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Irregular Bleeding in Adult Females: A Detailed Guide by Dr.Pothireddy Surendranath Reddy

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By Pothireddy Surendranath Reddy

Introduction

Irregular uterine bleeding — often called abnormal uterine bleeding (AUB) — is a very common concern among adult women. It refers to any bleeding pattern that deviates from what’s considered a “normal” menstrual cycle in terms of frequency, duration, flow, or regularity. For many women, AUB can affect quality of life, cause anemia, and lead to anxiety. Therefore, a thorough evaluation and appropriate management are essential.

In this guide, we will cover:

  1. What constitutes “irregular bleeding”
  2. The causes (both structural and non-structural)
  3. How doctors diagnose AUB
  4. Treatment options (medical and surgical)
  5. When to seek urgent care
  6. Long-term considerations
  7. Prevention and lifestyle
  8. Key references and resources

What Is Irregular Bleeding?

  • Definition: AUB refers to uterine bleeding that is abnormal in volume, regularity, frequency, or duration, and which is not due to pregnancy. MSD Manuals+2Cleveland Clinic+2
  • Normal menstrual parameters: Typically, menstruation occurs every 25–35 days, lasts 2–7 days, and involves a moderate amount of blood. https://www.cun.es+1
  • When bleeding happens outside these norms — for example, very frequent periods (< 21 days), very prolonged bleeding (> 7 days), bleeding between periods, or very heavy flow — it may be classified as AUB. AIIMS Rishikesh+1
  • AUB can be acute (sudden and heavy) or chronic (long-term) depending on its presentation.

Causes of Irregular Bleeding (Etiology)

Understanding the cause of AUB is critical, and doctors use a widely accepted classification system called PALM-COEIN (by FIGO) to categorize the reasons. AAFP+1

PALM-COEIN stands for:

A. Structural causes (PALM):

  1. Polyps — benign growths in the uterine lining. MSD Manuals+1
  2. Adenomyosis — when endometrial tissue grows into the uterine muscle wall. MSD Manuals
  3. Leiomyoma (fibroids) — benign tumors (myomas) in the uterine wall (submucosal, intramural, subserosal). PubMed
  4. Malignancy and hyperplasia — abnormalities such as endometrial hyperplasia or cancer. PubMed+1

B. Non-structural causes (COEIN):

  1. Coagulopathy — bleeding disorders (e.g., von Willebrand disease). AAFP
  2. Ovulatory dysfunction — problems with ovulation (anovulation, irregular ovulation) such as in PCOS, thyroid dysfunction, pituitary issues. AAFP+1
  3. Endometrial causes — problems with the lining itself, such as localized sensitivity or abnormal repair. PubMed
  4. Iatrogenic — caused by medication or medical devices, e.g., hormonal contraceptives, IUDs. MSD Manuals
  5. Not yet classified — causes that do not fit in the above categories. PubMed

Many patients may have more than one contributing factor.

Clinical Evaluation / Diagnosis

A systematic evaluation — history, physical exam, investigations — is the first step.

  1. Medical History
    • Detailed menstrual history: track the bleeding pattern — frequency, duration, volume (for example, how many pads/tampons per day), presence of clots, pain, associated symptoms. AAFP
    • Risk factors: check for systemic diseases (thyroid, bleeding disorders), medications (anticoagulants, hormonal therapy), prior gynecologic issues.
    • Reproductive history: pregnancies, miscarriages, desire for fertility.
    • Symptoms: fatigue, signs of anemia, bleeding after sex, weight changes.
  2. Physical Examination
    • General physical exam: look for signs of anemia, thyroid disease, systemic illness. AIIMS Rishikesh
    • Pelvic exam: speculum exam to look for cervical pathology, polyps; bimanual exam for uterine size (fibroids, adenomyosis), adnexal masses. AAFP+1
  3. Lab Investigations
    • Pregnancy test: All women of reproductive age with irregular bleeding should be tested to rule out pregnancy. AAFP
    • Complete blood count (CBC): To check for anemia or platelet issues. AAFP
    • Coagulation tests: If bleeding disorder suspected — platelet count, PT, PTT, or more specific tests (e.g., for von Willebrand disease). AAFP
    • Hormonal assays: If ovulatory dysfunction is suspected — TSH (thyroid), prolactin, FSH/LH, androgens as needed. AAFP+1
  4. Imaging
    • Transvaginal ultrasound: First-line imaging for structural causes (polyps, fibroids). AAFP+1
    • Saline-infusion sonohysterography: More sensitive to detect intracavitary lesions like polyps or submucosal fibroids. AAFP+1
    • Magnetic Resonance Imaging (MRI): Rarely, if ultrasound is inconclusive and more detail is needed. AAFP
  5. Endometrial Sampling / Biopsy
    • Indicated in women ≥ 45 years, or in younger women with risk factors (obesity, PCOS, unopposed estrogen) or persistent bleeding despite treatment. AAFP
    • Office endometrial biopsy is preferred. If sampling is inadequate, a hysteroscopic-directed biopsy or dilation and curettage may be needed. Fogsi
  6. Further Procedures
    • Hysteroscopy: Allows direct visualization of the uterine cavity, and polyps or submucosal fibroids can be removed. PubMed
    • Dilation and Curettage (D&C): In some cases, especially when biopsy fails or for diagnostic sampling. Fogsi

Treatment and Management

The management of irregular bleeding depends on the cause, severity, patient’s age, fertility desires, and how the bleeding affects her quality of life.

Medical (First-Line) Treatment

According to clinical guidelines and evidence-based medicine, medical therapy is generally the first approach once serious structural causes are ruled out. PubMed+2Fogsi+2

Key options include:

  1. Hormonal Therapy
    • Levonorgestrel-Releasing Intrauterine System (LNG-IUS): Very effective; reduces menstrual blood loss significantly, often recommended as first-line for chronic AUB. NCBI+1
    • Combined Oral Contraceptives (COCs): Estrogen + progestin pills help regulate bleeding and reduce blood loss. AAFP
    • Progestin-only Therapy:
      • Medroxyprogesterone acetate, norethindrone, or depot progestin can be used. PubMed
      • Continuous or cyclic dosing depending on the situation. NCBI
  2. Non‑Hormonal Medications
    • Tranexamic Acid: An antifibrinolytic that helps reduce heavy bleeding. NCBI
    • NSAIDs: Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen) reduce bleeding by lowering prostaglandin levels. MSD Manuals
    • Iron Supplements: To correct or prevent anemia due to chronic blood loss. MSD Manuals
  3. Other Medical Options
    • Gonadotropin-Releasing Hormone (GnRH) Agonists / Antagonists: Sometimes used when fibroids are contributing; helps shrink fibroids temporarily, but they have side effects, and “add-back” therapy may be needed. NCBI
    • Supportive Care: Includes antiemetics (if hormonal therapy causes nausea), close monitoring, and periodic blood tests.

Surgical / Procedural Treatment

If medical therapy fails, is not tolerated, or if there are significant structural lesions, procedural options are considered.

  1. Hysteroscopic Polypectomy
    • Polyps can be removed via hysteroscopy, especially in women who want to preserve fertility. Fogsi
  2. Myomectomy
    • Surgical removal of fibroids (leiomyomas) to alleviate bleeding while preserving the uterus. Wikipedia
  3. Endometrial Ablation
    • The lining of the uterus is destroyed (using heat, laser, microwave, freezing, etc.) to reduce or stop bleeding. Good for women who do not wish to conceive further. Cleveland Clinic
  4. Uterine Artery Embolization (UAE)
    • A minimally invasive procedure to block blood flow to fibroids, causing shrinkage. Cleveland Clinic
  5. Hysterectomy
    • Definitive surgical removal of the uterus; considered when other treatments fail or in cases of malignancy/hyperplasia, or when no future fertility is desired. NCBI

When to Seek Urgent Medical Attention

Some bleeding scenarios require immediate medical attention:

  • Hemodynamic instability (very heavy bleeding, signs of anemia, dizziness, weakness). NCBI
  • Bleeding that soaks through a pad/tampon in an hour or less repeatedly. NCBI
  • Symptoms of hypovolemia (low blood pressure, fast heartbeat, fainting).
  • Persistent bleeding despite medical treatment.
  • Suspicion of malignancy or abnormal biopsy results.

Risks, Complications & Long-Term Impact

  • Anemia: Chronic blood loss can lead to iron deficiency anemia, causing fatigue, weakness, and reduced quality of life. Cleveland Clinic
  • Endometrial Hyperplasia / Cancer: Unopposed estrogen (especially in anovulatory bleeding) can lead to thickening of the endometrium and increase the risk of hyperplasia or cancer. PubMed
  • Reduced Fertility: Depending on the cause (e.g., fibroids, polyps), there may be an impact on fertility.
  • Psychosocial Impact: Irregular or heavy bleeding can affect daily life, work, intimacy, and emotional well-being.
  • Surgical Risks: Procedures like myomectomy or hysterectomy come with typical surgical risks — infection, bleeding, recovery time.

Follow-Up and Monitoring

  • Regular follow-up is essential to assess response to treatment, check for side effects, and tweak therapies as needed.
  • Ultrasound or imaging may need to be repeated if structural lesions were suspected.
  • Endometrial sampling may need to be repeated if symptoms persist or biopsy was inconclusive.
  • Blood tests (CBC, ferritin) to monitor anemia and response to iron therapy.
  • For women using LNG-IUS or hormonal therapy, periodic check-ins to assess satisfaction, side effects, and bleeding patterns.

Prevention and Lifestyle Measures

While not all causes of irregular bleeding can be prevented, some lifestyle and supportive measures can help:

  1. Maintain a Healthy Weight: Obesity can lead to hormonal imbalances (e.g., more estrogen), contributing to AUB.
  2. Manage Underlying Conditions: Control thyroid disease, PCOS, or other endocrinopathies.
  3. Avoid Trigger Drugs: Review medications with your doctor to avoid or adjust medications that may worsen bleeding (e.g., anticoagulants, certain hormonal therapies).
  4. Track Menstrual Cycles: Use a period tracker app or diary to note bleeding patterns, flow, and symptoms; this helps in diagnosis.
  5. Iron-rich Diet or Supplements: If there’s chronic blood loss, nutritional support helps.
  6. Stress Management: Stress can influence hormonal balance. Regular exercise, good sleep, and relaxation techniques help.

Communicating With Your Doctor (As Dr. Pothireddy Surendranthreddy Might Advise)

  • Bring a menstrual diary: Track bleeding, pads/tampons used, duration, clots, associated symptoms.
  • Be honest about symptoms: Even if menstrual bleeding feels “normal” to you, mention fatigue, dizziness, heavy flow, or days off work.
  • Ask about all options: Medical therapy, IUDs, minimally invasive surgery — know the pros and cons.
  • Discuss fertility goals: If you want children later, management might differ.
  • Follow-up regularly: After starting treatment, keep appointments to monitor how well it’s working.

Challenges and Myths

  1. “Bleeding between periods is just stress”: Not always — it could be structural or hormonal and needs evaluation.
  2. “Surgery is the only solution”: Not true — many women respond well to medical therapy; LNG-IUS and medications are first-line for many. PubMed
  3. “If I’m anemic, only a blood transfusion will work”: Often, iron supplements and treating the bleeding cause are enough.
  4. “Hormonal therapy causes cancer”: Modern hormonal therapies, when used correctly, are generally safe; risks and benefits must be discussed.

Case Scenarios (Examples)

Here are a few simplified patient scenarios illustrating how AUB might be managed:

  1. Case A — Young woman (age 30), wants children
    • Presents with irregular, heavy bleeding every 2–3 weeks for months.
    • Work-up shows no fibroids on ultrasound, blood tests normal, hormonal profile suggests anovulation.
    • Management: Start combined oral contraceptive pills, monitor bleeding, counsel on LNG-IUS later if bleeding persists, provide iron supplements.
  2. Case B — Perimenopausal woman (age 45), no desire for future fertility
    • Bleeding is prolonged (7–10 days), sometimes very heavy.
    • Ultrasound finds a submucosal fibroid.
    • Management: Offer LNG-IUS (if uterine cavity allows), or consider endometrial ablation. If that fails, discuss hysterectomy.
  3. Case C — Woman with known fibroids
    • Diagnosed with intramural fibroids; heavy bleeding affecting quality of life.
    • Management: Medical therapy first (tranexamic acid, hormonal therapy), periodic imaging; if bleeding persists, consider myomectomy or uterine artery embolization depending on size, location, fertility, and patient preference.

Limitations and Considerations

  • Diagnostic delays: Some women may delay seeking help due to stigma, assuming “bleeding is normal.”
  • Resource constraints: In some settings, advanced imaging (e.g., sonohysterography, MRI) or office hysteroscopy may not be readily available.
  • Side effects of treatments: Hormonal therapy can cause nausea, mood changes; surgical options carry risks.
  • Follow-up compliance: It’s important for patients to attend follow-ups to assess effectiveness and side effects.

Summary and Key Take‑Home Points

  • Irregular uterine bleeding (AUB) is very common and can significantly impact life and health.
  • A structured approach using the PALM-COEIN classification helps in accurate diagnosis.
  • Evaluation includes history, physical, labs, imaging, and possibly endometrial biopsy.
  • First-line treatment is often medical (hormonal therapy, tranexamic acid, NSAIDs), unless structural lesions demand surgery.
  • Multiple surgical options exist if needed (polypectomy, myomectomy, ablation, hysterectomy).
  • Monitoring and follow-up are critical.
  • Lifestyle modifications and patient education play a key role.
  • The choice of therapy must be individualized based on the patient’s symptoms, age, fertility goals, and preferences.

References & Further Reading

Here are some reliable sources for further reading:

  • Cleveland Clinic – Abnormal Uterine Bleeding: Diagnosis & Treatment Cleveland Clinic
  • MSD Manual – AUB in Women: Causes, Diagnosis & Treatment MSD Manuals
  • PubMed – “The medical management of abnormal uterine bleeding in reproductive‑aged women” PubMed
  • Federation of Gynecology & Obstetrics (FIGO) / PALM‑COEIN classification PubMed+1
  • FOGSI (Federation of Obstetric and Gynaecological Societies of India) — Clinical practice guidelines on AUB Fogsi+1

Disclaimer & Note for Patients

  • This guide is informational only and not a substitute for medical advice.
  • If you are experiencing irregular or heavy bleeding, you should consult a qualified gynecologist (such as Dr. Pothireddy Surendranthreddy or any local specialist) who can evaluate you personally and recommend the right tests/treatment based on your condition.

1.    https://pothireddysurendranathreddy.blogspot.com/2025/11/adequate-sleep-benefits.html                                                  sleep benefits

2.    https://pothireddysurendranathreddy.blogspot.com/2025/11/primary-care-of-heart-attack-myocardial.html                              heart attack

3.    https://pothireddysurendranathreddy.blogspot.com/2025/11/vision-problems-in-children.html                                                          vision problem in kids

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