Gynecology · Newport Beach · 2026

Abnormal Uterine Bleeding
Heavy Periods & Menstrual Bleeding Issues

When bleeding is too heavy, too long, or too unpredictable.

Abnormal uterine bleeding is one of the most common reasons women see their gynecologist — and one of the most undertreated. Whether your periods have become heavier, longer, more irregular, or you are experiencing bleeding after menopause, there is always a reason. This guide covers how abnormal bleeding is classified, evaluated, and treated — from medical management to surgical options.

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◆ Short Answer

The Canonical Answer

Abnormal uterine bleeding (AUB) includes menstrual bleeding that is too heavy (menorrhagia — soaking through protection hourly), too long (>7 days), too frequent (<21-day cycles), between periods, or after menopause ACOG PB #128. The FIGO PALM-COEIN classification organizes causes into structural (Polyp, Adenomyosis, Leiomyoma, Malignancy) and non-structural (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified) FIGO 2011. Evaluation includes history, labs, transvaginal ultrasound, and endometrial biopsy when indicated. Treatment options include the Mirena IUD (reduces bleeding up to 90%) Cochrane 2020, hormonal and non-hormonal medications, and surgical procedures including endometrial ablation, hysteroscopic surgery, and hysterectomy ACOG CO #557. At Broad Medical Group, Dr. Jennifer Broad provides evidence-based evaluation and individualized treatment for abnormal uterine bleeding in Newport Beach.

Medically reviewed by Dr. Jennifer Broad, MD, FACOG Board-Certified Obstetrician-Gynecologist · Newport Beach, CA

Last reviewed: April 2026 Next review: October 2026

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What Is Abnormal Uterine Bleeding?

Abnormal uterine bleeding (AUB) is any bleeding from the uterus that differs from your normal menstrual pattern. A “normal” menstrual cycle occurs every 24–38 days, lasts 4–8 days, and involves blood loss that does not interfere with daily activities. When bleeding falls outside these parameters, evaluation is warranted.

Abnormal uterine bleeding can present in several ways:

Menorrhagia — Heavy menstrual bleeding. Defined as soaking through a pad or tampon every hour for two or more consecutive hours, or total blood loss exceeding 80 mL per cycle. Practically, if bleeding is interfering with your daily life, it is too heavy.
Prolonged bleeding — Periods lasting longer than 7 days.
Frequent cycles — Cycles occurring less than 21 days apart (polymenorrhea).
Metrorrhagia — Bleeding between periods, irregular spotting, or breakthrough bleeding unrelated to the menstrual cycle.
Postmenopausal bleeding — Any bleeding that occurs after 12 consecutive months without a period. This always requires evaluation.

AUB is one of the most common reasons women visit their gynecologist, accounting for approximately one-third of outpatient gynecology visits. Despite how common it is, many women tolerate heavy or irregular bleeding for years before seeking help — often assuming it’s normal or that nothing can be done. In virtually every case, there is an identifiable cause and an effective treatment.

The PALM-COEIN Classification

FIGO (the International Federation of Gynecology and Obstetrics) developed the PALM-COEIN classification system to standardize the way we describe and categorize the causes of abnormal uterine bleeding. The system divides causes into two categories: structural (things that can be seen on imaging or pathology) and non-structural (functional or systemic causes).

Category	Cause	How It’s Identified
PALM — Structural Causes
P	Polyp	Endometrial or cervical polyps — seen on ultrasound, saline infusion sonography (SIS), or hysteroscopy
A	Adenomyosis	Endometrial tissue within the uterine muscle wall — identified on ultrasound or MRI; causes heavy, painful periods
L	Leiomyoma (Fibroids)	Benign uterine tumors — most common structural cause; submucosal fibroids have greatest impact on bleeding. See Uterine Fibroids Guide
M	Malignancy & Hyperplasia	Endometrial cancer or precancerous changes — identified by endometrial biopsy; risk increases with age, obesity, chronic anovulation
COEIN — Non-Structural Causes
C	Coagulopathy	Bleeding disorders (e.g., von Willebrand disease) — affects up to 13% of women with heavy periods; identified by coagulation studies
O	Ovulatory Dysfunction	Irregular or absent ovulation (PCOS, thyroid disease, perimenopause) — leads to unpredictable, often heavy bleeding; identified by history and labs
E	Endometrial	Primary disorder of the endometrium itself — often a diagnosis of exclusion when other causes are ruled out
I	Iatrogenic	Caused by medications or devices — anticoagulants, hormonal contraceptives, copper IUD
N	Not Yet Classified	Rare causes that don’t fit the above categories — arteriovenous malformations, cesarean scar defects

PALM-COEIN classification diagram — structural causes (Polyp, Adenomyosis, Leiomyoma, Malignancy) on the left, non-structural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified) on the right — FIGO PALM-COEIN classification of abnormal uterine bleeding. Structural causes are identified by imaging and pathology; non-structural causes by history, labs, and exclusion.

Understanding the cause of abnormal bleeding is the foundation of effective treatment. A woman with heavy bleeding from a submucosal fibroid needs a different approach than a woman with heavy bleeding from a coagulopathy or ovulatory dysfunction. The PALM-COEIN system ensures that the evaluation is systematic and that no common cause is overlooked.

Many women have more than one contributing cause. For example, a woman may have both a small submucosal fibroid (L) and ovulatory dysfunction from perimenopause (O). Dr. Broad uses this classification framework to ensure that all contributing factors are identified and addressed in your treatment plan.

When to See Your Doctor

Warning

Any bleeding after menopause requires prompt evaluation. While many causes of postmenopausal bleeding are benign (vaginal atrophy, polyps), approximately 10% of women with postmenopausal bleeding are found to have endometrial cancer. Even light spotting should be evaluated. Do not assume it is “just hormones” — schedule an appointment.

Contact your OBGYN if you are experiencing any of the following:

Soaking through a pad or tampon every hour for two or more consecutive hours
Periods lasting longer than 7 days
Bleeding between periods or after intercourse
Any postmenopausal bleeding — even light spotting
Symptoms of anemia — persistent fatigue, dizziness, lightheadedness, shortness of breath with normal activity, or pale skin
Passing blood clots larger than a quarter
Needing to double up on pads and tampons, or using adult incontinence products for menstrual bleeding
Restricting activities because of your period — missing work, avoiding exercise, or staying home

Many women normalize heavy or irregular bleeding because it has been their pattern for years, or because they assume other women experience the same thing. Heavy bleeding that disrupts your life is not normal — and it is not something you should have to build your schedule around.

How Abnormal Bleeding Is Evaluated

Clinical Guideline

ACOG recommends a structured evaluation of heavy menstrual bleeding that includes history, physical exam, laboratory testing (CBC for anemia, thyroid function, and coagulation studies when indicated), transvaginal ultrasound, and endometrial biopsy for women over 45 or those with risk factors for endometrial hyperplasia.

History

A thorough menstrual history is the first and most important step. Dr. Broad will ask about the duration, frequency, and heaviness of your periods, when the pattern changed, associated symptoms (pain, clotting, fatigue), medications, contraceptive use, and family history of bleeding disorders. A menstrual tracking app or diary is extremely helpful — the more specific the data, the more efficient the evaluation.

Pelvic Exam

A physical examination evaluates the size and shape of the uterus (enlarged with fibroids or adenomyosis), checks for cervical lesions or polyps, and assesses for signs of other pelvic pathology.

Laboratory Testing

Complete blood count (CBC) — Assesses for anemia. Many women with chronic heavy bleeding have iron-deficiency anemia without realizing it.
Thyroid function — Both hypothyroidism and hyperthyroidism can cause menstrual irregularity.
Coagulation studies — If heavy bleeding began at menarche or there is a personal/family history of easy bruising, nosebleeds, or excessive bleeding with surgery, testing for von Willebrand disease and other coagulopathies is indicated.
Pregnancy test — Always performed in reproductive-age women with abnormal bleeding.
Iron studies and ferritin — To assess iron stores, which can be depleted even before hemoglobin drops.

Imaging

Transvaginal ultrasound is the first-line imaging study. It evaluates the uterus for fibroids, adenomyosis, endometrial thickness, and ovarian pathology. When greater detail about the endometrial cavity is needed (to evaluate for polyps or submucosal fibroids), saline infusion sonography (SIS) uses sterile saline to distend the cavity during ultrasound, providing a clearer view.

Endometrial Biopsy

An in-office procedure that samples the uterine lining for pathologic evaluation. Indicated for women over age 45 with abnormal bleeding, or younger women with risk factors for endometrial hyperplasia (obesity, chronic anovulation, PCOS, diabetes, tamoxifen use). The biopsy rules out endometrial cancer and hyperplasia.

Hysteroscopy

A thin camera is inserted through the cervix to directly visualize the endometrial cavity. Hysteroscopy is both diagnostic (identifying polyps, fibroids, or other lesions) and therapeutic (removing them in the same procedure). For information on this and other minimally invasive procedures, see our dedicated guide.

Medical Treatment

For many women, medical management is the first step — and for many, it is the only step needed. The choice of treatment depends on the underlying cause, the severity of bleeding, whether you are trying to conceive, and your preferences.

Hormonal Options

Levonorgestrel IUD (Mirena)

The levonorgestrel-releasing intrauterine device is one of the most effective medical treatments for heavy menstrual bleeding. It releases a small amount of progestin directly into the uterus, thinning the endometrial lining. The result: a reduction in menstrual blood loss of up to 90%. Many women have very light periods or stop menstruating altogether. The Mirena IUD is effective for up to 8 years and also provides highly effective contraception.

Patient Tip

The Mirena IUD is not just a contraceptive — it is a treatment for heavy periods. ACOG and NICE both recommend the hormonal IUD as a first-line medical treatment for heavy menstrual bleeding. If you have been told you need a hysterectomy for heavy periods, the Mirena IUD may be worth trying first. Learn more in our IUD & Birth Control guide.

Combined Oral Contraceptive Pills (OCPs)

Birth control pills regulate the menstrual cycle, reduce menstrual blood loss, and can eliminate irregular bleeding. They are a good option for women who also need contraception or who have irregular cycles from ovulatory dysfunction. OCPs are not appropriate for women over 35 who smoke or those with certain cardiovascular risk factors.

Progestins

Oral progestins (medroxyprogesterone acetate, norethindrone) can be used cyclically to regulate bleeding or continuously to suppress it. The injectable progestin (Depo-Provera) reduces or eliminates periods in most women after several months. Progestins are particularly useful for women with ovulatory dysfunction or those who cannot take estrogen.

GnRH Agonists

GnRH agonists (leuprolide) temporarily suppress ovarian function and induce a medical menopause, stopping menstrual bleeding entirely. These are typically used short-term (3–6 months) to control severe bleeding before surgery, to allow recovery from anemia, or to shrink fibroids preoperatively. They are not a long-term solution because of bone density loss and menopausal side effects.

Non-Hormonal Options

Tranexamic Acid

Tranexamic acid is an antifibrinolytic medication that reduces bleeding by preventing the breakdown of blood clots in the endometrium. It is taken only during the days of heavy bleeding (typically 3–5 days per cycle) and reduces menstrual blood loss by approximately 40–50%. It is a good option for women who prefer to avoid hormones or who are trying to conceive.

NSAIDs

Non-steroidal anti-inflammatory drugs (ibuprofen, naproxen) taken during menstruation reduce prostaglandin production, which decreases both bleeding and cramping. They reduce menstrual blood loss by approximately 20–40% and are most effective when started 1–2 days before the expected period.

Iron Supplementation

Many women with chronic heavy bleeding develop iron-deficiency anemia — sometimes severe enough to cause debilitating fatigue, dizziness, shortness of breath, and difficulty concentrating. Iron replacement is an essential part of the treatment plan. Oral iron (ferrous sulfate, taken with vitamin C to enhance absorption) is first-line; intravenous iron infusion may be necessary for severe deficiency or when oral iron is not tolerated.

Surgical Treatment

Surgery is considered when medical management has not provided adequate relief, when a structural cause requires removal, or when the patient prefers a definitive solution. The choice of procedure depends on the cause of bleeding, severity, whether you want to preserve fertility, and your goals.

Endometrial Ablation

Endometrial ablation destroys the uterine lining to reduce or eliminate menstrual bleeding. It is a minimally invasive procedure performed in the operating room, typically in under 10 minutes. Approximately 70–80% of women have significantly lighter periods or no periods after ablation.

Ablation is an excellent option for women who have completed childbearing and want to avoid hysterectomy. It is not appropriate for women who want to preserve fertility, as pregnancy after ablation carries serious risks. A reliable form of contraception is required after the procedure.

Hysteroscopic Polypectomy and Myomectomy

When polyps or submucosal fibroids are identified as the cause of abnormal bleeding, hysteroscopic removal is often both diagnostic and curative. A camera and specialized instruments are inserted through the cervix — no abdominal incisions. Recovery is typically 1–2 days. This approach preserves the uterus and fertility.

Laparoscopic or Robotic Myomectomy

For larger fibroids or those within the uterine wall (intramural) or on the surface (subserosal), a laparoscopic or robotic myomectomy removes the fibroids while preserving the uterus. This is the preferred approach for women who want to maintain fertility. For more detail, see our Uterine Fibroids guide and Minimally Invasive Surgery overview.

Hysterectomy

Hysterectomy — removal of the uterus — is the definitive treatment for abnormal uterine bleeding. It eliminates menstrual bleeding entirely and permanently. Hysterectomy is considered when:

Medical management and less invasive procedures have been tried and are insufficient
Pathology requires it (endometrial hyperplasia with atypia, endometrial cancer)
Multiple or large fibroids make myomectomy impractical
The patient has completed childbearing and desires a permanent solution
Quality of life is severely affected and the patient prefers definitive treatment

Most hysterectomies for AUB are performed minimally invasively — laparoscopic or robotic — with shorter recovery, less pain, and faster return to normal activities compared to open surgery.

Choosing the Right Approach

The decision between medical management, ablation, myomectomy, and hysterectomy is highly individual. Key factors include:

Cause of bleeding — A polyp may only need hysteroscopic removal; adenomyosis may respond best to the Mirena IUD or, ultimately, hysterectomy.
Severity — Mild irregular bleeding may respond to OCPs; severe menorrhagia with anemia may warrant more aggressive treatment.
Fertility goals — Ablation and hysterectomy are only for women who have completed childbearing. Myomectomy, the Mirena IUD, and medical therapies preserve fertility.
Patient preference — Some women want to try every conservative option first; others want a definitive solution and prefer not to manage symptoms long-term.

Dr. Broad walks through each option — including expected outcomes, risks, recovery, and what to expect — so you can make a fully informed decision that aligns with your goals.

Key Takeaways

Abnormal uterine bleeding includes periods that are too heavy, too long, too frequent, or any bleeding after menopause — all warrant evaluation.
The PALM-COEIN classification organizes causes into structural (polyps, fibroids, adenomyosis, malignancy) and non-structural (ovulatory dysfunction, coagulopathy, endometrial).
Any postmenopausal bleeding requires prompt evaluation to rule out endometrial hyperplasia and cancer.
The Mirena IUD is a first-line treatment for heavy menstrual bleeding, reducing blood loss by up to 90%.
Endometrial ablation is a minimally invasive option for women who have completed childbearing and want to avoid hysterectomy.
Hysterectomy is definitive but is not the only option — most women have effective alternatives to explore first.
Iron deficiency is common with chronic heavy bleeding — screening and treatment for anemia is an essential part of care.
Heavy periods are not something you should just tolerate — effective treatment exists for every cause and severity.

References & Clinical Sources

American College of Obstetricians and Gynecologists. Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. Obstetrics & Gynecology, 120(1), 197–206. 2012. Reaffirmed 2022.
Munro MG, Critchley HOD, Broder MS, Fraser IS; for the FIGO Working Group on Menstrual Disorders. FIGO Classification System (PALM-COEIN) for Causes of Abnormal Uterine Bleeding in Nongravid Women of Reproductive Age. International Journal of Gynecology & Obstetrics. 2011;113(1):3–13.
Lethaby A, Hussain M, Rishworth JR, Rees MC. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database of Systematic Reviews. 2015;4:CD002126. Updated 2020.
American College of Obstetricians and Gynecologists. Committee Opinion No. 557: Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. Obstetrics & Gynecology, 121(4), 891–896. 2013. Reaffirmed 2022.
National Institute for Health and Care Excellence (NICE). Heavy Menstrual Bleeding: Assessment and Management. NICE Guideline NG88. 2018. Updated 2021.

Related Resources

Heavy Periods Are Treatable. Find Out What’s Causing Yours.

If your bleeding is affecting your daily life, your energy, or your peace of mind, Dr. Broad provides expert evaluation and the full range of treatment options — from medical management to minimally invasive surgery — in Newport Beach.

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Broad Medical Group — Newport Beach, California

Medical Disclaimer: This content is for educational purposes only and does not constitute medical advice, diagnosis, or treatment. Consult Dr. Jennifer Broad or your healthcare provider for guidance specific to your situation. Current as of April 2026. If you are experiencing a medical emergency, call 911 immediately.