Menstrual Disorders: Types, Causes, Symptoms, and Management

What actually counts as a menstrual disorder? Any pattern of bleeding, pain, or missed periods that falls outside your body’s normal, predictable rhythm and hasn’t been explained, whether that’s periods too heavy, too painful, too unpredictable, or absent altogether. These conditions are common and treatable, yet many women go years without answers because “just deal with it” gets treated as medical advice. This guide walks through the main types, what typically causes them, the symptoms that mean it’s time to get checked, how doctors diagnose and treat each one, and when a period problem should send you to a doctor rather than waiting it out.

On this page

1. What counts as a normal menstrual cycle?
2. The hormones behind your cycle
3. The four phases of the cycle
4. Why does ACOG call the menstrual cycle a vital sign?
5. What are the different types of menstrual disorders?
6. Menstrual disorders at different life stages
7. What are the symptoms of menstrual disorders?
8. How do menstrual disorders affect daily life?
9. What causes menstrual disorders?
10. What are the risk factors for menstrual disorders?
11. Myths and facts about period problems
12. How are menstrual disorders diagnosed?
13. How are menstrual disorders managed?
14. What complications can menstrual disorders cause?
15. When to see a doctor?

What counts as a normal menstrual cycle?

Before you can tell whether something is wrong, it helps to know what “normal” actually looks like, and the accepted ranges are wider than most people assume.

The menstrual cycle begins at puberty with the first period, called menarche, and continues until menopause. Each month, the ovaries prepare and release an egg while the uterus builds a lining to support a possible pregnancy. When fertilization does not happen, that lining sheds as a menstrual period.¹

Normal menstrual cycle parameters

The hormones behind your cycle

A useful rule: What matters is not whether your cycle matches a textbook 28 days, but whether it is predictable for you. A consistent 33-day cycle is normal. A cycle that swings from 25 days to 45 days and back is worth investigating.²

Five hormones drive the cycle, working in sequence³:

• Gonadotropin-releasing hormone (GnRH): Released by the hypothalamus (a small structure in the brain that controls hormone signaling in your body), it signals the pituitary gland to release FSH and LH.
• Follicle-stimulating hormone (FSH): Released by the pituitary (also called the master gland, a small gland located at the base of your brain), it prompts ovarian follicles to grow and mature an egg.
• Luteinizing hormone (LH): A mid-cycle surge triggers ovulation, the release of the egg.
• Estrogen: Produced by the ovaries, it thickens the uterine lining and supports egg maturation.
• Progesterone: Produced by the corpus luteum after ovulation, it stabilizes the lining and prepares it for implantation.

Disruption anywhere along this chain, including the brain, pituitary, thyroid, ovary, or uterus, can affect your period. This is why a menstrual problem is so often a signal about something else entirely.

The four phases of the cycle

• Menstruation: The lining sheds; day one of bleeding is day one of the cycle.
• Follicular phase: FSH drives follicle growth while the uterine lining rebuilds.
• Ovulation: An LH surge releases the egg, which remains viable for roughly 12 to 24 hours.
• Luteal phase: The corpus luteum produces progesterone; if pregnancy does not occur, hormone levels fall and the next period begins.⁴

Why does ACOG call the menstrual cycle a vital sign?

The American College of Obstetricians and Gynecologists (ACOG) recommends that clinicians evaluate the menstrual cycle alongside temperature, pulse, respiration, and blood pressure. The reasoning is straightforward: recognizing abnormal menstrual patterns early, particularly in adolescence, can surface health problems that would otherwise go undetected into adulthood.⁵

This reframes how you should think about period changes. An irregular cycle is not only an inconvenience to manage. It is information.

What are the different types of menstrual disorders?

How doctors classify menstrual disorders

Terms such as menorrhagia, metrorrhagia, and menometrorrhagia have largely been retired in clinical practice.

Today, doctors use abnormal uterine bleeding (AUB) as the umbrella term, defined as a bleeding pattern that does not fit normal cycle parameters for frequency, regularity, duration, or volume.⁶ AUB is then paired with a plain descriptor, heavy menstrual bleeding (HMB) or intermenstrual bleeding (IMB), and a letter indicating the underlying cause.⁷

You may still see the older terms on a chart or in a referral letter, so both are included below.

The PALM-COEIN classification explained

Introduced by the International Federation of Gynecology and Obstetrics (FIGO) and adopted by ACOG, PALM-COEIN sorts the causes of abnormal uterine bleeding into structural causes, problems a scan or scope can see, and non-structural causes, which cannot be viewed by a scope and relate instead to hormones or other stresses.⁶⁷

PALM – structural causes

COEIN – non-structural causes

Ovulatory dysfunction is the single most common cause of abnormal uterine bleeding, and it occurs most frequently in adolescents and in women over 45.⁶

Amenorrhea (absent periods)

Amenorrhea means periods have not started or have stopped. There are two types:

• Primary amenorrhea: No period by age 15 in a girl who has otherwise developed normally, or no period by age 13 with no signs of pubertal development.
• Secondary amenorrhea: No period for three consecutive months in someone whose cycles were previously regular.⁸

Pregnancy, breastfeeding, and menopause all cause absent periods normally. A pregnancy test is the first step in evaluating any missed period.

Oligomenorrhea (infrequent periods)

Cycles longer than 38 days, or fewer than nine periods in a year. Bleeding may also be lighter than usual. PMOS and thyroid disease are the most frequent causes.⁹

Heavy menstrual bleeding (AUB-HMB)

Previously called menorrhagia. Rather than measuring milliliters, doctors now define heavy bleeding by how it affects you. You likely have heavy menstrual bleeding if you:

• Soak through one or more pads or tampons every one to two hours
• Pass clots larger than a quarter
• Bleed for more than 8 days
• Need to double up on period products
• Change your work, school, or daily schedule because of bleeding¹²

That last point matters most. If your period dictates your calendar, it is not a normal period, regardless of what the numbers say.

Intermenstrual bleeding (AUB-IMB)

Previously called metrorrhagia, bleeding or spotting between otherwise normal periods. When heavy bleeding during periods occurs alongside bleeding between them, older texts called this menometrorrhagia. Intermenstrual bleeding always warrants evaluation, because it can point to polyps, infection, or, less commonly, malignancy.¹⁰

Dysmenorrhea (painful periods)

Some cramping is normal. Period pain that stops you functioning is not.

• Primary dysmenorrhea: Pain without underlying disease, caused by prostaglandins that trigger strong uterine contractions. These contractions restrict blood flow to the uterine muscle, and the resulting oxygen deprivation produces pain. It typically begins in adolescence and often eases with age.¹
• Secondary dysmenorrhea: Pain caused by an underlying condition such as endometriosis, fibroids, or adenomyosis. It often begins later in life, worsens over time, and may come with heavy or irregular bleeding.

Premenstrual syndrome (PMS)

Physical and emotional symptoms in the one to two weeks before a period. These include bloating, breast tenderness, headaches, fatigue, irritability, food cravings, and mood changes driven by hormonal fluctuations and their downstream effects on brain chemistry.¹¹¹⁵

Premenstrual dysphoric disorder (PMDD)

PMDD is not simply severe PMS. It is a recognized psychiatric diagnosis in the DSM-5, characterized by marked mood swings, depression, anxiety, anger, and irritability in the luteal phase that resolve once bleeding begins. The symptoms are severe enough to interfere with relationships, work, or daily functioning. Women with a history of depression are more likely to experience PMS or PMDD.¹²

If premenstrual mood symptoms are affecting your life, this is a treatable medical condition, not something to manage alone. If you are experiencing depression or thoughts of suicide, contact a crisis lifeline immediately. In the US, call or text 988.¹⁴

Menstrual disorders at a glance

Menstrual disorders at different life stages

• Adolescence: The hormonal axis controlling ovulation takes time to mature, so irregular, anovulatory cycles are common in the first two years after menarche. However, “she’s just a teenager” should not be the end of the conversation when bleeding is heavy; see the section on bleeding disorders below.
• Reproductive years: PMOS, fibroids, endometriosis, and thyroid disease dominate. This is also when menstrual symptoms most often intersect with fertility concerns.
• Perimenopause: As ovulation becomes erratic, cycles shorten, lengthen, and often become heavier. This is expected, but heavy bleeding still deserves evaluation, and any bleeding after menopause is never normal.²

What are the symptoms of menstrual disorders?

General symptoms across menstrual disorders include:

• Absent, infrequent, or unpredictable periods
• Bleeding that is unusually heavy or prolonged
• Pelvic pain and cramping
• Spotting between periods
• Breast tenderness
• Fatigue, weakness, or shortness of breath (possible anemia)
• Mood changes, irritability, or anxiety^8101215

Symptoms that point to an underlying condition

Some symptoms suggest that a menstrual problem is secondary to another disease rather than a primary hormonal pattern:

• Pelvic pain that occurs outside your period, not just during it
• Pain during or after sex
• Bowel or bladder symptoms that flare with menstruation
• Difficulty conceiving after 12 months of trying, or 6 months if over 35
• Excess facial or body hair, acne, or hair thinning
• Milky nipple discharge, headaches, or vision changes¹⁶

That last group, nipple discharge with headaches or visual disturbance, points toward a pituitary cause and should be evaluated promptly.

How do menstrual disorders affect daily life?

Clinical descriptions rarely capture the real cost. Women with heavy menstrual bleeding frequently change their daily activities because of it.¹⁵ That may mean planning travel around a cycle, missing work or school days, avoiding exercise, sleeping on towels, or carrying a change of clothes for one week each month.

There is also a mental health dimension. Chronic pain, unpredictable bleeding, and the anxiety of leaks take a measurable toll, and hormonal disorders themselves can affect mood directly.¹³

None of this is something to accept quietly. Impact on daily life is itself a clinical reason to seek treatment.

What causes menstrual disorders?

Causes fall into the structural and non-structural groups described by PALM-COEIN.

Ovulatory and hormonal causes

These are conditions where ovulation becomes irregular or stops, which is the single most common reason for abnormal uterine bleeding overall.⁶ Without regular ovulation, the lining is not shed on a predictable schedule, so periods become unpredictable in timing, volume, or both.

Polycystic ovary syndrome (PCOS)/PMOS

What is it? A common hormonal condition in which the ovaries produce higher-than-usual levels of androgens (male-type hormones). These elevated levels interfere with the monthly signal that triggers ovulation, so eggs mature but are not reliably released. Insulin resistance is present in many women with PMOS and contributes to the hormonal imbalance.

In 2026, an international consensus process formally renamed the condition polyendocrine metabolic ovarian syndrome (PMOS), because the old name overemphasized ovarian cysts and obscured the metabolic and hormonal features that matter most.¹⁷ You will still see PCOS used in most places until everybody becomes familiar with the term.

How does it present? Infrequent periods (fewer than nine a year), long or unpredictable cycles, or absent periods altogether. Alongside the cycle changes, you may notice acne that persists past adolescence, excess hair growth on the face, chest, or abdomen, thinning hair at the scalp, weight that is difficult to manage, and darkened patches of skin at the neck or underarms. Difficulty conceiving is often what brings women in, since PMOS is a leading cause of ovulation-related infertility.¹⁸ Symptoms usually begin in the teens or early twenties.

How is it diagnosed? There is no single test. Diagnosis is made when at least two of three features are present: irregular or absent ovulation, signs of elevated androgens (either on examination or on blood tests), and a characteristic appearance of the ovaries on ultrasound, after other conditions have been ruled out. Your doctor will typically check testosterone, TSH, and prolactin to exclude alternatives, and may also test blood glucose or HbA1c and cholesterol, because PMOS carries long-term metabolic risk.¹⁸

What patients need to know: Ultrasound findings alone do not diagnose PMOS, and many women with PMOS have normal-looking ovaries. It is a lifelong condition that is managed rather than cured, but treatment works well, and because chronically absent ovulation allows the uterine lining to thicken over years, it needs treating even if you are not trying to conceive.

Thyroid disorders

What is it? The thyroid regulates metabolism throughout the body, including the hormone axis that controls ovulation. When thyroid hormone is too low (hypothyroidism) or too high (hyperthyroidism), the menstrual cycle changes accordingly.

How does it present? Hypothyroidism more often causes heavy or prolonged bleeding, alongside fatigue, cold intolerance, constipation, dry skin, and weight gain. Hyperthyroidism more often causes light or absent periods, with heat intolerance, palpitations, tremor, anxiety, and weight loss. Thyroid disease can also cause recurrent miscarriage and difficulty conceiving.¹¹⁹

How is it diagnosed? A simple blood test. TSH is the screening test, with free T4 added if TSH is abnormal. Thyroid antibodies may be checked to identify an autoimmune cause.¹⁹

What patients need to know: This is one of the most treatable causes on the list. Thyroid testing is part of the standard workup for abnormal bleeding precisely because correcting thyroid function frequently restores a normal cycle without any gynecologic treatment at all.

Hypothalamic dysfunction

What is it? The hypothalamus reduces or stops the hormonal signal that starts the cycle when it senses that the body does not have enough available energy to support a pregnancy. Common triggers are rapid or significant weight loss, low energy availability from restrictive eating patterns, high training volume in athletes, chronic illness, and sustained psychological stress. This is a protective shutdown, not a failure of the ovaries.

How does it present? Periods become infrequent and then stop, usually without heavy bleeding or pain. Other features may include low energy, cold intolerance, reduced libido, disturbed sleep, and stress fractures in athletes.

How is it diagnosed? By exclusion. Pregnancy is ruled out first. Blood tests typically show low or low-normal FSH and LH with low estradiol, while prolactin and TSH are normal. Your doctor will ask carefully about diet, training, stress, and weight history, and may recommend a bone density scan if periods have been absent for a prolonged time.⁸²⁰

What patients need to know: Absent periods from this cause are not harmless just because bleeding is not the problem. Low estrogen over months to years reduces bone density and raises fracture risk. Recovery is usually possible, but it involves addressing the underlying energy deficit or stressor rather than simply taking a hormone to restart bleeding.

Hyperprolactinemia and prolactinoma

What is it? Prolactin is the hormone that supports milk production. When levels are high outside pregnancy and breastfeeding, prolactin suppresses GnRH, switching off ovulation. The most common causes are certain medications, particularly antipsychotics, some antidepressants, and antinausea drugs. An underactive thyroid and a benign pituitary tumor called a prolactinoma are also causes of abnormal prolactin levels.

How does it present? Absent or infrequent periods, often with milky nipple discharge that occurs without pregnancy. If a pituitary tumor is large enough to press on nearby structures, it can also cause headaches and changes in peripheral vision.

How is it diagnosed? A blood prolactin level is usually repeated to confirm, with pregnancy and thyroid disease excluded and medications reviewed. If prolactin remains elevated without another explanation, an MRI of the pituitary is arranged. Visual field testing is added when a larger tumor is found.¹⁶

What patients need to know: Nipple discharge combined with headaches or vision changes should be reported promptly rather than at your next routine appointment. Prolactinomas are usually benign and respond well to tablets; surgery is rarely needed.

Primary ovarian insufficiency

What is it? The ovaries stop functioning normally before the age of 40, producing less estrogen and releasing eggs unpredictably or not at all. Causes include genetic conditions, autoimmune disease, and previous chemotherapy or pelvic radiation, though in many cases no cause is identified.

How does it present? Periods become irregular and then stop, often with menopause-type symptoms at an unexpectedly young age: hot flashes, night sweats, disturbed sleep, vaginal dryness, and mood changes. Difficulty conceiving is common.

How is it diagnosed? Absent or irregular periods for several months before age 40, together with FSH levels in the menopausal range on two separate tests taken at least a month apart, and low estradiol. Additional testing may include a chromosome analysis, testing for the fragile X premutation, and screening for autoimmune conditions. A bone density scan is usually recommended.²¹

What patients need to know: This is not the same as early menopause. Ovarian function can fluctuate, and pregnancy remains possible in a small proportion of women, so contraception is still needed if pregnancy is not wanted. Because low estrogen at a young age affects bone and cardiovascular health, hormone therapy is generally recommended until the usual age of menopause.²¹

Other endocrine causes

• Cushing syndrome: Prolonged exposure to high cortisol, most often from long-term steroid medication, suppresses reproductive hormones. It presents with irregular or absent periods alongside central weight gain, a rounded face, easy bruising, purple stretch marks, muscle weakness, and high blood pressure. Diagnosis uses cortisol testing: a late-night salivary cortisol, a 24-hour urine collection, or a dexamethasone suppression test.²²
• Congenital adrenal hyperplasia (non-classic form): An inherited enzyme deficiency causing excess adrenal androgens (a group of hormones that are precursors of the male hormone testosterone). It looks very similar to PMOS: irregular periods, acne, excess hair growth, and is diagnosed with an early-morning 17-hydroxyprogesterone blood test.²³
• Androgen-secreting tumors: Rare, but important. The clue is speed: symptoms appear over months rather than years, and may include a deepening voice, marked muscle development, and clitoral enlargement in addition to absent periods. Testosterone or DHEAS levels are markedly elevated, and imaging of the ovaries and adrenal glands follows.²⁴
• Poorly controlled diabetes: Both type 1 and type 2 diabetes can disrupt ovulation when blood glucose is persistently high. HbA1c testing establishes the picture.¹

Structural causes

These are physical changes in the uterus that a scan or a camera can identify. They are more likely when bleeding is heavy or prolonged, but the cycle itself stays fairly regular.

Uterine fibroids (leiomyomas)

What is it? Noncancerous growths of the muscular wall of the uterus. They are extremely common, and their effect depends far more on location than on size. Fibroids bulging into the uterine cavity cause the most bleeding, while those on the outer surface more often cause pressure symptoms.

How does it present? Heavy and prolonged bleeding with clots, period pain, pelvic pressure or a sensation of fullness, increased urinary frequency, constipation, back pain, and in some cases a visibly distended lower abdomen. Fatigue from anemia is common and is often the symptom that finally prompts an appointment.

How is it diagnosed? Pelvic examination may reveal an enlarged, irregular uterus. Transvaginal ultrasound is the main test. If a fibroid is suspected inside the cavity, saline infusion sonohysterography or hysteroscopy gives a clearer view. MRI is used to map fibroids in detail before surgery or uterine artery embolization.¹²⁵

What patients need to know: Fibroids do not need treatment simply because they exist. Treatment is guided by symptoms and by whether you want future pregnancy, which is why that question comes up early in the conversation.

Endometrial polyps

What is it? Soft, localized overgrowths of the uterine lining that project into the cavity. Most are benign, though a small proportion contain precancerous or cancerous change, particularly after menopause.¹

How does it present? The hallmark is unpredictable bleeding: spotting between periods, bleeding after sex, heavier periods, or any bleeding after menopause. Polyps can also contribute to difficulty conceiving.

How is it diagnosed? Transvaginal ultrasound may show focal thickening of the lining, but saline infusion sonohysterography or hysteroscopy is needed to confirm. Removal is performed hysteroscopically, and the tissue is sent for laboratory examination.²⁶

What patients need to know: Because removal and diagnosis usually happen in the same procedure, a polyp identified on a scan is generally taken out rather than watched.

Adenomyosis

What is it? Tissue resembling the uterine lining grows into the muscular wall of the uterus. The wall thickens, the uterus enlarges, and the embedded tissue bleeds with each cycle inside the muscle itself.

How does it present? Heavy periods combined with deep, dragging, cramping pain that is often worse than typical period pain and may extend through the whole period. It classically affects women in their late thirties and forties, frequently after childbirth, and the uterus may feel enlarged and tender on examination.

How is it diagnosed? Transvaginal ultrasound can show suggestive features: a globular, enlarged uterus, asymmetric thickening of the walls, and small cysts within the muscle. MRI is more sensitive and is used when the diagnosis is unclear, or surgery is being planned.²⁷

What patients need to know: Adenomyosis was historically diagnosed only after hysterectomy, which is why many women were told for years that nothing was wrong. Imaging can now identify it, and effective non-surgical treatment exists. It also commonly coexists with fibroids and endometriosis.

Endometriosis

What is it? Tissue similar to the uterine lining grows outside the uterus, on the ovaries, fallopian tubes, bowel, bladder, or the lining of the pelvis. It responds to the same monthly hormonal signals, so it bleeds and inflames tissue where that blood has no way to leave, producing scarring and adhesions over time.

How does it present? Severe period pain that starts before bleeding begins, pelvic pain outside the period, pain during or after sex, painful bowel movements or urination that worsens around the period, bleeding between periods, chronic fatigue, and infertility. The pattern that distinguishes it from primary period pain is pain that worsens over the years rather than easing, and pain that is not controlled by over-the-counter medication.

How is it diagnosed? Diagnosis begins clinically, from the symptom pattern and pelvic examination. Ultrasound and MRI can identify ovarian endometriomas and deep disease, but normal imaging does not rule endometriosis out; superficial disease is invisible on scans. Laparoscopy with tissue sampling remains the definitive test, though treatment is often started before surgery based on symptoms alone.¹²⁸²⁹

What patients need to know: Diagnosis is delayed by years for many women, largely because severe period pain gets normalized by patients and clinicians alike. If a scan comes back clear but your pain is disabling, that is a reason to keep pursuing an answer, not a reason to stop.

Endometrial hyperplasia and malignancy

What is it? When ovulation does not occur for long periods, the lining is exposed to estrogen without the balancing effect of progesterone. It thickens abnormally, and over time this can progress to precancerous change and, in some cases, endometrial cancer.

How does it present? Heavy, prolonged, or irregular bleeding; bleeding between periods; and, most significantly, any bleeding after menopause. Risk is higher with obesity, PMOS, chronic anovulation, never having been pregnant, tamoxifen use, a family history of endometrial or colorectal cancer, and increasing age.

How is it diagnosed? Endometrial biopsy (a procedure where the doctor takes a small piece of the tissue of the uterus) is the key test and can usually be done in the office. Transvaginal ultrasound measures the thickness of the lining, particularly after menopause. Hysteroscopy (a medical procedure where the doctor uses an instrument, called a camera, to view your uterus in real-time) with directed sampling is used when biopsy results are inconclusive, or bleeding persists.¹

What patients need to know: Hyperplasia is treatable, often with progestin therapy alone, and outcomes are good when it is caught early. This is the reason doctors take chronically irregular cycles seriously even in women who are not trying to conceive, and the reason postmenopausal bleeding is never watched and waited on.

Cervical stenosis, Asherman’s syndrome, and congenital differences

What is it? Physical obstruction of menstrual flow. Cervical stenosis is narrowing of the cervical canal, usually after surgery or treatment for abnormal cervical cells. Asherman’s syndrome is scar tissue inside the uterine cavity, typically following a dilation and curettage or uterine infection. Congenital differences include an imperforate hymen (a small membrane inside the vagina), vaginal septum (it’s kind of a wall that separates the vagina into two parts), or underdevelopment of the uterus and vagina (this is congenital, when the uterus and vagina are not formed properly).³⁰

How does it present? Periods that become very light or stop, often accompanied by cyclical cramping pain; the uterus is contracting, but blood cannot escape. In an adolescent, an imperforate hymen typically presents with monthly pelvic pain and a bulging membrane on examination, without any bleeding ever having occurred. Asherman’s syndrome may also cause recurrent pregnancy loss and difficulty conceiving.

How is it diagnosed? Examination, transvaginal ultrasound, hysteroscopy, and in some cases, MRI (magnetic resonance imaging) to define the anatomy.³⁰

What patients need to know: Cyclical pain without bleeding is a specific and meaningful symptom. It points toward obstruction rather than a hormonal problem, and it is worth stating in those exact terms at your appointment.

Bleeding disorders – an underdiagnosed cause in teens

What is it? An inherited or acquired condition in which platelets or clotting factors do not function properly, so normal menstrual bleeding becomes excessive. Von Willebrand disease is the most common, but platelet function disorders and factor deficiencies also occur. A substantial proportion of adolescents with heavy menstrual bleeding have an underlying bleeding disorder.³¹

How does it present? The pattern that distinguishes it is heavy bleeding from the very first period, rather than bleeding that gradually worsened over the years. Other clues include frequent or prolonged nosebleeds, bruising easily or in unusual places, bleeding for a long time after dental work, surgery, or childbirth, and a family history of bleeding problems. Iron deficiency anemia is often severe.³²

How is it diagnosed? A complete blood count with platelets, ferritin, and clotting studies, followed by a von Willebrand panel measuring von Willebrand factor and factor VIII activity. Referral to a hematologist is standard when a disorder is confirmed. Testing is ideally arranged before starting hormonal treatment, since hormones can raise von Willebrand factor levels and mask the result.³³

What patients need to know: ACOG recommends that adolescents presenting with heavy menstrual bleeding be screened for bleeding disorders.³¹ If your periods have been heavy since the very first one, say that explicitly; it is the single most useful sentence you can offer, and it changes the workup.

Infection

What is it? Inflammation and infection of the reproductive organs. Pelvic inflammatory disease results from bacteria, often chlamydia or gonorrhea, spreading upward from the cervix into the uterus, tubes, and pelvis. Endometritis is an infection of the uterine lining, which can also follow childbirth or a uterine procedure.

How does it present? Irregular bleeding or spotting, bleeding after sex, pelvic pain, unusual or foul-smelling vaginal discharge, pain during sex, fever, and pain on urination. Symptoms can be mild enough to be mistaken for a bad period, which is part of why the condition is often diagnosed late.

How is it diagnosed? Pelvic examination: pain on moving the cervix is a characteristic finding, together with swabs testing for chlamydia and gonorrhea, blood tests for infection markers, and pelvic ultrasound if an abscess is suspected. Treatment with antibiotics is usually started immediately rather than waiting for results.¹

What patients need to know: Untreated pelvic infection can scar the fallopian tubes, causing infertility, chronic pelvic pain, and ectopic pregnancy. Prompt treatment matters, and sexual partners need treating at the same time to prevent reinfection.

Medications and devices

What is it? This is the iatrogenic category of PALM-COEIN. Bleeding changes caused by a treatment rather than a disease. Common culprits include hormonal contraception of all types, the copper IUD, anticoagulants, antipsychotics and some antidepressants, antiepileptic drugs, tamoxifen, chemotherapy agents, and certain herbal supplements.¹

How does it present? The clue is timing. Spotting or irregular bleeding that began within a few months of starting or changing a medication points here. Hormonal contraception commonly causes unpredictable spotting in the first three to six months, which usually settles. Copper IUDs typically make periods heavier and more painful. Anticoagulants increase menstrual blood loss substantially.

How is it diagnosed? A careful medication history, correlated with when the bleeding started, plus a pregnancy test. With hormonal contraception, missed or late doses are a frequent and easily correctable explanation. If bleeding continues beyond the expected settling-in period, or started long after the medication did, the search moves on to other causes.

What patients need to know: Bring a full list of everything you take, including supplements and over-the-counter products. And do not stop a prescribed medication on your own because of bleeding; there is usually an alternative or an adjustment that solves the problem without losing the treatment you need.

What are the risk factors for menstrual disorders?

• Perimenopause: Fluctuating estrogen and progesterone make cycles irregular and often heavier
• Early menarche: Associated with higher rates of PMS, dysmenorrhea, and endometriosis
• Obesity or significant underweight: Body fat directly influences estrogen production and ovulation
• Intense exercise or athletic training: Energy deficiency suppresses the reproductive axis
• Chronic stress: Sustained cortisol elevation disrupts GnRH signaling
• Smoking: Linked to cycle changes and earlier ovarian decline
• Family history: Endometriosis, fibroids, PMOS, or bleeding disorders
• Chronic illness: Diabetes, kidney disease, celiac disease, and thyroid disorders
• Prior pelvic surgery: Including cesarean delivery and dilation and curettage
• Certain medications: Including chemotherapy¹

Myths and facts about period problems

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How are menstrual disorders diagnosed?

What to track before your appointment

Arriving with data changes the quality of the appointment. For two to three cycles, record²:

• The first day of each period and the first day of the next
• How many days you bleed
• Products used per day on your heaviest days
• Whether you passed clots, and how large
• Pain severity out of 10, and what relieved it
• Any days you missed work, school, or activities
• Spotting between periods

Medical history and examination

Your doctor will ask about your cycle pattern, age at first period, contraception, sexual and obstetric history, medications, family history, and other symptoms such as weight change or hair growth. This is usually followed by an abdominal and pelvic examination.

Tests your doctor may order

Selected laboratory and imaging tests of this kind form the standard assessment for abnormal uterine bleeding associated with ovulatory dysfunction.¹⁵

Questions to ask your doctor

• What is the most likely cause of my symptoms?
• Which tests do I need, and what will they rule out?
• Do I need to be checked for anemia or a bleeding disorder?
• What are my treatment options, and how quickly should they work?
• Will this treatment affect my fertility, now or later?
• What side effects should I expect?
• At what point should I come back if things do not improve?

How are menstrual disorders managed?

Treatment depends on the cause, your symptoms, and whether you want to become pregnant now or in the future.

Lifestyle measures

• Eat a balanced diet with adequate iron-rich foods, particularly if your periods are heavy
• Maintain a stable, healthy weight
• Exercise regularly, but avoid the extremes of training that suppress ovulation
• Limit alcohol and caffeine, and stop smoking
• Manage stress through sleep, therapy, or structured relaxation practice
• Use a heating pad for cramps

These help, but they are supportive measures. They do not replace treatment for fibroids, endometriosis, or a bleeding disorder.

Medications

• NSAIDs: Ibuprofen and naproxen reduce prostaglandin production, easing pain. Most period pain responds to over-the-counter NSAIDs, and starting one as soon as your period begins may also reduce bleeding and control pain better than waiting.¹
• Levonorgestrel-releasing IUD: A hormonal intrauterine device is the leading medical treatment for heavy menstrual bleeding. It thins the uterine lining, substantially reducing blood loss, and often improves period pain. It is long-acting, reversible, and compatible with future pregnancy after removal. Hormonal IUDs are also used to manage irregular or prolonged bleeding.³³
• Combined hormonal contraception: Pills, patches, and rings regulate cycles, lighten flow, and reduce cramping. Suitability depends on your medical history, including migraine, blood pressure, and clotting risk.³³
• Progestin-only options: Pills, injections, or implants for those who cannot take estrogen. Progestin-only and combined hormonal contraception are both established treatments for abnormal uterine bleeding related to ovulatory dysfunction.³³
• Tranexamic acid: A non-hormonal medication taken only during bleeding days, which slows the breakdown of clots and reduces blood loss.³³
• GnRH agonists: Used for endometriosis and fibroids, generally short-term or with add-back therapy because of effects on bone density.
• Iron supplementation: Often overlooked. Heavy bleeding is the most common cause of iron deficiency anemia in women of childbearing age.¹³ Correcting iron stores frequently resolves the fatigue that patients assume is unrelated.

Surgical and procedural options

Considered when medication has not worked, or a structural cause needs direct treatment:

• Hysteroscopic polypectomy or myomectomy: Removal of polyps or fibroids through the cervix, with no abdominal incision.
• Myomectomy: Removal of fibroids while preserving the uterus, for those who want future pregnancy.
• Uterine artery embolization: A minimally invasive procedure that shrinks fibroids by cutting off their blood supply.
• Endometrial ablation: Destruction of the uterine lining to reduce or stop heavy bleeding; not suitable if you may want to become pregnant.
• Laparoscopic excision: Surgical removal of endometriosis deposits.
• Hysterectomy: Definitive, and a last resort after other options have been considered.¹⁵³³

Treating the underlying cause

Symptom control alone is incomplete. If thyroid disease, PMOS, an infection, or a bleeding disorder is driving your symptoms, treating that condition is what produces lasting improvement.

What complications can menstrual disorders cause?

• Iron deficiency anemia: The most common complication of heavy bleeding, causing fatigue, weakness, breathlessness, and reduced concentration.¹³
• Infertility and subfertility: Through absent ovulation, endometriosis, fibroids, or PMOS.
• Endometrial hyperplasia and cancer: From prolonged unopposed estrogen exposure in chronic anovulation.
• Osteoporosis: Long-standing low estrogen, as in hypothalamic amenorrhea or early ovarian insufficiency, reduces bone density.
• Progression of untreated disease: Fibroids and endometriosis often worsen without treatment.
• Reduced quality of life: Including missed work and school, disrupted sleep, and anxiety or depression.¹³

When to see a doctor?

Schedule an appointment with your OB-GYN if:

• Your periods regularly last longer than 8 days
• You bleed through a pad or tampon every one to two hours
• You pass clots larger than a quarter
• Your cycles are consistently shorter than 24 days or longer than 38 days
• You have missed three or more periods and are not pregnant
• You bleed or spot between periods, or after sex
• Period pain is not relieved by over-the-counter pain medication
• Premenstrual mood symptoms interfere with your relationships or work
• You have been trying to conceive without success
• You are under 40 and experiencing hot flashes, night sweats, or vaginal dryness

Frequently asked questions