Menstrual Cycle Problems: Irregular, Heavy, Painful, and Absent Periods

The most common reason these problems go under-treated is that they are described in the same three words and then handled as one thing. They are not one thing.

Which of the four is it

Heavy bleeding is defined by its effect on your life

Women are often asked to quantify blood loss in a way nobody can do accurately. The definition used by both ACOG and FIGO is functional: excessive menstrual blood loss that negatively affects a woman’s physical, emotional, social or material quality of life. ACOG further specifies bleeding lasting more than seven days and/or loss exceeding 80 mL per cycle — but the quality-of-life half of that definition is the one you can actually apply to yourself.

In practice: bleeding that soaks through protection within an hour for several hours, that requires doubling up, that wakes you at night to change, that passes large clots, or that keeps you from work, school or leaving the house.

Iron, and the test result that misleads

ACOG advises that a serum ferritin level should be routinely obtained in young women presenting with heavy menstrual bleeding — not only a blood count. Iron deficiency is generally identified by a ferritin below 15 micrograms/L, while the World Health Organization defines anaemia in females aged 12 and over as haemoglobin below 12 g/dL. Those are two different thresholds testing two different things, and you can fail the first while passing the second.

Now the part that catches people out. ACOG states that although a low ferritin level always indicates low iron stores, a normal or high ferritin does not rule out iron deficiency anaemia, because ferritin rises in inflammatory states. So “your ferritin was normal” does not close the question if the clinical picture fits.

The arithmetic explains why this accumulates: roughly 0.4 to 0.5 mg of iron is lost with every 1 mL of blood. Among adolescents with heavy menstrual bleeding the incidence of iron deficiency is around 9%, rising to 15–20% when iron deficiency without anaemia is included. And where treatment successfully reduces flow, ACOG indicates a three- to six-month course of iron supplementation is sufficient — iron replacement is not indefinite, but it does need to outlast the correction of the blood count.

Pain that stops you functioning is not normal

Some cramping is expected. Pain that requires you to miss work or school, that does not respond to over-the-counter analgesia taken properly, that has changed in character, or that occurs outside your period deserves evaluation. Endometriosis is diagnosed late in a large proportion of cases, and the most common reason is that severe pain was normalised — by clinicians, by families, and by women themselves.

How causes are actually classified

Clinicians group causes of abnormal uterine bleeding using the FIGO system known by the acronym PALM-COEIN: polyp, adenomyosis, leiomyoma (fibroids), malignancy and hyperplasia — the structural causes — then coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified. Knowing the framework exists is useful because it shows what a proper workup is looking for, and it is reasonable to ask which category is being considered in your case.

Two findings are worth carrying: in adolescents, anovulation is the most common cause and an underlying bleeding disorder is the second most common. Structural causes are rare at that age, which is why ACOG advises that routine ultrasound should not be obtained solely to work up heavy menstrual bleeding in adolescents, though it can be considered when initial management does not work. A teenager with heavy periods and a family history of bleeding or clotting problems needs the bleeding-disorder question asked out loud.

Absent periods: pregnancy first

Whatever else is suspected, a pregnancy test comes first, including in women who believe it impossible. After that the question is why ovulation stopped: thyroid disease, elevated prolactin, polycystic ovary syndrome, low body weight or heavy training relative to intake, significant stress or illness, some medications, and approaching menopause are all on the list. Missing periods because of low energy availability is common in athletes and is not benign — it affects bone.

Bleeding that is a separate category

Bleeding between periods, after intercourse, or at any point after twelve months without a period is not a menstrual irregularity. It is its own question and needs assessment rather than a wait-and-see.

What to bring

• A cycle diary for three months: start date, length, and how heavy each day was
• How the bleeding or pain affects your daily life, specifically
• Whether you have been told your iron, ferritin or blood count was low, ever — and the actual numbers if you have them
• Contraception you use, and whether pregnancy is a possibility
• Family history of bleeding disorders, fibroids or endometriosis

Main takeaway

Decide which of the four problems you have before the appointment, because they diverge immediately. Heavy is defined by impact and by iron, not by counting. Pain that stops you functioning is a reason to be evaluated rather than a fact of life. And absent periods start with a pregnancy test.