Spotting the Signs: Understanding Abnormal Uterine Bleeding

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On this episode, I'm joined by Dr. Linda Bradley, who will be helping us better understand abnormal uterine bleeding and post-menopausal bleeding. What it means, why it matters, and what you should do if it happens to you. Thank you so much for joining me on the podcast, Dr. Bradley.

Linda Bradley, MD:

Thank you very much, Dr. Newlin for inviting me.

Erica Newlin, MD:

Before we start, can you tell our listeners a little about your role in the Cleveland Clinic and your background?

Linda Bradley, MD:

My background as an OB/GYN physician, but my practice for the last three decades is just involve patients for GYN visits with a special interest in abnormal uterine bleeding, alternatives to hysterectomy, operative hysteroscopy, diagnostic hysteroscopy. There's some procedures for women. I've started a collaborative practice several decades ago with interventional radiologists for offering uterine fibroid or uterine artery embolization. So I really like problem-based visits that have things to do with abnormal bleeding. Sometimes menstrual pain goes along with that, but the role of imaging, ultrasound, hysteroscopy, and helping women to get back to normal and avoiding hysterectomy and unnecessary angst with their menstrual cycles.

Erica Newlin, MD:

Yeah. So let's start by talking about what is considered normal and when does it become abnormal?

Linda Bradley, MD:

We're finding that the average age of starting the periods, really, we say is age 11 or 12, and could go all the way to age 51, but really the range is broad. It can start as early as nine or end at age 58. So a normal period is one, whenever a woman starts her periods during that time that lasts on the average of three to seven days occurs from the first day of one period to the first day of another period every 21 to 35 days apart. And the total number of consecutive days of bleeding is usually three to seven days. And we look at that as sort of the timelines that we have. And also normal means it's not interrupting your school, missing activities, hobbies, sports, being socially embarrassed because of too much blood, soiling through clothing, mattresses, padding. So basically, bleeding that you shed every month, and it may be a nuisance, but it should never be a problem in terms of becoming anemic and other symptoms I'm sure we'll talk about.

Erica Newlin, MD:

How does someone, particularly a teenager, young 20-something, quantify if their amount of bleeding is too much bleeding?

Linda Bradley, MD:

Okay. Right. Well, the average blood loss really is only 20 to 30 milliliters, which is like three tablespoons. Each tampon that a young woman wears, if she wears tampons, holds five ccs. And so somebody would know that there's a problem when they're missing activities and they're socially embarrassed with their periods. Most women should be able to change their pads or tampons every three to four hours without having an overflow. So they're going to know it's a problem with the amount of bleeding. They're going to know it's a problem. If you bleed a lot, then you start getting symptomatic if you're a patient. Strange things like, we call it pica, but eating ice or starch or I had a patient that eats the wood from her pencil or rollers that you might put in your hair, plastic, unusual things. And so tiredness, fatigue, shortness of breath, someone says that you look pale.

I think I use the word lethargy or lack of energy. So young adolescents, and actually all women through our reproductive life cycles should never be impaired by how they feel. It's just that you should wear a pad or tampon and go along with your life, but all the things that you and I see with our patients, especially the quality of life, the amount of bleeding, clotting, gushing, those are the things that really should bring a patient to a doctor, no matter how old she is. And there's different causes at different ages or different parts of the reproductive lifecycle, things that doctors think about.

Erica Newlin, MD:

For sure. I remember way back when I was a resident and I was in your clinic, I remember you really delving into how much bleeding is impacting someone's life.

Linda Bradley, MD:

You shouldn't have to wake up at night to change. You shouldn't soil through your bedding. Mattresses cost a lot of money. I mean, I have patients just saying they're lining their beds. It shouldn't be like that. And there's so many stories that patients have and some things might run in families where their mother, aunties, grandmothers may have had period problems. And then the patient or young, especially adolescent teen or college age student will say my mother, when I talk with her, she had problems with her period. But how we evaluate women now in 2026 is very different than 10 years ago in terms of our thoroughness and our workup. So I think doctors are listening more and we want to hear from the patient. Really, it's the impact on quality of life.

Certainly, those tangibles, how many pads, how many tampons, how many days of bleeding. There are some apps that women keep, period apps that kind of helps you keep on track. But it shouldn't be that you're worried about it impacting your life and social embarrassment.

Erica Newlin, MD:

How common is abnormal uterine bleeding?

Linda Bradley, MD:

It really varies throughout a woman's lifetime. So we would say once a woman stops her period between ages 51 and 58, any bleeding is abnormal. So if you're 55 and you bleed 100% of the time, it's abnormal. It doesn't mean cancer, but it means we need to evaluate it. We look at the decade before the periods stop. Women in their 40s or perimenopausal years, late 30s, may have shortening of their cycle, and it can be very frequent. I usually say in terms of the numbers and the textbooks can be anywhere from 25 to 50%. Very few women have a regular, predictable, monthly menstrual cycle for four or 500 cycles, and then just stops her period at age 51 to 58. So it begins to change hormonally, and then there are other things that we think about structural causes that cause it to change.

And so when we look at young women, a young woman that starts her periods at 10, 11, 12, 13, that has a bleeding disorder like Von Willebrand's disease, 50% to 70% of those women with this often underdiagnosed disease has heavy, heavy periods, nose bleeds, gums bleeding, easy bruising. And during the beginning of a young teenager's life, periods are abnormal the majority of the time, two to three years until they start to ovulate, make an egg, that women may go months. You could start your period at 13 and not have another period for six or eight months. And then it could be shorter or further apart. I would say for adolescents, it's very abnormal and then it varies based on the age. But it's a frequent problem and it's easily evaluated and it's nothing that you have to live with, be worried about. Most of the time, most bleeding only 10% of crazy bleeding is due to uterine cancer. And there's usually other things that we can fix, evaluate and treat.

Erica Newlin, MD:

Why is it important for women to pay attention to changes in their bleeding patterns?

Linda Bradley, MD:

Well, I think the menstrual cycle is like a fifth vital sign, right? Some people will use that, like your weight and your blood pressure, height, temperature, pulse, because menstrual cycles can reflect potential onset of chronic illnesses or different disease states. So getting a regular menstrual cycle every 21 to 35 days apart means that your hypothalamus, your brain, your pituitary, the signals to the ovaries all work. When you have chronic illnesses, women with anorexia sometimes stop their periods. So having normal periods usually symbolizes health. Abnormal periods can, we can look at illnesses like anorexia, lots of exercise, PCOS, overweight, obesity, stress, change in our circadian rhythm. I have a lot of patients that were stewardess and, you know, they're in different time zones and periods start a day or two early or late. And our periods reflect our overall general health. So when they go out of whack or stop, we have to think about things from thyroid disorders.

There's just a lot of things that we think about and a normal period often indicates good health for the majority of patients.

Erica Newlin, MD:

What are the most common causes of abnormal uterine bleeding in reproductive aged women?

Linda Bradley, MD:

A couple years ago, we started something called the PALM COIEN nomenclature. Palm, meaning like the palm of your hand and the P-A-L-M. So doctors will think of structural things and in the uterus, the P stands for maybe polyps. Usually a nuisance with growths inside the uterus that can cause irregular bleeding, spotting or staining after intercourse, intermenstrual bleeding, heavier bleeding, difficulty getting pregnant and staying pregnant. A, for adenomyosis. Adenomyosis is where the lining of the uterus starts to grow into the muscle of the uterus, the myometrium. It can lead to irregular, heavy, very painful periods and can be seen on imaging.

L is leiomyoma or fibroids size, number and location. The uterus has three different regions to it and fibroids that are causing bleeding. It can really be in all areas in general, but usually it's something that's in the lining of the uterus where baby would grow or touching the lining of the uterus. The ones on the really the outside of the uterus may cause more pressure. M, meaning malignancy, cancer, and that could range from vaginal cancer to cervical cancer to uterine cancer, rarely fallopian tube cancer, 3% of ovarian cancers present as abnormal bleeding, so it can be outside of the actual uterus. And then the COIEN, C-O-I-E-N, the C stands for coagulopathies, problems with the clotting factors, too much aspirin, too much Motrin, Von Willebrand's disease, on blood thinners.

And O, meaning how women, do they ovulate? Do they make an egg every month? Are they having the rhythmic circadian monthly cycle for ovulation? I means iatrogenic, could be medication, IUD, birth control pills, progestin therapy, actually many different medications including antidepressants, could be blood thinners, and N means like right now we don't have a name for it, but we keep that for future reference. We think of it in that way when we see a patient. Other things that we could put into this might be iatrogenic. A woman could have a vaginal infection. The most common one that causes bleeding is trichomonas. The other could be less commonly, but you can get an inflammation in the uterus from endometritis from gonorrhea and chlamydia. I've seen that a number of times. So we have to think that your physician interaction, to be honest with your doctor, we are not here to judge you.

We look from top to bottom and not just at the pelvis to think about things. We want to know with an exam if we look at everything. You could have lesions on the outside of the vagina, vulvar lesions that could present with bleeding. Right at the opening of the uterus is where the urine comes out. You could have a, we call it a urethral caruncle or diverticulum. I've seen that on many times, especially in older women and you think not everything comes from the uterus. So we didn't mention things like endometriosis can have lesions or small growths in the vagina that episodically bleed or endometriosis as its own category can lead to abnormal bleeding. And so we have to think as your physician, we need your history and a really detailed history and to know when your periods are, have an idea. Like this morning, I was like, "Tell me about your periods in the last six months." And that kind of gives me a flavor of what's, what's happening and what were they like six years ago.

So, you know, what they were like, what they become, what's changed in your life, things like that. So we're counting on patients to really give us a good history and we're asking patients to really explain more. At least for me, and I think most physicians, like you're saying, quality of life. You could have regular periods every month for five days, but bleed so much that you stay home, you miss school, you need blood transfusions, you need iron transfusions. On the paper, it might look like she has periods every 28th or 30th, but you have to dig deep to know what they're like. That's what we want patients to be aware of.

Erica Newlin, MD:

What about after menopause? Why is any bleeding after menopause considered abnormal?

Linda Bradley, MD:

We always say that there should be no bleeding after 12 months of stopping the period. So the numbers are such that by the age of 40, one out of 100 women stops their period, goes to menopause. They stop before that we call that premature menopause. By age 45, 10 out of 100 women stops their period. By age 51, 80 out of 100 women stops their period. By age 55, 95 out of 100 stop their period, and by age 58, everybody. So that magic age of 51, I have patients that periods up to age 58. It's what it is. It's just like some girls start their periods at nine or start at 16. So there's this sort of range in where we start our periods. But after we really stop, we have to think about other disease states with aging. One being uterine cancer, the other in the 60s would be ovarian cancer.

And again, three to 5% of ovarian cancers can present with bleeding because the matrix of the ovary, the stroma, without getting into detail, makes chemicals that can make you bleed. The development of pre-cancer of the lining of the uterus is very high in this country because of many reasons we're seeing. Turns out in menopause that 70% of the uterine causes of bleeding are not cancer, but from atrophy, the lining of uterus just gets dry and very atrophic and it bleeds. But you have to evaluate the patient.

Some women, as we get older, you've had a C-section, you've had a LEEP or a cone biopsy for treatment of your cervix, and that cervix is just tight. And sometimes the blood doesn't come out. And, you know, women can get a hematometra, blood buildup. There's a lot of blood in there, but only a little bit comes out now and then. So we like patients to report their bleeding after menopause.

And I actually think we as doctors should be asking our patients about five ways the blood could look. Do you have anything that's red? Brown, rust colored, pink. You see what I'm saying? You and I would say if we ask that yellow, mucoid, leukorrhea, that watery discharge, feeling like you're going to start your period, all those things are not normal, doesn't mean cancer, but it means your doctor should evaluate. And I think we do a disservice to patients in the menopause years to ask, "Do you have postmenopausal bleeding?"

Patients will answer what we ask them. If we don't dig second, third tier down, then we won't get the answers. So I like all the colors that blood could be, including the mucoid discharge or leukorrhea is something that's a really important factor that we should ask for and that patients should tell us about if they have. It's not always blood as we see it.

Erica Newlin, MD:

What should someone do if they do recognize they're having that bleeding or if they have abnormal discharge that they're worried about after menopause?

Linda Bradley, MD:

They should see their physician and they should have a pelvic exam. We are very high tech, but very low touch in medicine. Ultrasound does not pick up everything. So I think you have to be your own patient advocate let your doctor do the exam from the outside vulva, speculum exam, palpation of the vagina, feeling the size of the uterus and if there's any masses by the ovaries. So the answer is they should let their physician know and know that it's never okay for an answer to be, "Oh, that's okay because it was just a little bit. Tell me if it happens again." I mean, if you're bleeding more with your passing clots, doubling up on pads, we're not looking at teaspoons of blood, we're looking at cups of blood that you may be losing.

So we want to evaluate and it should include a pelvic exam. And even if you're past the age of screening for cervical cancer, or even if your pap smear was normal two or three years before, your visit is a problem-based visit. By age, you might not be due for a pap smear, but you should have a pap, so many things you pick up on PAP that start from the endocervix, with endocervical lesions, endocervical polyps, to endometrial cells on PAP, to things. So I really insist on a complete exam is a physical pap smear, when appropriate cultures, and then imaging based upon the size of the uterus or other complaints that the patient has. But it's never a telephone or a virtual visit.

Erica Newlin, MD:

Are there any lifestyle or medical risk factors that increase the likelihood of abnormal bleeding?

Linda Bradley, MD:

Let's see, lifestyle factors. So abnormal could be no period. So if someone is really under their ideal body weight, eating disorders, bulimia, they're exercising all the time. Sometimes they don't get a period. Sometimes it's just a matter of gaining some weight. And my other lifestyle thing would just be the level of overweight and obesity in this country that really 20 some, for some patients, 25 to 50 pounds over an ideal body weight will keep them from having regular predictable periods and then set them up for the PCOS syndrome. So that would be lifestyle. I think weight, we don't talk about that much, but we have some very elite athletes that we take care of. So if they are not getting a period, we're concerned because they may not be making estrogen, we want to protect their bones and we may, as physicians, make recommendations for medical therapy with estrogen, often birth control pills of any type with estrogen to protect their bones and recommend the calcium and vitamin D.

Erica Newlin, MD:

And then we've gone over a lot of the causes and understanding the causes is important, but knowing what to do next can be even more critical. So let's dive into how abnormal bleeding is evaluated and diagnosed. So you've mentioned what a patient should do if she notices that abnormal bleeding. What does that first visit or initial evaluation typically involve?

Linda Bradley, MD:

So first, I try to let the patient speak, you know, her story. I just always say, "I'm here to listen and just tell me about what made you make your appointment." And I try to not interrupt and I ask her to be very descriptive and sometimes I'll pause meaning, okay, it's heavy. They'll use the word it's heavy. Well, what does that mean? What do you have to use for sanitary protection? And then for me, I want to know quality of life. So that first visit is getting a very, very detailed history, and then I like to do a physical exam, which includes, I usually check the thyroid gland, depending if they're not having periods, just want to make sure that they don't have any milk secretion from their nipples or complain of anything that could be a pituitary disorder and then do abdominal and pelvic exam. Just looking for anatomic things that we talked about, polyps that you could see on the cervix or vaginal polyps even or things like that.

And then the size of the uterus and any masses where the ovaries would be. And depending if they're also having pain, I often do a rectal exam if I'm concerned about endometriosis, so I can potentially examine some special spaces that that condition may affect.

Erica Newlin, MD:

And then what imaging or diagnostic tools do we have at our disposal?

Linda Bradley, MD:

So the next for me would be lab tests. So, and I go by the patient's history. We're lucky at the Cleveland Clinic we can do, I would say, say to anyone that's listening broadly, your doctor needs to do a minimum of CBC, but also a ferritin level, because that looks at sort of your iron stores.

We never want someone to get so low that you immediately need an urgent blood transfusion, but we can give IV iron that really bumps a blood count hemoglobin up very quickly. So I would do that first. Often I do a thyroid test, then my physical exam will determine what type of imaging. I mean, if someone has a 20-week size uterus, then a regular transvaginal ultrasound, which may not pick up all the size of the uterus. I might order a transabdominal followed by transvaginal ultrasound, but I really, with a normal uterus, and they're bleeding a lot, or episodically, we order what's called SIS, saline infusion sonogram, which is an enhanced transvaginal ultrasound where the doctor puts in a little catheter size of a piece of angel hair pasta and puts in a few teaspoons of fluid so we can really see what the lining of the uterus looks like, what the muscle looks like for things like fibroids or adenomyosis, and also looks at the ovaries.

I would say normal size uterus on exam, usually SIS with bleeding. If it's very large and we can get it through insurance companies, I'll do an MRI. Because the problem with SIS and a 20-week size uterus, you may not be able to distend the cavity because you could have disease with meaning polyps or intracavitary fibroids, but you just can't get that uterus expanded.

Erica Newlin, MD:

What about the role of endometrial biopsy or office hysteroscopy?

Linda Bradley, MD:

For endometrial biopsy, it's just taking a sample of the lining of the uterus with a little device that looks like a piece of pasta. And I always tell patients we're not cutting anything. We're just aspirating tissue. It creates a vacuum because many women think we're down there cutting something. It still can be uncomfortable and that aspirates tissue, but by itself, it's really inaccurate. It only samples 4% of the endometrium and it misses focal lesions. So I rarely use that by itself. Hysteroscopy, for me, in a normal size uterus, especially in the postmenopausal woman, I will look directly within the uterine cavity versus SIS for me. There's different algorithms and let's for the audience. Hysteroscopy is a test that some facilities can do in the office where we look with something three millimeters, the size of a little pen or pencil inside the uterine cavity to see the endocervix, cervix, proximal tubal ostia, and look at the topography of the endometrium.

So I go with that when the size of the uterus is normal, or if I get a test, sometimes SIS, they can't distend the cavity, or someone's done a transvaginal ultrasound, it looks thick, irregular, or it's equivocal, and then I use hysteroscopy to take a look.

When possible, if a patient can advocate if their facility does saline infusion sonogram, it is far better for imaging for causes of abnormal bleeding than transvaginal ultrasound alone. In menopause, the normal lining of the uterus, when we measure it, the stuff that should not be bleeding should be four millimeters or less. And if you just have a transvaginal ultrasound, it's going to say it's seven millimeters. It's just going to say it's thick, but we don't know why it's thick. And then you do a biopsy, which can't sample everything. So it's better to look into the cavity with fluid.

The biggest takeaway I think for patients, if your doctor starts and ends only with a pipelle biopsy and you continue to bleed and you still don't have an answer, that biopsy, a negative biopsy is not enough because you're going to miss focal lesions. It'll miss lesions in a big uterine cavity. It'll miss lesions if you have what we call mullerian anomalies when your uterus has a, like a septum or something's not right with the cavity or it has adhesions or lesions way up near the tubal osteo, you're just going to miss it.

So a negative biopsy with continued menstrual disorders, it's not negative. It's only helpful if you happen to get cancer, you can stop there and refer. But I see far too many patients, "Oh, I had a negative biopsy." And like my study showed, you just are missing a lot of lesions, including endocervical lesions that just aren't going to be picked up on a pipelle.

So for women, our patients, now that we have miniaturized equipment, we should not be doing anything in the dark or blindly. And so whether that's SIS, looking or hysteroscopy, we have the tools of the trade now for comfort, for often ease of use in the office, and it's doable and highly effective.

Erica Newlin, MD:

Once we have a diagnosis, the next question is, what are the treatment options?

Linda Bradley, MD:

Okay. If we find something in the PALM COIEN pneumonic polyp, we would recommend an outpatient procedure to take out the polyp. And that's, can just be done through the hysteroscope, and the patients can usually go back to work and activities within one to two days after a procedure. Increasingly, we're getting some new technology that allows us with the right patient, right-sized lesion or growth like a polyp to take out in the office. So somebody might have a polyp fully removed in the office and go back to activities that very day. Or right now, more commonly, it's a brief outpatient procedure to say if you have a Friday procedure, go back to full activities by Monday. Fibroids that are in the right place, meaning we're talking about minimally invasive surgeries through the vagina, through a hysteroscope, we can resect or remove a fibroid.

We look for things like adenomyosis. That might be a treatment instead of hysterectomy. We want to treat the symptoms of bleeding and pain. That could be birth control pills. It could be insertion of a progestin IUD. So that would be treatment. There are treatments including medicines for heavy menstrual cycles that have been around for 30 years that women can take that's not hormonal. How I use that, there's sometimes you do the workup and you don't find anything structurally abnormal. Blood tests are fine, but we just have to treat the heavy bleeding. So we might use that. We might use birth control pills, someone that has pain and bleeding, we might add an NSAID to help with that.

So I think we have to know what it's due to if someone has PCOS, recommend, you know, exercise, weight loss, and then regulation of the period, because we want to prevent the development of pre-cancer cancer to be on cyclical progestin therapy if they don't want to be on birth control pills, or more often in PCOS patients, birth control pills, because it helps to regulate their periods also helps their skin beautifully. The acne, the extra hair growth, the cystic acne, to get better. So I think what we do is we individualize everything, but major surgery, i.e., removal of the uterus in a young woman should be extremely rare.

I would say be broad, be open, and really most of the things we're recommending are so safe and most important, extremely effective.

Erica Newlin, MD:

What's your key message for women listening today?

Linda Bradley, MD:

I think understanding your menstrual cycles lets you understand your health and that if there's a problem you should not suffer in silence. We should not be afraid to talk about our menstrual cycles and to be truthful about your history and your storytelling. And then that way we can both work together and figure out what's going on.

Erica Newlin, MD:

Dr. Bradley, thank you so much for joining me on the podcast today. For more resources on abnormal uterine bleeding, visit clevelandclinic.org/aub. If you found this episode helpful, subscribe and share it with a friend. Remember, your health matters and understanding your body signals is the first step to living your best.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.