Beyond The Menstrual Pad Count: The Truth Of Abnormal Uterine Bleeding

Women’s menstrual cycles often reflect the pace and pressures of daily life. Long hours, stress, irregular sleep, and missed meals can disrupt hormonal balance, making periods arrive early or late, feel heavier, or last longer than usual. While this can be frustrating, it highlights how closely menstrual health is linked to overall physical and emotional well-being. A normal menstrual cycle typically occurs every 21–35 days in adults (21–45 days in adolescents), lasts 3–7 days, and involves moderate bleeding that does not interfere significantly with daily activities. Understanding what is normal helps women recognise when something feels off.
Abnormal uterine bleeding (AUB) refers to any change in the timing, duration, regularity, or amount of menstrual bleeding, including heavy periods, irregular cycles, bleeding between periods, or post-menopausal bleeding. It is not a disease but a sign of possible underlying issues such as hormonal imbalances, fibroids, infections, medication effects, or more serious conditions. Unfortunately, AUB is often under-reported, as many women are taught to normalise heavy or painful periods. Improving awareness and breaking menstrual stigma are essential to ensure early medical evaluation, prevent complications like anaemia, and protect long-term health.

From Taboo To Talked About: Realising How Common Abnormal Uterine Bleeding Is

Research has shown that 30% of women in their reproductive age experience abnormal uterine bleeding, thus making it an extensively clinically glaring worry.

Abnormal uterine bleeding (AUB) varies with age due to hormonal regulation and structural changes in the uterus, and is also influenced by factors such as pregnancy-related issues, infections, systemic diseases, alcohol use, and smoking. In adolescents, AUB is most commonly due to anovulatory cycles caused by an immature hypothalamic-pituitary-ovarian (HPO) axis after menarche, leading to hormonal imbalance and irregular, sometimes heavy bleeding that is usually benign. In reproductive-age women, AUB often results from benign hormonal and structural conditions such as fibroids, endometrial polyps, ovulatory dysfunction, and polycystic ovarian syndrome, which disrupt normal uterine function and menstrual regularity.

In perimenopausal women, declining ovarian function leads to irregular hormone production, frequent anovulation, and a higher incidence of conditions like fibroids, adenomyosis, and endometrial hyperplasia, making AUB more common and clinically significant. While AUB often raises concerns about cancer, most cases are non-cancerous, especially in younger women. However, the risk of endometrial cancer increases after 45 years, particularly in women with obesity, diabetes, chronic anovulation, or prolonged estrogen exposure, necessitating careful evaluation in older women.

Causes Of Abnormal Uterine Bleeding

Abnormal uterine bleeding is not a disease by itself but a symptom that can occur due to many reasons, such as hormonal problems, uterine conditions, blood disorders, or side effects of medicines. Historically, terms like menorrhagia, metrorrhagia, and dysfunctional uterine bleeding were used inconsistently to describe abnormal uterine bleeding, confusing diagnosis and management. This lack of clear terminology sometimes led to delayed diagnosis and improper treatment. To avoid this, a proper classification system became necessary, allowing doctors to focus on identifying the actual cause of the bleeding rather than merely describing its severity or irregularity.
To bring clarity, the International Federation of Gynaecology and Obstetrics (FIGO) introduced the PALM-COEIN classification system. It categorizes the causes of abnormal uterine bleeding into structural causes (PALM), which involve physical problems in the uterus that can be visualized on scans or confirmed by tests, and non-structural causes (COEIN), which are related to hormonal imbalances, medical conditions, or medications. This system helps doctors diagnose the problem accurately, choose the right tests and treatments, and provide better, more focused care to patients.

Structural Causes Of Abnormal Uterine Bleeding (PALM)

Non-structural causes of Abnormal Uterine Bleeding (COEIN)

Right Diagnosis For Abnormal Uterine Bleeding

Abnormal uterine bleeding is identified through a systematic evaluation involving patient history, clinical examination, laboratory tests, and imaging or tissue sampling as needed, with causes classified using the PALM-COEIN system.

To diagnose abnormal uterine bleeding, the doctor first takes a detailed medical history, including how often bleeding occurs, how long it lasts, how heavy it is, and associated symptoms. A normal menstrual period usually lasts between 2 and 7 days. Symptoms such as painful periods, fatigue, weight changes, hot flashes, or excess hair growth may suggest hormonal problems like PCOS. Information about current medications, existing illnesses, family history of bleeding disorders or cancer, and reproductive history is also reviewed.

A physical and pelvic examination is then performed to look for signs of anaemia, thyroid issues, infections, or structural problems. A speculum examination of the cervix is done to look for polyps, infections, or abnormal lesions, and tests like a Pap smear or screening for sexually transmitted infections may be performed. A bimanual examination helps assess the size, shape, and tenderness of the uterus and ovaries to detect any masses or abnormalities.

Laboratory tests such as pregnancy testing, blood counts, iron levels, hormone tests, and clotting studies help identify hormonal or systemic causes.

If necessary, imaging tests such as a transvaginal ultrasound are used to detect fibroids or polyps. Further tests, such as sonohysterography, endometrial biopsy, hysteroscopy, or MRI, may be done in selected cases.

This structured approach allows gynaecologists to accurately identify the cause of abnormal uterine bleeding and plan the most appropriate treatment.

Specific Treatment Plan For Abnormal Uterine Bleeding
Consult a Gynaecologist Now

Gaining Control Over Unpredictable Flows Of Abnormal Uterine Bleeding

Management of abnormal uterine bleeding focuses on both immediate control and long-term treatment. The approach depends on the cause (PALM-COEIN classification), the patient’s age, severity of bleeding, associated medical conditions, and future pregnancy plans. Treatment options include medical therapy, procedures, surgery, and emergency care when needed.

Medical Management or first-line therapy is typically the initial approach for managing long-term abnormal uterine bleeding episodes and can be divided into hormonal and non-hormonal therapies.

Non-hormonal therapies are favoured by patients who do not want hormonal side effects or who desire to maintain their fertility, as they are only used during menstruation. Tranexamic acid (antifibrinolytic) works by preventing the breakdown of fibrin, the protein responsible for the formation of blood clots, and decreases menstrual blood loss by 30-50%. Tranexamic acid does not interfere with ovulation or hormonal levels. Non-steroidal anti-inflammatory drugs are used to reduce prostaglandin levels. Prostaglandin is associated with pain and bleeding. NSAIDs are thus effective in reducing blood flow by 25%-50% along with menstrual pain.

Hormonal treatments for abnormal uterine bleeding stabilise the uterine lining, ensuring a more predictable and lighter shedding pattern. Levonorgestrel-releasing intrauterine system (LNG-IUS) is a long-acting, reversible contraceptive device placed inside the uterus that continuously releases a low dose of progestin. This therapy is known to be the gold standard in treating abnormal uterine bleeding with highly effective long-term management for up to 3-8 years. It is known to reduce blood loss by over 90%. Advantages include long-term efficacy, high satisfaction, effective contraception and minimal side effects. This therapy is combined with combined hormonal contraceptives, progestin-only pills, injections or implants, and gonadotropin-releasing hormone agonists or antagonists.

Surgical treatment of abnormal uterine bleeding is considered when medical management fails or is contraindicated. Dilation and curettage, Hysteroscopy with targeted resection, endometrial ablation, uterine artery embolisation, and hysterectomy are normally the techniques used.

Get A Good Understanding of LNG-IUS Treatment
Talk To A Gynaecologist Now

Beyond the Bleed: Final Perspectives on Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is a common gynaecological condition that reflects disturbances in normal menstrual patterns. It can be caused by an imbalance in hormones, structural abnormalities in the uterus, systemic diseases, or malignancy. Correct diagnosis requires careful clinical evaluation. Early identification and tailored management are important to improve the quality of life and prevent future reproductive problems like anaemia and infertility.

u003ch2u003eTransformative Treatments for Post-Traumatic Stress Disorderu003c/h2u003enu003culu003enu003cliu003eThe effective treatment for Post-traumatic stress disorder centres of attention is to decrease the effect of symptoms, improve functioning, and help individuals in regaining a sense of safety and control.u003c/liu003enu003cliu003eTrauma-focused cognitive behavioural therapy (Tf-CBT) is the most evidence-based psychological treatment that helps in reframing distorted trauma-related thoughts and decreasing avoidance.u003c/liu003enu003cliu003eProlonged exposure therapy is a structured therapy that gradually exposes patients to memories of trauma and avoided situations, which reduces responses of fear and avoidance behaviours.u003c/liu003enu003cliu003eEye movement desensitisation and reprocessing (EMDR) uses guided eye movements while recalling trauma, which helps the brain in reprocessing traumatic memories and decreases the emotional intensity.u003c/liu003enu003cliu003eCognitive processing therapy focuses on the identification and modification of unhelpful trauma-related beliefs like guilt, shame, and blame. Sertraline, paroxetine, fluoxetine, and venlafaxine are medicines that decrease anxiety, intrusive thoughts, and symptoms dependent on mood. Prazosin is often used for trauma-related nightmares, with sleep hygiene and behavioural strategies also being vital.u003c/liu003enu003cliu003eGrounding, relaxation, and emotional regulation are used to process deep traumas, along with group therapy that provides community, reduces loneliness and enables healing. This technique has been quite helpful in cases of veterans, abuse survivors, and disaster survivors.u003c/liu003enu003cliu003eRegular exercise, sleep hygiene, balanced diet, avoiding alcohol, and substance use combined with mindfulness meditation, and yoga reduce hyperarousal and reconnect the body awareness.u003c/liu003enu003cliu003ePost-traumatic stress disorder can recur due to stress, so long-term monitoring and booster therapy sessions help in maintaining the recovery phase.u003c/liu003enu003c/ulu003e