Abnormal Uterine Bleeding: When Is Bleeding Not a Normal Period?

Periods are not always perfectly predictable. Your cycle can change with stress, hormonal contraception, illness, changes around puberty or perimenopause, and many other factors.

But sometimes bleeding is different enough from your usual pattern that it deserves medical attention. This is known as abnormal uterine bleeding (AUB). So, what counts as abnormal bleeding, what can cause it, and when should you see a doctor?

What is abnormal uterine bleeding?

Abnormal uterine bleeding refers to bleeding from the uterus that is different from your expected menstrual pattern.

This could mean:

• Periods that are unusually heavy

• Bleeding that lasts longer than usual

• Periods that occur very frequently

• Periods that are very far apart or unpredictable

• Bleeding between periods

• Bleeding after sex

• Bleeding after menopause

• Bleeding when you are not expecting a period

What is "normal" can vary from person to person, so an important question is whether your bleeding has changed from your usual pattern.

How heavy is too heavy?

It can be difficult to judge how much menstrual bleeding is actually "too much".

Heavy menstrual bleeding may involve:

• Needing to change a pad or tampon very frequently

• Bleeding through sanitary protection or clothing

• Passing large blood clots

• Needing to use more than one type of menstrual product at the same time

• Periods that interfere with school, work, sleep or normal activities

• Feeling exhausted, weak or short of breath during or after your period

  
  

Heavy bleeding can sometimes lead to iron-deficiency anaemia, particularly when it continues over a long period of time. You don't have to measure your menstrual blood loss to know that something is wrong. If your periods have become significantly heavier or are interfering with your everyday life, it is reasonable to discuss them with a doctor.

What can cause abnormal uterine bleeding?

There isn't one single cause. Abnormal bleeding can happen because of changes in hormones, problems affecting the uterus, certain medications, pregnancy-related conditions, or medical conditions elsewhere in the body.

Some possible causes include:

Hormonal changes

Hormonal fluctuations can affect when ovulation occurs and how the lining of the uterus develops.

This can happen during:

• The first few years after starting periods

• The years approaching menopause (perimenopause)

• Times of significant hormonal change

• Some forms of hormonal contraception

Irregular bleeding is particularly common during perimenopause, but new or unusually heavy bleeding should not automatically be attributed to "just hormones".

Fibroids and polyps

Fibroids are non-cancerous growths that develop in or around the uterus. Depending on their size and location, they can cause heavy or prolonged periods.

Polyps are growths that arise from the lining of the uterus and can sometimes cause irregular bleeding or bleeding between periods.

Adenomyosis

Adenomyosis occurs when tissue similar to the lining of the uterus grows into the muscular wall of the uterus. It can cause heavy or prolonged periods and may be associated with painful periods.

Endometriosis

Endometriosis occurs when tissue similar to the lining of the uterus grows outside the uterus.

It is particularly associated with pelvic pain and painful periods, but some people may also experience changes in bleeding.

Pregnancy

If pregnancy is possible, unexpected bleeding should not simply be assumed to be a period. The bleeding may be related to pregnancy. Bleeding during pregnancy has several possible causes and may require assessment, particularly when accompanied by pain, dizziness or heavy bleeding.

Medications and contraception

Some medications and contraceptive methods can change bleeding patterns.

This can happen with hormonal contraception, intrauterine devices (IUDs), blood-thinning medication and some other medicines. If bleeding begins after starting or changing a medication or contraceptive method, mention this to your doctor.

What about bleeding after sex?

Bleeding after sex is sometimes caused by irritation, but it can also have other causes, including infections, cervical changes or abnormalities of the cervix.

If you repeatedly bleed after sex, it is worth having this assessed rather than simply assuming it is normal for you.

Your doctor may recommend an examination, cervical screening if it is due, STI testing, or other investigations depending on your age, symptoms and medical history.

What about bleeding after menopause?

Bleeding after menopause should always be assessed by a healthcare professional.

Even if the bleeding is light or only happens once, it is important to have it checked.

There are several possible causes, many of which are not cancerous. However, bleeding after menopause can sometimes be an early sign of cancer of the lining of the uterus, so it should not be ignored.

When should I see a doctor?

Make an appointment with your GP if:

• Your periods have suddenly become much heavier

• Your periods are lasting significantly longer than usual

• You regularly bleed between periods

• You repeatedly bleed after sex

• Your periods have become very irregular without an obvious explanation

• You have developed new bleeding during or after perimenopause

• You have symptoms of anaemia, such as unusual tiredness, weakness or shortness of breath

• Your bleeding is affecting your everyday life

  
  

Your doctor can help determine whether you need testing or further investigation.

What will the doctor ask?

Talking about menstrual bleeding can feel awkward, but these questions are an important part of medical care.

Your doctor may ask:

• When did your last period start?

• How long do your periods usually last?

• How often do they occur?

• How has the bleeding changed?

• How frequently are you changing sanitary products?

• Are you passing clots?

• Do you have pelvic or abdominal pain?

• Are you bleeding between periods or after sex?

• Could you be pregnant?

• What contraception are you using?

• What medications are you taking?

• When was your last cervical screening test?

  
  

You may find it useful to keep a simple record of your periods and bleeding before your appointment.

What tests might be needed?

The investigations depend on your symptoms, age and medical history. Your doctor may recommend blood tests, including a blood count to check for anaemia. A pregnancy test may be appropriate if pregnancy is possible. Depending on the situation, you may also need an examination, STI testing, cervical screening if due, or an ultrasound scan. Not everyone with abnormal bleeding needs every test. The aim is to identify the likely cause while avoiding unnecessary investigations.

Treatment depends on the cause

There isn't one treatment for abnormal uterine bleeding. Treatment may include managing an underlying medical condition, changing contraception, medication to reduce bleeding, treating anaemia, or referral to a gynaecologist when appropriate. If fibroids, polyps, adenomyosis or another structural problem is suspected, further assessment may be needed.

Your treatment should be based on why you are bleeding, rather than simply trying to stop the bleeding without finding out what is causing it.

When is heavy bleeding an emergency?

Heavy bleeding can occasionally require urgent medical attention. Seek urgent medical care if you are experiencing very heavy bleeding, particularly if you feel faint, dizzy, unusually weak, short of breath, or otherwise seriously unwell. Severe pelvic or abdominal pain, particularly when pregnancy is possible, also requires urgent assessment.

Online consultations are not suitable for emergencies. If you think you may have an emergency, seek immediate in-person medical care.

Your period doesn't have to be "perfect"

Menstrual cycles naturally vary, and an occasional early, late or different period is not necessarily a sign that something is wrong. But you know your usual pattern. If your bleeding has changed significantly, is unusually heavy, keeps happening between periods, occurs after sex, or happens after menopause, it is worth finding out why.

You don't have to simply put up with difficult or disruptive bleeding. If you're concerned about abnormal uterine bleeding, an online consultation with Dr Brandt can be a convenient first step. We can discuss your symptoms, consider possible causes, arrange appropriate tests or treatment where suitable, and refer you for an in-person assessment when necessary. Simply book an online GP consultation from the comfort of your home.

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Please note: This article is intended for general information and is not a substitute for an individual medical consultation. Online consultations are not suitable for emergencies or conditions requiring an immediate physical examination.

Dr. Sonja Brandt is an HPCSA registered online GP helping South Africans manage abnormal uterine bleeding and other common conditions – conveniently and legally from home.