Abnormal Uterine Bleeding: Targeted History
Abnormal uterine bleeding - whether it’s a heavier than normal period, light but irregular bleeding or even regular menses with occasional intermenstrual potting - is one of the most common gynecologic complaints. It is also one where patients’ concerns are often ignored. As an OBGYN, I get referrals for this symptom all the time. While almost everyone gets a pelvic ultrasound, there are often gaps in the history or simple blood tests that would have helped the patients get some reassurance or relief before a three- to six- month wait to see me.
The first step to understand if a patient’s bleeding is abnormal - and if it abnormal, the key to finding the underlying cause - is a solid understanding of what a normal cycle should be like and how that compares to your client’s symptoms.
Normal Menstrual Cycle
Menarche (the onset of menses) usually begins around age 11 - 12, but onset as early as age 8 and as late as age 16 can still be normal.
The menstrual cycle is counted in days, with the first day of bleeding marking day 1. The average cycle (meaning the period from day 1 of one cycle to day 1 of the next cycle) lasts about 28 days; though cycles anywhere from 24 to 38 days are normal. Most people do not have perfect cycles, and variation of up to seven to nine days from shortest to longest cycle can be normal.
Up to 8 days of bleeding with each cycle is considered normal, though many patients have periods that are much shorter than that. For clinical purposes, there is no standard for a normal volume of bleeding. If the amount of bleeding bothers your patient i.e. causes them physical, social or emotional distress or interferes with their quality of life, then it is not normal.
The menstrual cycle can be broken down into three phases:
Proliferative/Follicular phase
This phase - where the ovaries begin to produce eggs (oocytes) - overlaps with menstrual flow. It begins on the first day of bleeding and ends the day before ovulation. On day 1, estradiol (think of this as lining fertilizer) and progesterone (think of this as lining glue) levels are both low. The brain produces increasing levels of follicle-stimulating hormone (FSH) to encourage the ovaries to produce eggs (oocytes). Large fluid-filled cysts (follicles) that contain eggs begin to grow on the ovary and produce estradiol. As follicles grow, estradiol levels rise, causing the endometrial lining to thicken and replace the layer that has been sloughed off during menses. This increase in estradiol sends a message to the brain to decrease FSH production, so FSH levels start to drop by cycle day 4 Though several follicles are recruited with each cycle, one will become dominant and develop to a mature ovum by mid-cycle.
Ovulation (mid-cycle)
At mid-cycle, a surge of luteinizing hormone (LH) triggers causes the dominant follicle to burst open and release a mature oocyte 36 hours later. The remnant of the follicle becomes a corpus luteum cyst, which will be visible on ultrasounds performed during this time.
Secretory/Luteal phase
This phase begins after ovulation and ends when menses return. Following ovulation, the ovum moves into the fallopian tube to await fertilization. The corpus luteum (remnant of the dominant follicle after ovulation) secretes progesterone which holds the thickened endometrial lining in place to support a possible pregnancy. The changes in hormone levels (especially the rise in progesterone) around ovulation can lead to “moliminal” symptoms for some people including acne, headaches, bloating from fluid retention, mood swings, cramps, fatigue, breast tenderness of the breasts, and problems with sleep. The corpus luteum eventually disintegrates and if there is no fertilized oocyte to take over progesterone production, falling progesterone levels cause the endometrial lining to destabilize and shed, and the next menstrual cycle begins.
Getting the History
Now that we have a framework for what’s normal, it’s time to get a set of structured questions to help you get a clear picture of what’s happening in your patient’s body.
I collect some standard information from every patient that I won’t include in our tailored question list: past medical history, past surgical history, family history (particularly of breast, ovarian, uterine or colon cancer), past OBGYN history (age at menarche, menstrual history, pregnancy history, last pap smear and any history of abnormal pap results, history of sexually transmitted infections), medications (prescribed and over-the-counter, supplements), and allergies.
Everyone describes their bleeding differently, but to make the correct diagnosis and recommend appropriate testing and treatment, it is essential that you and your client are on the same page. Here are some questions I recommend you ask , and suggestions for how to think about the response you get:
When was the first day of your last normal period?
This helps you understand where you are in the patient’s cycle. As we’ve reviewed, hormone levels shift around during the menstrual cycle and the ovaries produce multiple cysts before eventually forming a dominant cyst that transitions into a corpus luteum. This is information is mission-critical to interpreting the results of any tests you order and deciding what to do next. People track their periods differently - some people will know the first day, others will remember when their period ended, some folks don’t track at all. When a client begins to describe how long their period was or when it ended at this point in the interview, I listen closely and then clarify: So, your last period started on [insert date here]?
Are you generally able to predict when your next period will come? Does it ever surprise you? Do you ever skip periods?
I stopped asking patients if their periods were “regular” years ago. From a clinical perspective, when I ask if a period is regular, I am asking a very specific question about timing. I want to know if the number of days between the first day of bleeding with one cycle and the first day of bleeding with the next is reasonably predictable. But I’ve learned that word just means too many different things to different people. Patients may describe their bleeding as irregular because the bleeding was heavier on day 2 than other days, or because they had bleeding for 3 days with some cycles and 5 days with others. That is good information to have, but not what I am driving at with this question.
I’ve had patients describe their periods as irregular because they sometime start bleeding at the beginning of the month and sometimes at the end of the month or because they don’t experience bleeding every calendar month. But a regular 25-day cycle will cause periods that start on July 1, then July 25, then August 18 and a regular 35-day cycle may lead to periods on July 28 and September 1. More commonly, patients may think of their periods as irregular because the cycle length varies by a few days each month (28 days, then 34, then 32), but from a clinical perspective that level of variation is also considered normal. Clinically, irregular menses do not occur with a discernable pattern. For instance, a client with irregular periods may have a 28-day cycle, followed by a 60-day cycle, then a 40-day cycle. The goal with this question and the next one on the list is to get very concrete data about when the bleeding is happening, which will allow to you accurately determine a) if their cycles are regular or irregular and b) if their cycle length is normal (24-38 days) or abnormal (anything else). Their responses may even let you to reassure your client that all is well. For instance, there are certain moments in life when irregular periods are expected. Periods may be irregular for the first few years after the onset of menses as it takes time for ovulation to occur regularly. Periods also become irregular in the period leading up to menopause.
Do you remember the first day of your last few periods?
Cycles can be both regular and abnormal. (Again, for our purposes “regular” only refers to predictability). A client can also have “regular” cycles that are shorter than normal (<24 days; polymenorrhea) or longer than normal (>38 days; oligomenorrhea). Cycles longer than 35 days apart are still normal but considered “infrequent”. So, a client who has bleeding that starts predictably every 40 days or so has a regular, infrequent cycle.
How many times do you change your pads or tampons in a day? Are they soaked or fully saturated? Do you also notice large clots?* Is that a change for you?
If the amount of bleeding your patient is having causes them distress of interferes with their life, it’s worth investigating. The one objective measure of bleeding I can offer is that if a patient or client is soaking through pads in less than 2 hours, that is considered a hemorrhage and should prompt urgent gynecology evaluation. Otherwise, “normal volume” for periods is subjective. Normal can be 4 pads a day for 3 days for one person, and 2 pads daily for 6 days for another. This means that terms like “heavy” or “light” are great for knowing how your patient feels about their bleeding (which is important!), but don’t really tell you how much blood they lose with their menses. This can be helpful to know before for example, you refer a patient to gynecology to evaluate the possibility menstrual blood loss is the cause of their anemia. True story: I once saw a referral for management of “heavy” menses leading to anemia. However, the patient a) did not feel her bleeding was heavy b) described an amount of bleeding that did not sound alarming and c) felt her bleeding had not changed recently, but she had never been anemic before in her life. I recommended evaluation for other causes . . . and she was later diagnosed with multiple myeloma.
How long do your periods last?
This gives you some information about how much blood your patient is losing each cycle. Prolonged menses is defined as menstrual bleeding lasting longer than 8 days. Anything less than that is considered normal (though it may still be bothersome to the patient) and some variation in the duration of bleeding from one cycle to the next is fine.
Do you have bleeding in between periods? When and how much?
Often, clients can draw a distinction between their normal period, and some other funky bleeding that is separate. They may say something like “I always get my period around the 3rd of the month, and recently I have also been getting a few days of bleeding two weeks after my period ends that is a little lighter”. This can range from spotting around penetrative vaginal sex, to spotting or heavier bleeding in the middle of their cycle. The details really matter here: your differential diagnosis may shift if your patient is noticing pink on the tissue when they wipe, versus spotting so they wear a pantiliner but don’t quite need a pad, versus soaking through maxipads. Your differential will also be slightly different from completely irregular bleeding than for normal periods with extra episodes of bleeding.
Are your periods painful? What do you use for menstrual pain? Have you ever had to call out of work or school because of menstrual pain?
Some cramping during menses is common, but pain beyond mild cramps that cannot be managed with over-the-counter medication or disrupts the patient’s life usually indicates something happening the pelvis like fibroids and endometriosis.
Have you noticed other symptoms that occur around your period (e.g. breast tenderness, acne, bloating, mood changes)?
This question is most informative with clients who are having irregular periods, because it helps you ascertain if your client is experiencing signs of the hormone changes that occur with ovulation.
Are you sexually active? What does sex mean for you? Are you using anything to prevent pregnancy?
I know, I know, most medical practices insist patients provide a pee sample before they’ve barely stepped in the door. But I like to save the questions about sex for later in the interview because it gives me time to build a rapport and gives the client an opportunity to share more about what is happening before them before they start to worry that I am dismissing their symptoms as a sign of pregnancy. It is also intentional that I ask about sexual activity and barrier contraception separately from the chance of pregnancy. In summary, these questions are getting at two possible causes of bleeding abnormalities: sexually transmitted infections (which anyone who is having any type of sex is at some risk for) and pregnancy (which may be a factor with some penetrative vaginal intercourse, but not other forms of sexual activity).
Also intentional: I do not ask my patients how many sexual partners they have. It doesn’t matter. I have diagnosed sexually transmitted infections (STIs) in people who had only had sex once in their lives, or who were in what they believed (up until the point I called to say they have Trichomoniasis) were monogamous relationships. Shit happens, people cheat, condoms break: it’s not my place to judge. I ask this question to determine if it is appropriate for me to offer STI or pregnancy testing and then I move on.
What is most bothersome to you about your bleeding?
The patient’s subjective experience of their bleeding is important, and sometimes what the person on the exam table needs most from you is reassurance. Besides, we have tools to help people have the amount of bleeding they desire. As you gather objective information, don’t forget to take a moment to check in with how the patient is feeling. In a scenario where the client has several concerns and you have one of those awful 15-minute visits, this is another way to find out which concern should be the priority you focus on during your limited time.
* A note about clots: Many patients come in concerned because they’ve noticed clots on their pads or in the toilet and as a gynecologist I sometimes get referalls or calls from providers worried that their client is noticing clots for the first time or more clots than usual. But clotting is what normally happens to blood outside the body. It is helpful to know how big clots are and how frequently patients are seeing them because that helps give a complete picture of how much blood a person is losing, but their presence is not concerning
So we’ve covered the normal menstrual cycle and 10 questions to help you gather information about what’s happening with your patient. In the next post, we’ll go through our diagnostic categories for abnormal bleeding and map the possible responses to these questions into each of those categories.
Before you go - some bonus questions:
Do you struggle with acne or hair growth in less common places (back, chest, face)?
These are common tip-offs for conditions like PCOS that are restionsult of increased androgen levels. Patients have often figured out a regimen for controlling their acne or excess hair growth, so don’t really on birds-eye observation to figure this out. I generally ask this question when patients have irregular bleeding.
Any vaginal discharge or itching? Pain with sex?
I ask this question to patients with intermenstrual spotting to check for signs of infection or inflammation in the cervix, vagina or uterus.
Have you ever gone a full 12 months without bleeding? *
This question is most important for our more mature patients who may be in menopause. Menopause occurs when the client has gone a full 12 months without bleeding (before that it is pre-menopause or perimenopause). While it is common to have irregular menses in the period leading up to menopause, bleeding that comes back after a full 12 months without menstrual bleeding is NEVER normal and ALWAYS calls for investigation. We will review the evaluation and management of postmenopausal bleeding separately, but I think it’s worthwhile to touch on it briefly here.
Thanks for reading! Have thoughts, questions, suggestions for future posts, or your own story to share? Drop a comment below - I’d love to hear from you. And if you enjoy our content or find it helpful, hit subscribe to stay in the loop!