Having a period every month can be a pain - both literally and figuratively - but as disruptive as it can be, it also gives regular insight into your health. Your cycle and any deviations from usual patterns can signal changes in your body and help you understand where you are in your gynecological journey.

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Abnormal uterine or vaginal bleeding is quite common, but there are many different causes. Therefore, it can take multiple discussions, tests, or procedures before finding the root cause. Below, we discuss the many causes, tests, and treatments for abnormal bleeding. You may also find it useful to read our article on the Importance of Tracking Your Menstrual Cycle, so you can identify what abnormal bleeding is and when it is happening. 

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What is abnormal uterine or vaginal bleeding? 

Abnormal bleeding can look different depending on where you are in your gynecological journey. 

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Abnormal bleeding does not mean spotting at the beginning or end of your normal period, bleeding from progesterone-only contraceptives, or bleeding from continuous birth control pills. 

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Rather, abnormal bleeding typically includes:

• Bleeding in between periods and/or more than 10 days per month
• Recurrent bleeding after sex (when not on your period)
• Bleeding after menopause (menopause is defined as no bleeding for twelve consecutive months)

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Below are some indications of abnormal bleeding based on your life stage: 

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Premenopause: For individuals who are premenopausal, abnormal bleeding is when bleeding is heavy, irregular (i.e., between periods), or happens when it shouldn’t (i.e., after sex). 

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Perimenopause: When reaching the age range for perimenopause (typically 45-50 years old, but can happen earlier), abnormal bleeding is often an early sign indicating this transition. This is due to the ovaries producing inconsistent amounts of estrogen, triggering new patterns of ovulation and bleeding, in addition to other symptoms.

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Menopause: After menopause (median age of menopause in the U.S. is 51 years old), any bleeding that happens a year or more after your last period is abnormal and should be discussed with your provider. Although there are several potential causes for bleeding during this time, this usually requires an evaluation to rule out precancer or cancer in the uterus (endometrial cancer). 

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What causes abnormal bleeding?

There can be many different causes of abnormal bleeding:

• Structural causes, i.e., uterine fibroids, adenomyosis, endometrial polyps
• Hormone changes, i.e., pregnancy, perimenopause
• Hormonal birth control
• Infection of the cervix or endometrium
• Cervical pre-cancer or cancer
• Endometrial cancer
• Medical conditions, i.e., thyroid disorder, PCOS (polycystic ovarian syndrome), or endometriosis

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What tests do I need to evaluate abnormal bleeding?

Based on your age, health status, and risk factors, your provider will help to determine what tests are needed, which may include:

• Physical examination (including a pelvic exam): to determine the location of the bleeding and assess for underlying structural causes
• Lab tests: depending on the suspected cause, this may include a pregnancy test, cervical cancer screening test, vaginal swab to test for infections, and blood tests which check for anemia, thyroid disorder, liver or kidney disorder, hormone tests, and more.
• Imaging: may include a transvaginal ultrasound or more advanced imaging like a pelvic MRI
• Endometrial biopsy: an office procedure that may be recommended based on your age and symptoms to rule out endometrial cancer
• Procedures: this could include a hysteroscopy, which uses a scope with a camera and sterile fluid to see inside the uterus, or a dilation and curettage (D&C) to sample and remove abnormal uterine/endometrial tissue

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How is the abnormal bleeding treated?

The treatment for abnormal bleeding will be based on the cause of the bleeding, your plans for future pregnancy, and your personal medical and surgical history.

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Treatment options may include:

• Hormonal treatments: birth control pills, vaginal rings, progesterone-only pills, progesterone arm implant, injections, or progesterone IUDs (intrauterine devices).
• Non-hormonal treatments: non-steroidal anti-inflammatory medications (NSAIDs) like ibuprofen or antifibrinolytic medications like tranexamic acid.
• Uterine artery embolization: a minimally invasive procedure that uses pellets to block the main blood supply to the uterus, used to shrink fibroids and/or reduce menstrual bleeding over time.
• Surgery: to remove and treat abnormal structural causes, i.e., fibroids, polyps, or the endometrial layer of the uterus.  
  
  • Hysteroscopy: uses a scope with a camera and sterile fluid to see inside the uterus and remove lesions (polyps or fibroids) if present.
  • A dilation and curettage (D&C): is done alone or in combination with a hysteroscopy to sample and remove abnormal uterine/endometrial tissue.
  • Endometrial (Uterine) ablation: a procedure that destroys the inner lining of the uterus using different energy forms (i.e., thermal, freezing, radiofrequency, or microwave energy), usually combined with a hysteroscopy.
  • Myomectomy: a laparoscopic or robotic surgery done to remove fibroids. 
  • Hysterectomy: a surgical procedure done to remove the uterus. This may or may not include the ovaries and cervix, depending on the underlying condition being treated.

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If you are having any abnormal uterine or vaginal bleeding, regardless of your age or menopause status, we recommend that you talk to a medical provider as soon as possible so you can get to the root cause of your symptoms.

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