Topic Overview

Is this topic for you?

This topic is for women who
want to learn about or have been diagnosed with abnormal uterine bleeding
(AUB). Abnormal uterine bleeding has several causes. If you don’t know what kind of
bleeding you have, see the topic
Abnormal Vaginal Bleeding.

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 exam, 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 nonsteroidal 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.

Frequently Asked Questions

Learning about abnormal uterine bleeding:

Being diagnosed:

Getting treatment:

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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 cannot 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 childbearing 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 a Doctor

If you have not been diagnosed with
abnormal uterine bleeding (AUB), see the topic
Abnormal Vaginal Bleeding to find out whether you
should see your doctor.

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 exam 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

Health professionals who can do an initial evaluation of a
vaginal bleeding problem include:

If you need to be seen for further evaluation or surgery,
your doctor may refer you to a gynecologist.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams 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.)
  • Conduct a pelvic exam.
  • 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
      perimenopausal women, because abnormal endometrial
      tissue is common in this age group. 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:
  • 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 exam, 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.
  • Endometrial biopsy, usually for women older than 35 or
    who are
    postmenopausal, to learn whether the
    lining of the uterus (endometrium) is healthy and
    functioning normally.
  • 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. Also known as uterine cancer, it is 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 for many years.

  • If you have heavy or unusual vaginal bleeding
    after menopause, your doctor will do tests, usually either ultrasound or
    endometrial biopsy, to look for cancerous cell changes.
  • If you are
    perimenopausal, have not responded to other treatment for uterine bleeding, or
    have things that increase your risk 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 childbearing 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 Lysteda) 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 cannot 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.

Home Treatment

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

For
menstrual pain and heavy bleeding, you can use a
nonsteroidal 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.

Medications

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 Lysteda) 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 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 abnormal 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 nonsurgical treatment.

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

  • Abnormal uterine bleeding does not respond to medicine or other treatment.
  • Childbearing 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.

Other Places To Get Help

Organizations

American Congress of Obstetricians and Gynecologists
(ACOG)
www.acog.org

U.S. Department of Health and Human Services: Women’s Health
www.hrsa.gov/womenshealth/index.html

References

Citations

  1. Fritz MA, Speroff L (2011). Abnormal uterine bleeding. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 591-620. Philadelphia: Lippincott Williams and Wilkins.
  2. Lobo RA (2007). Abnormal uterine bleeding: Ovulatory and anovulatory dysfunctional uterine bleeding, management of acute and chronic excessive bleeding. In VL Katz et al., eds., Comprehensive Gynecology, 5th ed., pp. 915-931. Philadelphia: Mosby Elsevier.

Other Works Consulted

  • American College of Obstetricians and Gynecologists (2007, reaffirmed 2009). Endometrial ablation. ACOG Practice Bulletin No. 81. Obstetrics and Gynecology, 109(5): 1233-1248.
  • American College of Obstetricians and Gynecologists (2011). Intrauterine device. ACOG Practice Bulletin No. 121. Obstetrics and Gynecology, 118(1): 184-196.
  • Duckitt K (2015). Menorrhagia. BMJ Clinical Evidence. http://clinicalevidence.bmj.com/x/systematic-review/0805/overview.html. Accessed October 15, 2015.
  • Goldstein SR (2008). Abnormal uterine bleeding. In RS Gibbs et al., eds., Danforth’s Obstetrics and Gynecology, 10th ed., pp. 664-671. Philadelphia: Lippincott Williams and Wilkins.
  • Hillard P (2007). Benign diseases of the female reproductive tract. In JS Berek, ed., Berek and Novak’s Gynecology, 14th ed., pp. 431-504. Philadelphia: Lippincott Williams and Wilkins.
  • Kalan MJ (2010). Abnormal and dysfunctional uterine bleeding: Treatment. In T Goodwine et al., eds., Management of Common Problems in Obstetrics and Gynecology, 5th ed., pp. 261-266. Chichester: Wiley-Blackwell.
  • Munro MG, et al. (2011). FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age.International Journal of Gynecology and Obstetrics, 113(1): 3-13. DOI: 10.1016/j.ijgo.2010.11.011. Accessed February 11, 2014.

Credits

ByHealthwise Staff
Primary Medical Reviewer Kirtly Jones, MD – Obstetrics and Gynecology
Kathleen Romito, MD – Family Medicine
Specialist Medical Reviewer Femi Olatunbosun, MB, FRCSC – Obstetrics and Gynecology

Current as ofOctober 6, 2017