Menstrual disorders are fairly common during a woman’s reproductive years and can cause significant physical and psychological distress.
Normal menstruation starts at menarche around age 12, and lasts until menopause at around 50 years of age. This bleeding is controlled by the hypothalamo-pituitary-ovarian axis and consists of cyclical changes in the ovary as well as the endometrium (inner uterine lining). Normal menstruation consists of blood and uterine cellular debris. It usually lasts between 2 and 7 days and occurs every 21 to 35 days.
Abnormal uterine bleeding
Abnormal uterine bleeding may be the prolongation of bleeding beyond 7 days, heavy if clots are present, bleeding that stains cloth or causes anaemia, bleeding more frequent than 21 days or delayed more than 35 days, intermenstrual or post-menopausal bleeding or bleeding in which the cyclical pattern is lost. The term ‘dysfunctional uterine bleeding’ implies that there is no structural or pathological cause to this, but only an endocrine abnormality.
Causes of abnormal uterine bleeding in the teenage years are anovulation, pelvic infection, use of hormonal pills as well as disorders of coagulation and hormone-producing tumours. In the reproductive years, the causes are pregnancy, polyps, adenomyosis, fibroids, anovulation, endometrial hyperplasia and endometrial cancers. In the peri-menopausal age group, anovulation, endometrial hyperplasia, endometrial cancer and endometrial atrophy are likely to be the causes.
Managing abnormal bleeding
The goals of management are based on the age of the patient, desire for fertility, family history of cancers and functional disability. Investigations would include checking haemoglobin levels, renal and liver function, coagulation disorders, ultrasound scans, cervical cytology and an endometrial biopsy. The doctor would want to know about prior investigations and treatments and establish the cause of the bleeding problem. Patients would be advised on menstrual hygiene and how to keep a menstrual diary. The pattern of bleeding needs to be assessed over a few months. Severe bleeding may need to be controlled, and anaemia corrected with iron supplements or blood transfusion. Pain may also be a problem and that needs to be alleviated.
In adolescents, heavy menstrual bleeding can lead to emotional distress, absenteeism from school, social withdrawal and anaemia. After a detailed history and physical examination, tests are done to rule out liver, renal and coagulation disorders. An ultrasound scan is done to rule out fibroids and ovarian cysts. Endometrial biopsy is only rarely done. Girls are taught to cope with heavy menses by keeping track of menses, using high absorbency pads, ensuring menstrual hygiene, staying hydrated, consuming iron-rich foods and controlling body weight. Non-hormonal medications including Tranexamic acid and Mefenamic acid are first-line treatments. If menses are not controlled with these, then hormonal treatment such as progesterones or oral contraceptive pills are prescribed. Surgery is rarely indicated and only for large fibroids or ovarian tumours.
In the reproductive years, pregnancy has to always be ruled out. The causes of abnormal uterine bleeding are polyps, adenomyosis, fibroids, endometriosis, malignancy, hyperplasia, endometrial disorders, and iatrogenic reasons. Treatment of the underlying cause must be carried out. Bleeding and pain can be controlled by Tranexamic acid, Mefenamic acid, oral and injectable progestogens, combined pills, a levonorgestrel intrauterine device, mifepristone, ormeloxifene and gonadotrophin analogues. Surgery can be done endoscopically: laparoscopic, robotic or hysteroscopic. In younger women, surgery is most often organ preserving.
In the perimenopausal and post-menopausal group, malignancy and hyperplasia have to be ruled out. The risk of malignancy with post-menopausal bleeding is 10 to 20%. An endometrial biopsy is a must in this age group before hysterectomy. In these women, removal of the uterus is done more readily. All treatments, both medical and surgical have complications. So, the doctor should weigh the risks and benefits as well as take into consideration the wishes and desires of the patient before embarking on any treatment. It is a principle that the simplest, safest and most cost-effective option should be chosen.
What women should know
Women should understand their bodies, and the changes in physiology with time. They should not ignore menstrual problems and must undergo regular gynaecological check-ups. Timely treatment can spare them from unnecessary psychological and physical distress. A healthy lifestyle, a preventive approach to health and good health-seeking behaviours can go a long way in ensuring a good quality of life.
This article was first published in The Hindu’s e-book Care and Cure
(Dr. Abraham Peedicayil is senior consultant, gynae-oncology, Naruvi Hospitals, Vellore apeedicayil@yahoo.com; P.B. Akilasree is senior consultant, obstetrics and gynaecology, Naruvi Hospitals, Vellore akilasree.pb@naruvihospitals.com; Jeyasheela Kamaraj is consultant, obstetrics and gynaecology, Naruvi Hospitals, Vellore jeyasheela.k@naruvihospitals.com)
Published – January 16, 2026 03:33 pm IST