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The inside of the uterus has two layers. The thin inner layer is called the endometrium. The thick outer muscular wall is the myometrium. Menstruation occurs 10 to 14 days after ovulation. In women who ovulate and menstruate regularly, the endometrium thickens every month in preparation for pregnancy. If the woman does not become pregnant, the endometrial lining is shed during the menstrual period. With menopause, ovulation stops and the lining stops growing and shedding.

Under normal circumstances, a woman’s uterus sheds a limited amount of blood during each menstrual period (less than 5 tablespoons or 80 mL). Bleeding that occurs erratically or excessive regular menstrual bleeding is considered to be abnormal uterine bleeding. Once a woman who is not taking hormone therapy enters menopause and the menstrual cycles have ended, any uterine bleeding is considered abnormal. Abnormal uterine bleeding can be caused by many different conditions


Most conditions that cause abnormal uterine bleeding can occur at any age, but some are more likely to occur at a particular time in a woman’s life.

Abnormal uterine bleeding in young girls

Bleeding before menarche (the first period in a girl’s life) is always abnormal. It may be caused by trauma, a foreign body (such as toys, coins, or toilet tissue), irritation of the genital area (due to bubble bath, soaps, lotions, or infection), or urinary tract problems. Bleeding can also occur as a result of sexual abuse.


Many girls have episodes of irregular bleeding during the first few months after their first menstrual period. This usually resolves without treatment when the girl’s hormonal cycle and ovulation normalizes. If irregular bleeding persists beyond this time, or if the bleeding is heavy, further evaluation is needed.

Abnormal bleeding in teens can also be caused by any of the conditions that cause bleeding in all premenopausal women, including: pregnancy, infection, and bleeding disorder or other medical illnesses.

Premenopausal women

Many different conditions can cause abnormal bleeding in women between adolescence and menopause. Abrupt changes in hormone levels at the time of ovulation can cause vaginal spotting, or small amounts of bleeding. Breakthrough bleeding can also occur in premenopausal women who use hormonal birth control methods.

Some women do not ovulate regularly and may experience unpredictable light or heavy vaginal bleeding. Although irregular ovulation is most common when periods first begin and during perimenopause, it can occur at any time during the reproductive years. Some women who ovulate regularly experience excessive blood loss during their periods or bleed between periods. The most common causes of such bleeding are uterine fibroids, uterine adenomyosis, or endometrial polyps. Fibroids are benign masses in the muscle layer of the uterus (myometrium), while adenomyosis is a condition in which the lining of the uterus (endometrium) grows into the myometrium. Endometrial polyps are fleshy (usually benign) growths of tissue which project into the uterine cavity. These conditions are common causes of abnormal uterine bleeding. Fibroids, adenomyosis and polyps can also occur in anovulatory women.

Other causes of abnormal uterine bleeding in premenopausal women include:

  • Pregnancy
  • Cancer or precancer of the cervix or the endometrium (lining of the uterus) (see
  • Infection or inflammation of the cervix or endometrium
  • Clotting disorders such as von Willebrand disease, platelet abnormalities, or problems with clotting factors
  • Medical illnesses such as hypothyroidism, liver disease, or chronic renal disease

Hormonal birth control

Girls and women who use hormonal birth control (eg, pills, ring, patch) may experience “breakthrough” bleeding between periods. If this occurs during the first few months, it may be due to changes in the lining of the uterus. If it persists for more than a few months, evaluation may be needed and/or a different birth control pill may be recommended.

Breakthrough bleeding can also happen if a hormonal birth control method is forgotten or taken late. In this situation, there is a risk that the woman could become pregnant if she has sex. An alternate or “back-up” form of birth control (eg, condoms) is recommended if the pill/patch/shot is not taken on time.

Women in the menopausal transition

Before menstrual periods end, a woman passes through a period called the menopausal transition or perimenopause. During the menopausal transition, the timing of periods begins to change as ovulation becomes less regular. While ovaries in perimenopausal women continue to make estrogen, progesterone secretion declines. These hormonal changes can cause the endometrium to grow and produce excess tissue, increasing the chances that polyps or endometrial hyperplasia (thickened lining of the uterus that can progress to cancer) will develop and potentially cause abnormal bleeding. The menopausal transition is a time when women are more likely to experience abnormal uterine bleeding.

Women in the menopausal transition are also at risk for other conditions that cause abnormal bleeding, including cancer, infection, and body-wide (systemic) illnesses. Further evaluation is needed in women with persistent irregular menstrual cycles or an episode of profuse bleeding.

Women in the menopausal transition still ovulate some of the time and can become pregnant; pregnancy itself can cause abnormal bleeding. In addition, women in perimenopause may use hormonal birth control medications, which can cause breakthrough bleeding.

Menopausal women

Any other bleeding that occurs during menopause is abnormal and should be investigated. Causes of abnormal bleeding during menopause include:

  • Atrophy or excessive thinning of the tissue lining the vagina and uterus, caused by low hormone levels
  • Cancer or precancerous changes (hyperplasia) of the uterine lining (endometrium) (see
  • Polyps or fibroids
  • Infection of the uterus
  • Use of blood thinners or anticoagulants
  • Side effects of radiation therapy


Initial assessment

While taking a woman’s medical history, a clinician will review the duration and amount of bleeding; factors that seem to bring the bleeding on; symptoms that occur along with the bleeding such as pain, fever, or vaginal odor; if bleeding occurs after sexual intercourse; whether there is a personal or family history of bleeding disorders; the woman’s medical history and medications she is taking; recent weight changes, stress, a new exercise program, or underlying medical problems.

The clinician will perform a physical examination to evaluate the woman’s overall health, and a pelvic examination to confirm that the bleeding is from the uterus and not from another site (eg, the external genitals or rectum). During the pelvic exam, the clinician will look for any obvious lesions (cuts, sores, or tumors) and will examine the size and shape of the uterus. He or she will examine the cervix to look for signs of cervical bleeding, and a Pap smear/human papillomavirus (HPV) test may be obtained to screen for cervical cancer (the cervix is at the lower end of the uterus, where it opens to the vagina)

Lab tests

In premenopausal women, a pregnancy test is performed. If there is any abnormal vaginal discharge, a cervical test may be performed. Blood tests may also be done to determine if anemia (low blood count) is present or if there are problems with blood clotting or other body-wide conditions, such as thyroid disease, liver disease, or kidney problems.

Tests to determine ovulatory status

As hormonal irregularities can contribute to abnormal uterine bleeding, testing may be recommended to determine if the woman ovulates (produces an egg) during each monthly cycle.

Endometrial assessment

Tests that assess the endometrium (lining of the uterus) may be performed to rule out endometrial cancer and structural abnormalities such as uterine fibroids or polyps. Such tests include:

During the biopsy, a thin instrument is inserted through the vagina and cervix into the uterus to obtain a small sample of endometrial tissue. The biopsy (which often causes temporary severe uterine cramping) can be performed in a healthcare provider’s office without anesthesia. Because only a small portion of the endometrium is sampled, the biopsy may miss some causes of bleeding and other tests are sometimes necessary.

Transvaginal ultrasound

An ultrasound uses sound waves to measure an organ’s shape and structure. In a transvaginal ultrasound, an ultrasound probe is inserted into the vagina so that it is closer to the uterus and can provide a clear image of the uterus. The lining of the uterus is evaluated and measured; postmenopausal women normally have a thin endometrial lining; in postmenopausal women with uterine bleeding, if the lining is thicker than 4 or 5 mm, additional evaluation with an endometrial biopsy may be appropriate. Ultrasound cannot distinguish between different types of abnormalities (eg, polyp versus cancer) and further testing may be necessary.


During hysteroscopy, a small scope is inserted through the cervix and into the uterus. Air or fluid is injected to expand the uterus and to allow the physician to see the inside of the uterus. Tissue samples may be taken. Anesthesia may be used to minimize discomfort during the procedure. Hysteroscopy may be performed in the office or in a same-day surgery in an operating room.

Dilation and curettage (D&C)

In a D&C, the cervix or opening of the uterus is dilated and instruments are inserted and used to remove endometrial or uterine tissue. A D&C usually requires anesthesia.


The treatment of abnormal bleeding is based upon the underlying cause.

Birth control pills

Birth control pills are often used to treat uterine bleeding that is due to hormonal changes or hormonal irregularities. Nonsteroidal anti-inflammatory drugs (NSAIDS, eg ibuprofen, naproxen sodium) may also be helpful in reducing blood loss and cramping in these women.


Surgery may be necessary to remove abnormal uterine structures (eg, fibroids, polyps). Women who have completed childbearing and have heavy menstrual bleeding can consider a surgical procedure such as endometrial ablation. This procedure may be performed in a gynecologist’s office or in an operating room as a same-day surgery, and uses heat, cold, electrical energy, or a laser to destroy the lining of the uterus.

Intrauterine device

An intrauterine contraceptive device (IUD) that secretes progestin (eg, Mirena, Liletta, Kyleena, or Skyla) may be recommended for women who have abnormal uterine bleeding. IUDs are T-shaped devices inserted by a healthcare provider through the vagina and cervix into the uterus. IUDs include an attached plastic string that projects through the cervix, enabling the woman to check that the device remains in place.

Progestin-releasing IUDs decrease menstrual blood loss by more than 50 percent and decrease pain associated with periods. Some women completely stop having menstrual bleeding as a result of the IUD, which is reversible when the IUD is removed.