Abnormal Menstruation (Periods)
What is abnormal menstruation?
Most women have menstrual periods that last four to seven days. A woman's period usually occurs every 28 days, but normal menstrual cycles can range from 21 days to 35 days.
Examples of menstrual problems include:
- Periods that occur less than 21 days or more than 35 days apart
- Missing three or more periods in a row
- Menstrual flow that is much heavier or lighter than usual
- Periods that last longer than seven days
- Periods that are accompanied by pain, cramping, nausea or vomiting
- Bleeding or spotting that happens between periods, after menopause or following sex
Examples of abnormal menstruation include the following:
- Amenorrhea is a condition in which a woman’s periods have stopped completely. The absence of a period for 90 days or more is considered abnormal unless a woman is pregnant, breastfeeding, or going through menopause (which generally occurs for women between ages 45 and 55). Young women who haven't started menstruating by age 15 or 16 or within three years after their breasts begin to develop are also considered to have amenorrhea.
- Oligomenorrhea refers to periods that occur infrequently.
- Dysmenorrhea refers to painful periods and severe menstrual cramps. Some discomfort during the cycle is normal for most women.
- Abnormal uterine bleeding may apply to a variety of menstrual irregularities, including: a heavier menstrual flow; a period that lasts longer than seven days; or bleeding or spotting between periods, after sex, or after menopause.
Symptoms and Causes
What causes abnormal menstruation (periods)?
There are many causes of abnormal periods, ranging from stress to more serious underlying medical conditions:
- Stress and lifestyle factors. Gaining or losing a significant amount of weight, dieting, changes in exercise routines, travel, illness, or other disruptions in a woman's daily routine can have an impact on her menstrual cycle.
- Birth control pills. Most birth control pills contain a combination of the hormones estrogen and progestin (some contain progestin alone). The pills prevent pregnancy by keeping the ovaries from releasing eggs. Going on or off birth control pills can affect menstruation. Some women have irregular or missed periods for up to six months after discontinuing birth control pills. This is an important consideration when you are planning on conception and becoming pregnant. Women who take birth control pills that contain progestin only may have bleeding between periods.
- Uterine polyps or fibroids. Uterine polyps are small benign (noncancerous) growths in the lining of the uterus. Uterine fibroids are tumors that attach to the wall of the uterus. There may be one or several fibroids that range from as small as an apple seed to the size of a grapefruit. These tumors are usually benign, but they may cause heavy bleeding and pain during periods. If the fibroids are large, they might put pressure on the bladder or rectum, causing discomfort.
- Endometriosis. The endometrial tissue that lines the uterus breaks down every month and is discharged with the menstrual flow. Endometriosis occurs when the endometrial tissue starts to grow outside the uterus. Often, the endometrial tissue attaches itself to the ovaries or fallopian tubes; it sometimes grows on the intestines or other organs in the lower digestive tract and in the area between your rectum and uterus. Endometriosis may cause abnormal bleeding, cramps or pain before and during periods, and painful intercourse.
- Pelvic inflammatory disease. Pelvic inflammatory disease (PID) is a bacterial infection that affects the female reproductive system. Bacteria may enter the vagina via sexual contact and then spread to the uterus and upper genital tract. Bacteria might also enter the reproductive tract via gynecologic procedures or through childbirth, miscarriage, or abortion. Symptoms of PID include a heavy vaginal discharge with an unpleasant odor, irregular periods, pain in the pelvic and lower abdominal areas, fever, nausea, vomiting, or diarrhea.
- Polycystic ovary syndrome. In polycystic ovary syndrome (PCOS), the ovaries make large amounts of androgens, which are male hormones. Small fluid-filled sacs (cysts) may form in the ovaries. These can often been seen on an ultrasound. The hormonal changes can prevent eggs from maturing, and so ovulation may not take place consistently. Sometimes a woman with polycystic ovary syndrome will have irregular periods or stop menstruating completely. In addition, the condition is associated with obesity, infertility and hirsutism (excessive hair growth and acne). This condition may be caused by a hormonal imbalance, although the exact cause is unknown. Treatment of PCOS depends on whether a woman desires pregnancy. If pregnancy is not a goal, then weight loss, oral contraceptive pills, and the medication Metformin® (an insulin sensitizer used in diabetes) can regulate a woman’s cycles. If pregnancy is desired, ovulation-stimulating medications can be tried.
- Premature ovarian insufficiency. This condition occurs in women under age 40 whose ovaries do not function normally. The menstrual cycle stops, similar to menopause. This can occur in patients who are being treated for cancer with chemotherapy and radiation, or if you have a family history of premature ovarian insufficiency or certain chromosomal abnormalities. If this condition occurs, see your physician.
Other causes of abnormal menstruation include:
- Uterine cancer or cervical cancer
- Medications, such as steroids or anticoagulant drugs (blood thinners)
- Medical conditions, such as bleeding disorders, an under- or overactive thyroid gland, or pituitary disorders that affect hormonal balance
- Complications associated with pregnancy, including miscarriage or an ectopic pregnancy (the fertilized egg is implanted outside the uterus; for example, within the fallopian tube)
Diagnosis and Tests
How is abnormal menstruation (periods) diagnosed?
If any aspect of your menstrual cycle has changed, you should keep an accurate record of when your period begins and ends, including the amount of flow and whether you pass large blood clots. Keep track of any other symptoms, such as bleeding between periods and menstrual cramps or pain.
Your doctor will ask you about your menstrual cycle and medical history. He or she will perform a physical examination, including a pelvic exam and sometimes a Pap test. The doctor might also order certain tests, including the following:
- Blood tests to rule out anemia or other medical disorders
- Vaginal cultures, to look for infections
- A pelvic ultrasound exam to check for uterine fibroids, polyps or an ovarian cyst
- An endometrial biopsy, in which a sample of tissue is removed from the lining of the uterus, to diagnose endometriosis, hormonal imbalance, or cancerous cells. Endometriosis or other conditions may also be diagnosed using a procedure called a laparoscopy, in which the doctor makes a tiny incision in the abdomen and then inserts a thin tube with a light attached to view the uterus and ovaries
Management and Treatment
How is abnormal menstruation (periods) treated?
The treatment of abnormal menstruation depends on the underlying cause:
- Regulation of the menstrual cycle: Hormones such as estrogen or progestin might be prescribed to help control heavy bleeding.
- Pain control: Mild to moderate pain or cramps might be lessened by taking an over-the-counter pain reliever, such as ibuprofen or acetaminophen. Aspirin is not recommended because it might cause heavier bleeding. Taking a warm bath or shower or using a heating pad might help to relieve cramps.
- Uterine fibroids: These can be treated medically and/or surgically. Initially, most fibroids that are causing mild symptoms can be treated with over-the-counter pain relievers. If you experience heavy bleeding, an iron supplement might be helpful in preventing or treating anemia. Low-dose birth control pills or progestin injections (Depo-Provera®) may help to control heavy bleeding caused by fibroids. Drugs called gonadotropin-releasing hormone agonists may be used to shrink the size of the fibroids and control heavy bleeding. These drugs reduce the body’s production of estrogen and stop menstruation for a while. If fibroids do not respond to medication, there are a variety of surgical options that can remove them or lessen their size and symptoms. The type of procedure will depend on the size, type and location of the fibroids. A myomectomy is the simple removal of a fibroid. In severe cases where the fibroids are large or cause heavy bleeding or pain, a hysterectomy might be necessary. During a hysterectomy, the fibroids are removed along with the uterus. Other options include uterine artery embolization, which cuts off the blood supply to the active fibroid tissue.
- Endometriosis: Although there is no cure for endometriosis, over-the-counter or prescription pain relievers may help to lessen the discomfort. Hormone treatments such as birth control pills may help prevent overgrowth of uterine tissue and reduce the amount of blood loss during periods. In more severe cases, a gonadotropin-releasing hormone agonist or progestin may be used to temporarily stop menstrual periods. In severe cases, surgery may be necessary to remove excess endometrial tissue growing in the pelvis or abdomen. A hysterectomy might be required as a last resort if the uterus has been severely damaged.
There are other procedural options which can help heavy menstrual bleeding. A five-year contraceptive intrauterine device (IUD), called Mirena®, has been approved to help lessen bleeding, and can be as effective as surgical procedures such as endometrial ablation. This is inserted in the doctor’s office with minimal discomfort, and also offers contraception. Endometrial ablation is another option. It uses heat or electrocautery to destroy the lining of the uterus. It is usually only used when other therapies have been tried and failed. This is because scars from the procedure can make monitoring the uterus more difficult if bleeding persists in the future.
How can the risk of abnormal menstruation (periods) be reduced?
Here are some recommendations for self-care:
- Try to maintain a healthy lifestyle by exercising moderately and eating nutrious foods. If you have to lose weight, do so gradually instead of turning to diets that drastically limit your calorie and food intake.
- Make sure you get enough rest.
- Practice stress reduction and relaxation techniques.
- If you are an athlete, cut back on prolonged or intense exercise routines. Excessive sports activities can cause irregular periods.
- Use birth control pills or other contraceptive methods as directed.
- Change your tampons or sanitary napkins approximately every four to six hours to avoid toxic shock syndrome and prevent infections.
- See a doctor for regular check-ups.
When should you seek medical attention for abnormal menstruation (periods)?
Contact a doctor or medical professional if you have any of the following symptoms:
- Severe pain during your period or between periods
- Unusually heavy bleeding (soaking through a sanitary pad or tampon every hour for two to three hours) or passing large clots
- An abnormal or foul-smelling vaginal discharge
- High fever
- A period lasting longer than seven days
- Vaginal bleeding or spotting between periods or after you have gone through menopause
- Periods that become very irregular after you have had regular menstrual cycles
- Nausea or vomiting during your period
- Symptoms of toxic shock syndrome, such as a fever over 102 degrees, vomiting, diarrhea, fainting or dizziness
You should also see a doctor if you think you might be pregnant.