The menstrual cycle is not the same for every woman. Normal menstrual flow occurs about every 28 days, lasts about 4 days, and produces a total blood loss of 30 to 80 milliliters (2 tablespoons to about 1 cup). Periods may be regular, irregular, light, heavy, painful, pain-free, long, or short, and still be normal. Variation in the menstrual cycle is medically less significant than bleeding, pain, or discharge between periods.

Bleeding may be something to worry about for women over age 50 (postmenopausal). The risk of malignancy increases with age.

Make sure that bleeding is coming from the vagina and not from the rectum or in the urine. This can be accomplished by inserting a tampon into the vagina to confirm that the vagina is the source of the bleeding. A serious problem can best be detected by a health care provider.

• Anovulation (failure of ovaries to produce, mature, or release eggs)
• Endometrial polyps
• Endometrial hyperplasia and cancers
• Uterine fibroids
• Abnormal thyroid or pituitary function
• Pregnancy complications (miscarriage or ectopic)

Bed rest may be recommended if bleeding is heavy.

The number of pads or tampons used should be recorded (so that the doctor can determine the amount of bleeding). Change tampons regularly, at least twice a day.

Because aspirin may prolong bleeding, it should be avoided if possible. For menstrual cramps, use ibuprofen (for example, Advil or Nuprin). Ibuprofen is usually more effective than aspirin for relieving menstrual cramps.

If you use an IUD for birth control, slight spotting is normal if you are not pregnant. If no other symptoms are present, the spotting is probably insignificant.

• You are pregnant!
• You have severe pain, or if periods have been heavy and recurrent over 3 or more months.
• You have bleeding after menopause.
• You have abnormal bleeding accompanied by other symptoms.
• You have severe pain that does not respond to home treatment.

The medical history will be obtained and a physical examination performed.

Medical history questions documenting abnormal menstrual periods in detail may include:

• Menstrual history
  • Are you a woman presently in a menstruating age group?
  • Was the previous menstrual period a normal amount?
  • Do you use tampons?
  • Do you normally have regular periods?

• Quality
  • Has there been passage of blood clots?
  • How long per menstrual period is the bleeding?
  • How heavy is it?

• Time pattern
  • When was the last menstrual period?
  • What was the age at which you had your first menstrual period?
  • How long have you had the same menses pattern?

• Aggravating factors
  • Do you use birth control pills?
  • Do you take an estrogen supplement?
  • Do you use an IUD for birth control?
  • Do you take aspirin more than once per week?
  • Do you take Coumadin, heparin, or other anticoagulant?
  • Has there been a recent childbirth, surgery on or near the vagina or uterus, vaginal infection, uterine infection, or other possible source of trauma to the vagina or uterus?

• Other
  • What other symptoms are also present?
  • Is there abdominal pain?
  • Is there pelvic pain?
  • Is there morning nausea or vomiting?
  • Is there a growth or lump on the genitals?
  • Is there a genital lesion?
  • Is there known pregnancy?
  • Are you vomiting blood?
  • Is there blood in the stools?
  • Is there bleeding into the skin or easy bruising?

The physical examination may include a pelvic examination if the patient is in the premenstrual phase of the menstrual cycle (particularly if endometriosis is suspected). Uterine blood loss can be estimated if the patient knows how many sanitary napkins or tampons were used during a period.

Diagnostic tests that may be performed include:

• Pap smear (if bleeding is inactive)
• Endometrial biopsy
• Pelvic ultrasound
• Lab tests such as thyroid function tests, CBC, pregnancy test

Intervention:
Ibuprofen or another prostaglandin inhibitor is often prescribed. Ibuprofen is also available in lower dosages (Advil, Nuprin) without prescription.

In some cases of heavy bleeding, dilation and curettage, "D and C", may be required if high dose intravenous estrogen therapy fails.

If a tumor is found, surgery (a hysterectomy) will sometimes be needed, but the common "fibroid" tumor (uterine fibroids) may stop growing by itself, and surgery may not be needed depending on the amount of bleeding and the response to various treatment attempts. Such tumors often grow slowly and stop growing at menopause, so an operation can be avoided by waiting. However, if there has been rapid growth of the fibroid tumor or if the Pap smear is abnormal, surgery or other type of therapy may be necessary.

If the heavy bleeding is related to hormonal abnormalities, treatment of the specific abnormality will correct the bleeding. Female hormones (birth control pills or progestins) are commonly used to regulate menses.

After seeing your health care provider:
If a diagnosis was made by your health care provider related to abnormal menstrual periods, you may want to note that diagnosis in your personal medical record.