Quick Answer
Seek immediate care for heavy bleeding (soaking through pad/hour), bleeding with severe pain/dizziness, bleeding during pregnancy, or any postmenopausal bleeding. See a doctor within days for irregular bleeding, bleeding between periods, or bleeding after sex.
🚨 Seek Emergency Care Immediately If:
- Heavy bleeding: Soaking through pad or tampon every hour for 2+ hours
- Passing large clots: Larger than a quarter, repeatedly
- Signs of severe blood loss: Dizziness, fainting, rapid heartbeat, pale skin, confusion
- Pregnancy-related bleeding: Any bleeding during pregnancy, especially with cramping
- Severe abdominal pain: With bleeding (possible ectopic pregnancy)
- Fever with bleeding: Temperature above 100.4°F (38°C)
📅 Schedule Appointment Within Days If:
- • Postmenopausal bleeding: Any bleeding after 12 months without period (requires evaluation)
- • Bleeding between periods (intermenstrual bleeding)
- • Bleeding after sexual intercourse (postcoital bleeding)
- • Periods lasting longer than 7 days
- • Periods coming more frequently than every 21 days
- • Irregular bleeding on hormone therapy or birth control
- • Breakthrough bleeding after menopause on HRT
- • New onset of very heavy periods
Understanding Normal vs. Abnormal Bleeding
Normal Menstrual Bleeding
- • Cycle length: 21-35 days
- • Period duration: 2-7 days
- • Blood loss: 30-40 mL (2-3 tablespoons)
- • Pad/tampon use: Change every 3-4 hours
- • Small clots: Occasional, smaller than a quarter
- • Color: Bright to dark red
Abnormal Bleeding Patterns
- • Menorrhagia: Heavy flow, >80 mL per period
- • Metrorrhagia: Bleeding between periods
- • Menometrorrhagia: Heavy + irregular bleeding
- • Polymenorrhea: Periods <21 days apart
- • Postcoital: Bleeding after sex
- • Postmenopausal: Any bleeding after menopause
Common Causes of Abnormal Bleeding
Hormonal Imbalances
- • Anovulation: Not ovulating regularly (PCOS, perimenopause)
- • Thyroid disorders: Hypothyroidism or hyperthyroidism
- • Prolactin excess: Elevated prolactin levels
- • Perimenopause: Irregular cycles in 40s-early 50s
- • Birth control: Breakthrough bleeding on pills/IUD
Structural Problems
- • Uterine fibroids: Benign tumors causing heavy bleeding
- • Polyps: Endometrial or cervical polyps
- • Adenomyosis: Uterine lining grows into muscle wall
- • Endometrial hyperplasia: Thickened uterine lining
- • Cervical abnormalities: Cervical ectropion, dysplasia
Pregnancy-Related
- • Miscarriage: Bleeding with cramping in early pregnancy
- • Ectopic pregnancy: Life-threatening, one-sided pain + bleeding
- • Placenta problems: Placenta previa or abruption
- • Molar pregnancy: Abnormal growth of placental tissue
- • Subchorionic hematoma: Bleeding behind placenta
Infections & Inflammation
- • Pelvic inflammatory disease (PID): Infection of reproductive organs
- • Cervicitis: Inflammation of cervix
- • Endometritis: Uterine lining infection
- • STIs: Chlamydia, gonorrhea can cause bleeding
- • Vaginitis: Vaginal infections
Bleeding Disorders
- • Von Willebrand disease: Most common inherited bleeding disorder
- • Platelet disorders: ITP, low platelet count
- • Clotting factor deficiencies: Hemophilia carriers
- • Anticoagulant medications: Blood thinners
Cancer (Less Common but Serious)
- • Endometrial cancer: Most common cause of postmenopausal bleeding
- • Cervical cancer: Often presents with postcoital bleeding
- • Uterine sarcoma: Rare malignant tumor
- • Ovarian cancer: Can cause irregular bleeding
Postmenopausal Bleeding: Always Investigate
ANY bleeding after menopause requires evaluation:
- • Definition: No period for 12 consecutive months, then bleeding occurs
- • Risk: 10% of postmenopausal bleeding is endometrial cancer
- • Common causes: Atrophy (thin lining), polyps, hyperplasia, cancer
- • Evaluation: Transvaginal ultrasound, endometrial biopsy
- • Don't delay: Early detection improves cancer outcomes significantly
Never assume postmenopausal bleeding is “normal” - always see your doctor promptly
What Your Doctor Will Check
History & Physical Exam
- • Detailed menstrual history, pattern of bleeding
- • Pregnancy test (if reproductive age)
- • Pelvic exam to check cervix, uterus, ovaries
- • Speculum exam to visualize bleeding source
Laboratory Tests
- • Complete blood count (CBC): Check for anemia from blood loss
- • Hormone levels: TSH, prolactin, FSH/LH
- • Coagulation studies: If bleeding disorder suspected
- • STI testing: Chlamydia, gonorrhea
Imaging & Procedures
- • Transvaginal ultrasound: Assess uterine lining thickness, check for fibroids/polyps
- • Saline infusion sonogram: Better visualization of uterine cavity
- • Endometrial biopsy: Sample uterine lining tissue
- • Hysteroscopy: Camera inside uterus, can remove polyps
- • D&C (dilation and curettage): Scrape uterine lining for testing
Treatment Options
Medical Management
- • Birth control pills: Regulate cycles, lighten flow
- • Progesterone: Control irregular bleeding
- • Tranexamic acid: Reduce heavy bleeding
- • NSAIDs: Reduce prostaglandins, lighten flow
- • Hormonal IUD: Mirena significantly reduces bleeding
- • GnRH agonists: Shrink fibroids temporarily
Surgical Procedures
- • Endometrial ablation: Destroy uterine lining (no more periods)
- • Myomectomy: Remove fibroids, preserve uterus
- • Hysterectomy: Remove uterus (definitive treatment)
- • Hysteroscopic polypectomy: Remove polyps
- • Uterine artery embolization: Block blood flow to fibroids
When to Be Concerned: Red Flags
- • Age >45 with new onset heavy bleeding: Higher cancer risk
- • Risk factors for endometrial cancer: Obesity, diabetes, PCOS, tamoxifen use
- • Family history: Lynch syndrome, BRCA mutations
- • Failed medical management: Bleeding continues despite treatment
- • Severe anemia: Hemoglobin <7 g/dL from chronic blood loss
Self-Care & Monitoring
- • Track your cycles: Apps help identify patterns and abnormalities
- • Monitor blood loss: Count pads/tampons, note clot size
- • Iron supplementation: If heavy bleeding causes anemia
- • Healthy weight: Obesity increases endometrial cancer risk
- • Regular Pap smears: Screen for cervical cancer per guidelines
- • Don't ignore symptoms: Abnormal bleeding deserves evaluation
Medical Review
Reviewed by: Ricardo Hamilton, MD
Last Updated: November 26, 2025
Sources: American College of Obstetricians and Gynecologists (ACOG), Mayo Clinic, National Cancer Institute (NCI)