Menstrual Problems

Periods that are heavy, painful, unpredictable, absent, or simply different from how they used to be are worth investigating. Not because every irregular cycle signals disease — most do not — but because the ones that do are treatable, and because "that's just how my periods are" has left a great many women anemic and exhausted for years.

This service covers the evaluation and treatment of menstrual problems at the Women's Health Center of Chicago.

What counts as a problem

Cycles shorter than 21 days or longer than 35 days, consistently
Bleeding lasting more than 7 days
Soaking through a pad or tampon every hour for several hours, passing clots larger than a quarter, or bleeding through onto clothes and bedding
Bleeding between periods, after sex, or any bleeding after menopause
Pain that stops you working, studying or sleeping, or that is not controlled by over-the-counter medication
No period for three months when you are not pregnant, breastfeeding or on a method that stops periods
A clear change from your own normal, in either direction

The last one matters most. Your baseline is the reference point, not a textbook average.

Why it happens

Causes fall into a few groups, and the workup is designed to tell them apart.

Structural. Fibroids, polyps, adenomyosis, and endometriosis. These typically cause heavy or painful bleeding with a regular cycle.
Hormonal. PCOS, thyroid disease, elevated prolactin, and the erratic cycles of perimenopause. These typically cause irregular or absent periods.
Bleeding disorders. Von Willebrand disease and platelet disorders are under-diagnosed in women, and heavy periods since the very first one is the classic history.
Medications and devices. Anticoagulants, some antipsychotics and antidepressants, hormonal contraception, and the copper IUD.
Pregnancy, including early pregnancy loss and ectopic pregnancy. Always excluded first.
Precancer and cancer of the uterine lining. Uncommon, but the reason postmenopausal bleeding and persistent abnormal bleeding after 45 are never dismissed.

What the evaluation involves

A history. Bring a record of your last three to six cycles: start date, length, how heavy, how much pain, and anything associated with it. A phone app or a note is fine and makes the visit far more useful.

A pregnancy test, whatever you think the odds are.

Blood work. Complete blood count and ferritin to check for iron deficiency, thyroid function, and prolactin, androgens or other hormones depending on the pattern.

A pelvic exam and pelvic ultrasound. Ultrasound shows fibroids, polyps, ovarian cysts, and the thickness of the uterine lining. Saline infusion sonography gives a clearer view inside the cavity when needed. See how ultrasound works.

Endometrial biopsy. A brief office procedure sampling the uterine lining, done when there is postmenopausal bleeding, abnormal bleeding over about 45, or persistent abnormal bleeding with risk factors at any age.

**Hysteroscopy.** A camera passed through the cervix to look directly inside the uterus, and to remove a polyp or a small fibroid in the same sitting.

Treatment

Treatment follows the cause, and almost always starts with the least invasive option that fits.

Iron replacement. If you are anemic, this is treated alongside the bleeding, not after it. Fixing the iron often changes how you feel more quickly than anything else.
Tranexamic acid. Taken during your period only. Reduces menstrual blood loss substantially and contains no hormones.
NSAIDs. Started at the onset of bleeding, they reduce both flow and cramping.
The hormonal IUD. The most effective medical treatment for heavy bleeding. Many women stop bleeding altogether. See the IUD.
Combined hormonal contraception or progestin therapy. Regulates the cycle, lightens flow, and treats the pain of endometriosis and adenomyosis.
Treating the underlying condition. Thyroid replacement, PCOS management, or medication for a bleeding disorder.
Procedures. Hysteroscopic removal of polyps or submucosal fibroids, endometrial ablation once childbearing is complete, myomectomy for fibroids where the uterus is to be kept, and hysterectomy as the last option rather than the first.

You are entitled to hear the full list before agreeing to surgery. Most heavy bleeding is controlled without it.

Be seen urgently for

Bleeding that soaks a pad an hour for more than two hours
Dizziness, fainting, breathlessness, or a racing heart with heavy bleeding
Severe one-sided pelvic pain, particularly with a positive pregnancy test
Fever with pelvic pain
Any vaginal bleeding after menopause

Talk to us

Medical disclaimer

This page is general health information, not medical advice for any individual. The right evaluation and treatment depend on your age, your history and your findings, and should be decided with a physician. Seek emergency care for bleeding that soaks a pad an hour, fainting or breathlessness with bleeding, or severe one-sided pelvic pain with a positive pregnancy test.