines

Medicines often help treat abnormal uterine bleeding, and they have fewer risks than surgical treatment. If you plan to become pregnant in the future, or if you are nearing the time when your menstrual periods will stop (menopause), you may want to try medicines first.

Goals of medicine treatment

The goal of medicine treatment for abnormal uterine bleeding is to reduce or eliminate blood loss. This can be done in one or both of the following ways:

• Reducing the endometrium's rate of blood loss
• Regulating or eliminating the menstrual cycle by changing hormonal levels

Medicine choices

There are several hormone therapies for managing abnormal uterine bleeding. These treatments help reduce bleeding and regulate the menstrual cycle:

• Birth control pills (synthetic estrogen and progesterone). Daily birth control pills prevent pregnancy. They also reduce the amount of heavy menstrual bleeding by about half.^{footnote 2} In other words, when you take birth control pills, your menstrual bleeding can be half as heavy as it was before you took the pills. But when you stop taking the pills, irregular bleeding or perimenopausal symptoms may return.
• Progestin pills (synthetic progesterone). In some women, progestins can control endometrial growth and bleeding. You usually take progestins 10 to 12 days every month.
• The levonorgestrel intrauterine device (IUD). A doctor inserts this birth control device into your uterus through your vagina. It stays in your body for up to 5 years and releases levonorgestrel, a form of progesterone, into the uterus.
• Estrogen. In some severe or urgent cases, estrogen may be used to reduce bleeding.
• Hormone suppressors such as gonadotropin-releasing hormone analogues (GnRH-As). GnRH-As are rarely used. These drugs reduce estrogen production, making your body think it is in menopause. This reduces or stops menstrual periods for as long as you take the medicine. Side effects with GnRH-As are common.

A medicine called tranexamic acid (such as Cyklokapron) is sometimes used for women who have bleeding that is heavier than normal. This medicine is not a hormone. It prevents bleeding by helping blood to clot. Talk to your doctor to find out if this option is right for you.

What to think about

Intravenous estrogen therapy is typically used when severe blood loss must be quickly stopped.

Surgery

Surgery is generally reserved for treating abnormal uterine bleeding (AUB) that can't be controlled with medicine.

Surgery choices

The following procedures are used to treat abnormal uterine bleeding.

• Hysteroscopy can be used to diagnose and treat abnromal uterine bleeding at the same time. A lighted viewing instrument called a hysteroscope is inserted through the vagina and cervix and into the uterus. When areas of bleeding are located, biopsies can be taken and then the areas of bleeding can be treated with either a laser beam or electric current (electrocautery).
• Hysterectomy is the removal of the uterus. It may be done when a sample of the uterine lining (endometrial biopsy) shows abnormal cell changes or cancer, when uterine bleeding is uncontrollable, or when the cause of chronic bleeding cannot be found and treated. A hysterectomy is a major surgery with risks of complications. Recovery from surgery can take 4 to 8 weeks, depending on the type of hysterectomy done. If the ovaries are also removed, you may need to take long-term estrogen therapy after surgery.
• Endometrial ablation is a minimally invasive alternative to hysterectomy when other medical treatments fail or when you or your doctor have reasons for not using other treatments. Endometrial ablation scars the uterine lining, so it is not a treatment option if you are planning to become pregnant.

What to think about

Hysteroscopy may be done to rule out serious uterine conditions:

• Before long-term treatment with medicines or surgical treatment for abnormal uterine bleeding.
• When uterine bleeding has continued despite non-surgical treatment.

Hysterectomy may be used as surgical treatment for abnormal uterine bleeding when:

• Abnormal uterine bleeding does not respond to medicine or other treatment.
• Child-bearing is completed and you do not wish to try treatment with medicine.
• Symptoms of abnormal uterine bleeding outweigh the risks and discomforts of surgery.

Regrowth of the endometrium may occur after you have endometrial ablation.