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Irregular menstruation

Irregular menstruation, also referred to as abnormal uterine bleeding (AUB), encompasses any deviation from the typical menstrual cycle pattern in reproductive-aged individuals, including variations in the frequency, regularity, duration, or volume of vaginal bleeding outside of pregnancy.^[1] A normal menstrual cycle generally occurs every 21 to 35 days, with bleeding lasting 2 to 7 days and involving a blood loss of 5 to 80 milliliters per cycle.^[1] In contrast, irregular menstruation may manifest as cycles shorter than 21 days (polymenorrhea), longer than 35 days (oligomenorrhea), prolonged bleeding exceeding 7 days, excessively heavy flow (menorrhagia), absent periods (amenorrhea), or spotting between cycles.^[2]^[3] This condition affects 14% to 25% of menstruating individuals, with higher prevalence during adolescence (menarche) and the perimenopausal transition, where up to one-third may experience episodes.^[2]^[1] Irregularities can be classified using the PALM-COEIN system, which distinguishes structural causes—such as uterine polyps, adenomyosis, leiomyomas (fibroids), or malignancy—from nonstructural factors like coagulopathies, ovulatory dysfunction, endometrial issues, iatrogenic effects, or other unclassified etiologies.^[1] Common underlying causes include hormonal imbalances (e.g., from polycystic ovary syndrome or thyroid disorders), extreme weight changes, excessive exercise, eating disorders, uterine fibroids or polyps, pelvic inflammatory disease, and certain medications.^[3]^[4] While occasional irregularities may resolve without intervention, persistent or severe cases warrant medical evaluation to rule out serious conditions like endometrial hyperplasia or cancer, particularly in those over age 45 or with risk factors.^[1] Diagnosis typically involves a detailed menstrual history, physical examination, laboratory tests (e.g., pregnancy test, complete blood count), and imaging such as transvaginal ultrasound, with endometrial biopsy recommended for persistent bleeding.^[4]^[1] Treatment options range from hormonal therapies (e.g., oral contraceptives) and nonsteroidal anti-inflammatory drugs to procedural interventions like endometrial ablation or hysterectomy, tailored to the underlying cause and individual needs.^[4]

Overview

Definition

Irregular menstruation, also known as abnormal uterine bleeding, refers to any deviation from the typical menstrual cycle pattern, characterized by variations in cycle length, duration of bleeding, or volume of flow that differ from the established norm of cycles lasting 21 to 35 days and bleeding episodes spanning 2 to 7 days.^[5] This encompasses unpredictable timing of periods, such as cycles shorter than 21 days (polymenorrhea) or longer than 35 days (oligomenorrhea), as well as alterations in bleeding characteristics like prolonged menses or excessive heaviness.^[2] These irregularities can manifest as missed periods, spotting between cycles, or inconsistent flow, impacting reproductive health and quality of life.^[4] A common underlying mechanism for irregular menstruation is anovulation, the absence of ovulation during a menstrual cycle, which disrupts the hormonal balance necessary for regular cyclic bleeding.^[6] Anovulation often leads to irregular patterns, including skipped cycles where no bleeding occurs or irregular spotting due to unopposed estrogen effects on the uterine lining.^[5] While not all irregular cycles stem from anovulation, it represents a key physiological deviation from the ovulatory menstrual cycle phases.^[7] The understanding and definition of irregular menstruation have evolved significantly since the early 20th century, driven by advances in endocrine research that illuminated the role of hormones in menstrual regulation.^[8] Prior to these developments, terminology was inconsistent and descriptive; by the 1930s, concepts like dysfunctional uterine bleeding emerged, linking irregularities to endocrine dysfunction without precise standardization.^[8] Modern definitions, refined through international consensus such as the FIGO systems in the 2010s, now provide structured criteria emphasizing measurable cycle parameters informed by hormonal insights.^[8]

Normal versus irregular cycles

The normal menstrual cycle typically averages 28 days in length, ranging from 21 to 35 days, and consists of four distinct phases: the follicular phase (days 1-13), ovulatory phase (around day 14), luteal phase (days 15-28), and menstrual phase (days 1-5, involving shedding of the uterine lining).^[9] During menstruation, average blood loss is 30-40 mL per cycle, with volumes exceeding 80 mL considered excessive.^[10] This cycle is regulated by fluctuating levels of estrogen and progesterone, which prepare the body for potential pregnancy.^[9] Signs of a regular cycle include consistent lengths between periods, with minimal variation of less than 7 days from one cycle to the next, predictable ovulation typically occurring around day 14 in a 28-day cycle, and the absence of bleeding between periods.^[3]^[11] Menstrual bleeding in regular cycles lasts 2-7 days and is moderate in flow without significant spotting.^[12] Irregular cycles deviate from these norms, such as those shorter than 21 days (polymenorrhea) or longer than 35 days (oligomenorrhea), or those with cycle-to-cycle variations exceeding 7-9 days.^[9]^[3] For instance, a woman might experience cycles of 25 days one month and 40 days the next, indicating irregularity.^[11] Cycle patterns vary by age and life stage; in adolescence, particularly the first few years after menarche, cycles are often longer and more variable, with averages ranging from 32 to 61 days in the initial gynecological year due to immature hypothalamic-pituitary-ovarian axis function.^[12]^[13] Similarly, during perimenopause, cycles become irregular with persistent variations of 7 or more days, often lengthening as ovarian function declines.^[14]

Causes

Hormonal factors

Irregular menstruation often stems from disruptions in the hypothalamic-pituitary-ovarian (HPO) axis, which orchestrates the menstrual cycle through interactions among key reproductive hormones. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH), secreted by the pituitary gland, stimulate ovarian follicle development and ovulation, respectively. Estrogen, produced by growing follicles, promotes endometrial proliferation during the follicular phase, while progesterone, secreted by the corpus luteum post-ovulation, stabilizes the endometrium in the luteal phase. Imbalances, such as insufficient progesterone due to anovulation, can lead to unopposed estrogen exposure, resulting in irregular or heavy bleeding.^[15] Specific endocrine conditions exemplify these disruptions. In polycystic ovary syndrome (PCOS), elevated androgens and an increased LH-to-FSH ratio impair ovulation, causing oligomenorrhea or amenorrhea in up to 70-80% of affected women, who represent 5-10% of reproductive-age individuals. Hypothalamic amenorrhea arises from suppressed gonadotropin-releasing hormone (GnRH) pulsatility, reducing FSH and LH secretion and halting ovulation, often linked to energy deficits or stress. Thyroid disorders also contribute: hypothyroidism elevates thyrotropin-releasing hormone, which stimulates prolactin and disrupts GnRH, leading to oligomenorrhea or heavy menses; hyperthyroidism, conversely, shortens cycles or causes light, irregular bleeding.^[15]^[16]^[17] Physiological transitions further highlight hormonal influences. During puberty, the immature HPO axis results in inconsistent GnRH pulses, leading to anovulatory cycles and irregular menstruation in 50-80% of adolescents for the first few years post-menarche. In perimenopause, declining ovarian reserve reduces estrogen and progesterone production, causing cycle lengthening or skipping as follicle responsiveness wanes. Hormonal causes, primarily endocrine in nature, account for a significant portion of irregular cycles, with overall prevalence of such irregularities ranging from 14% to 25% among reproductive-age women.^[15]^[2]

Lifestyle and medical conditions

Lifestyle factors can significantly disrupt menstrual regularity by influencing energy balance, hormonal signaling, and overall physiological stress. Extreme weight loss or gain alters leptin levels, a hormone produced by fat cells that signals the brain to regulate reproductive function; rapid changes in body weight create a U-shaped association with menstrual irregularity, where both underweight and obesity increase risk through disrupted appetite and energy homeostasis.^[18] Excessively low body weight, often about 10% under normal for age and height, suppresses ovulation and leads to amenorrhea, commonly seen in eating disorders like anorexia nervosa.^[17] Conversely, obesity elevates estrogen production from adipose tissue, prolonging cycles and contributing to irregular bleeding patterns.^[5] Excessive exercise, particularly in athletes, suppresses gonadotropin-releasing hormone (GnRH) pulsatility due to high energy expenditure and reduced body fat, interrupting the hypothalamic-pituitary-ovarian axis and causing oligomenorrhea or amenorrhea.^[17] This effect is compounded by the physical and psychological demands of rigorous training, such as in ballet or endurance sports, where low energy availability halts menstrual cycles to conserve resources.^[19] Chronic stress further exacerbates these disruptions by elevating cortisol, which interferes with GnRH release and can lead to hypothalamic amenorrhea; mental or emotional stress alters hypothalamic function, temporarily stopping ovulation until stress levels decrease.^[20]^[17] Poor nutrition, including calorie deficits or deficiencies in key nutrients like iron, contributes to menstrual irregularities by impairing energy availability and hormonal balance, often overlapping with low body weight and excessive exercise.^[19] Sustained low caloric intake signals the body to reduce reproductive function, mimicking starvation states and leading to delayed or absent periods.^[17] Epidemiological data indicate that lifestyle factors like these are implicated in 20-25% of irregular menstruation cases among athletes and individuals with eating disorders, with one study of high school female athletes reporting 23.5% prevalence of menstrual irregularity, including 17.1% oligomenorrhea and 5.3% secondary amenorrhea.^[21] Medical conditions unrelated to primary endocrine disorders can also trigger irregular menstruation through structural, inflammatory, or systemic mechanisms. Coagulopathies, such as von Willebrand disease, impair blood clotting and cause heavy or prolonged bleeding, affecting up to 20% of adolescents with menorrhagia.^[1] Uterine fibroids, benign tumors in the uterine wall, cause heavy or prolonged menstrual bleeding by increasing the endometrial surface area and disrupting normal shedding; submucosal fibroids particularly lead to irregular spotting between periods due to their location within the uterine cavity.^[22] Similarly, endometrial polyps, growths on the uterine lining, result in abnormal bleeding patterns, including intermenstrual spotting or heavy flow, by interfering with the uniformity of the endometrial layer. Pelvic inflammatory disease (PID), an infection of the upper reproductive tract often caused by sexually transmitted bacteria like chlamydia or gonorrhea, inflames the uterus and fallopian tubes, leading to unusual vaginal bleeding between periods or after intercourse.^[23] Endometriosis, where tissue resembling the uterine lining grows outside the uterus, causes painful and irregular periods through inflammation and scarring; the ectopic tissue responds to hormonal cycles by thickening and bleeding, resulting in heavy menstrual flow lasting over seven days and pelvic pain extending beyond typical menstruation.^[24] Chronic illnesses such as diabetes contribute via associated insulin resistance, which can manifest as irregular cycles, particularly when linked to conditions affecting ovarian function.^[25] Celiac disease, an autoimmune disorder causing intestinal malabsorption, indirectly disrupts menstruation through nutrient deficiencies like iron and vitamins, leading to reproductive issues including irregular bleeding.^[26] Iatrogenic causes arise from medical interventions or substance use that alter hormonal metabolism or uterine integrity. Certain medications, such as hormonal contraceptives, induce irregular bleeding or spotting, especially in the initial months, due to fluctuations in estrogen and progestin levels that thin the endometrial lining unevenly.^[27] Antipsychotics, particularly those elevating prolactin like risperidone, cause menstrual irregularities through hyperprolactinemia, which suppresses ovulation and leads to amenorrhea or oligomenorrhea in up to a significant portion of premenopausal women.^[28] Post-surgical effects, such as after hysterectomy, permanently alter menstruation; a total hysterectomy removes the uterus, halting periods entirely, while partial procedures may leave residual bleeding from the cervical stump.^[29] Substance use further contributes to disruptions in menstrual regularity. Smoking accelerates estrogen metabolism in the liver, shortening cycles and increasing irregularity risk as a modifiable environmental factor.^[5] Excessive alcohol consumption affects reproductive hormones, potentially lengthening cycles or inducing anovulation through interference with gonadotropin secretion.^[30]

Types

Cycle length variations

Cycle length variations encompass deviations in the interval between menstrual periods, typically defined as normal ranging from 21 to 35 days, with disruptions classified into specific subtypes based on frequency and timing. These irregularities often stem from disruptions in ovulation or hormonal regulation, though detailed causes are addressed elsewhere. Oligomenorrhea is characterized by prolonged menstrual cycles exceeding 35 days in length. This condition frequently results from infrequent ovulation, leading to symptoms such as light bleeding or entirely absent periods in affected cycles.^[31]^[32] Amenorrhea represents the complete absence of menstrual bleeding. Primary amenorrhea is identified when menstruation has not begun by age 15 years, or within three years of the onset of secondary sexual characteristics such as breast development. Secondary amenorrhea involves the cessation of previously established menses for at least three months in individuals with regular cycles or six months in those with prior irregularity. Subtypes include physiologic forms, such as those occurring during pregnancy or breastfeeding, and pathologic variants arising from underlying disorders.^[31]^[33]^[34] Polymenorrhea features excessively frequent menstrual cycles, with intervals shorter than 21 days. It often signals a shortened luteal phase, characterized by inadequate progesterone secretion following ovulation, which may elevate the risk of endometrial hyperplasia through unopposed estrogen exposure.^[31]^[2]^[5] Amenorrhea affects approximately 3-5% and oligomenorrhea 10-20% of women of reproductive age, with prevalence rising to 20-30% among adolescents due to maturing hypothalamic-pituitary-ovarian axis dynamics. These length-based irregularities may briefly relate to hormonal imbalances like anovulation, but such etiologies are explored in dedicated sections on causes.^[35]^[36]^[32]^[5]

Bleeding pattern irregularities

Bleeding pattern irregularities refer to variations in the volume, duration, consistency, or timing of menstrual flow itself, distinct from alterations in cycle intervals. These disruptions can manifest as excessive blood loss, unexpected spotting, or prolonged bleeding, often impacting daily activities and quality of life. Such patterns are common among reproductive-aged women and may signal underlying physiological or pathological processes. Menorrhagia, also known as heavy menstrual bleeding, is characterized by excessive or prolonged menstrual flow, typically defined as blood loss exceeding 80 mL per cycle or lasting more than seven days.^[37] This condition increases the risk of iron deficiency anemia due to significant blood loss over time.^[38] Women experiencing menorrhagia may require frequent pad or tampon changes, often every hour, and can pass large blood clots.^[1] Hypomenorrhea involves diminished menstrual flow, generally quantified as less than 5 mL of blood loss per cycle, and stands apart from patterns of excessive bleeding. While primarily a descriptor of bleeding volume, it can accompany other disruptions and warrants evaluation to rule out associated hormonal factors.^[39]^[1] Metrorrhagia involves irregular bleeding or spotting between menstrual periods, sometimes referred to as intermenstrual or breakthrough bleeding.^[31] This pattern disrupts the expected cyclical flow and can occur unpredictably, often in small amounts but persistently enough to cause concern.^[40] Menometrorrhagia refers to prolonged and irregular heavy bleeding, combining features of menorrhagia and metrorrhagia.^[1] Postcoital bleeding, occurring after sexual intercourse, serves as a red flag for potential cervical or vaginal irregularities, warranting prompt evaluation.^[40] Associated symptoms of these bleeding irregularities often include the passage of blood clots larger than a quarter and fatigue or shortness of breath from chronic blood loss leading to anemia.^[38] Heavy menstrual bleeding affects an estimated 10-30% of women globally during their reproductive years.^[41]

Diagnosis

Clinical evaluation

The clinical evaluation of irregular menstruation begins with a detailed medical history to identify patterns, potential causes, and associated symptoms. Clinicians inquire about cycle tracking methods, such as the use of calendars or mobile applications, to document the frequency, duration, and variability of menstrual cycles; normal adolescent cycles range from 21 to 45 days, with evaluation recommended if intervals exceed 90 days.^[12] The age of menarche and onset of irregularities are assessed, as primary amenorrhea is defined as no menses by age 15 or within three years of thelarche, while irregularities in reproductive-aged women may signal ovulatory dysfunction.^[42] Family history is explored for endocrine disorders, such as polycystic ovary syndrome (PCOS) or premature ovarian failure, and bleeding disorders that could contribute to abnormal patterns.^[43] Questions also cover sexual activity to rule out pregnancy as a cause of bleeding, along with symptoms like unintentional weight changes, which may indicate hypothalamic amenorrhea from undernutrition or excessive exercise, or hirsutism suggesting androgen excess.^[42] A comprehensive physical examination follows to detect structural or systemic clues. The pelvic examination evaluates for anatomical anomalies, such as uterine fibroids or polyps, by inspecting the external genitalia and performing a speculum and bimanual assessment if indicated, particularly in adolescents after menarche.^[43] Body mass index (BMI) is calculated to identify obesity or underweight states that influence hormonal balance and cycle regularity.^[12] Signs of androgen excess, including acne, hirsutism, or alopecia, are examined, as these may point to conditions like PCOS affecting up to 10% of reproductive-aged women.^[42] Certain features in the history and exam raise red flags requiring urgent referral. Sudden onset of irregular bleeding, especially with severe pelvic pain, may indicate acute issues like ectopic pregnancy or infection and necessitates immediate evaluation.^[42] Postmenopausal bleeding, defined as any bleeding after 12 months of amenorrhea, warrants prompt investigation to exclude endometrial hyperplasia or malignancy.^[43] According to American College of Obstetricians and Gynecologists (ACOG) guidelines, evaluation of menstrual cycles should begin at age 13 during preventive health visits, treating the cycle as a vital sign to detect irregularities early and guide further assessment, potentially including hormonal testing if clinical findings suggest endocrine involvement.^[12]

Laboratory and imaging tests

Laboratory and imaging tests serve as objective tools to identify underlying causes of irregular menstruation, such as hormonal imbalances, structural abnormalities, or systemic conditions, following initial clinical assessment.^[35] These tests are selected based on patient history and examination findings to confirm diagnoses like polycystic ovary syndrome (PCOS), primary ovarian insufficiency (POI), or hyperprolactinemia.^[1] Blood tests form the cornerstone of laboratory evaluation, beginning with a pregnancy test using serum human chorionic gonadotropin (hCG) to rule out pregnancy as the primary cause of amenorrhea or irregular bleeding in reproductive-aged individuals.^[35] A comprehensive hormone panel typically includes follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, prolactin, and thyroid-stimulating hormone (TSH) to assess ovulatory function and endocrine disorders.^[1] For instance, elevated FSH levels (>25 IU/L on one occasion) suggest POI per 2024 ASRM guidelines, while low FSH and LH with estradiol below 30 pg/mL indicate functional hypothalamic amenorrhea.^[35]^[44] Anti-Müllerian hormone (AMH) levels may also be measured to assess ovarian reserve in cases of suspected POI.^[44] Prolactin levels above 20 ng/mL prompt further investigation for hyperprolactinemia, and abnormal TSH requires free thyroxine follow-up to detect thyroid dysfunction.^[35] In cases of suspected hyperandrogenism, such as in PCOS, total testosterone and dehydroepiandrosterone sulfate (DHEAS) are measured.^[1] Imaging studies provide visualization of reproductive structures to detect anomalies contributing to irregular cycles. Pelvic ultrasound, often transvaginal, is the first-line imaging modality to evaluate for ovarian cysts, fibroids, or polycystic ovarian morphology meeting Rotterdam criteria for PCOS.^[35] It also assesses endometrial thickness to evaluate for potential hyperplasia, though decisions for biopsy are guided by clinical risk factors such as age over 45 or persistent anovulatory bleeding, rather than thickness alone.^[1] For suspected pituitary issues, such as in persistent hyperprolactinemia, magnetic resonance imaging (MRI) of the sella turcica is recommended to identify adenomas or other lesions.^[35] Advanced tests are employed when initial evaluations suggest specific etiologies. Endometrial biopsy is indicated in anovulatory irregular bleeding to assess for endometrial hyperplasia, particularly in women over 45 years or those with unopposed estrogen exposure, involving sampling of the uterine lining for histopathological analysis.^[1] In suspected PCOS, an oral glucose tolerance test evaluates insulin resistance, with impaired glucose tolerance supporting the diagnosis alongside clinical and ultrasound findings.^[35] Recent guidelines emphasize cost-effective sequencing, starting with targeted labs before imaging, to optimize diagnostic yield while minimizing unnecessary procedures.^[35]

Management and treatment

Non-medical approaches

Lifestyle modifications play a key role in managing mild cases of irregular menstruation by addressing factors that influence hormonal balance. Maintaining a healthy body mass index (BMI) within the normal range of 18.5 to 24.9 kg/m² is associated with improved menstrual regularity, as both underweight and overweight conditions can disrupt cycle length and ovulation. For instance, women with obesity (BMI ≥30 kg/m²) are twice as likely to experience irregular cycles compared to those with normal weight, while underweight status (BMI <18.5 kg/m²) often leads to amenorrhea or oligomenorrhea due to reduced energy availability.^[45] ^[46] A balanced diet rich in iron and vitamin D supports menstrual health; iron deficiency, common in women with heavy or irregular bleeding, can exacerbate cycle disruptions, and supplementation or dietary intake from sources like leafy greens and lean meats has been shown to mitigate these effects.^[47] Similarly, vitamin D deficiency correlates with menstrual disorders, including irregular cycles, and adequate levels from fortified foods or sunlight exposure may help regulate ovulation and hormonal function.^[48] Moderate exercise, such as 150 minutes per week of aerobic activity like brisk walking or swimming, promotes cycle regularity by improving insulin sensitivity and reducing inflammation, particularly in conditions like polycystic ovary syndrome (PCOS) where irregularity is prevalent.^[49] Stress reduction techniques offer non-invasive ways to normalize cycles influenced by psychological factors, which affect up to 30% of menstrual irregularities through hypothalamic-pituitary-ovarian axis disruption. Mindfulness-based practices, such as meditation or mindfulness-based stress reduction (MBSR), have demonstrated benefits in restoring cycle regularity in stress-related cases; for example, mind-body interventions improved menstrual outcomes in women with PCOS, a common cause of irregularity, by lowering cortisol levels and enhancing quality of life.^[50] Yoga, including poses and breathing exercises, reduces premenstrual symptoms and supports cycle normalization, with randomized trials showing alleviation of depressive and physical symptoms that indirectly stabilize menstrual patterns.^[51] Cognitive behavioral therapy (CBT) addresses stress-induced amenorrhea effectively; studies indicate that over 70% of women with stress- or exercise-related absent periods recover menstrual function following CBT combined with lifestyle adjustments.^[52] These approaches, when practiced consistently for 8-12 weeks, yield measurable improvements in cycle predictability without pharmacological intervention. Cycle tracking empowers individuals to monitor and predict menstrual patterns, aiding in the management of irregularities through increased awareness of fertile windows and symptom triggers. Mobile applications, such as those using algorithms based on user-input data like cycle start dates and symptoms, provide predictions for ovulation and period onset, helping users identify deviations early.^[53] Basal body temperature (BBT) tracking, where daily morning temperatures are recorded to detect the post-ovulatory rise (typically 0.5-1°F), offers a reliable, low-cost method for confirming ovulation in irregular cycles and supporting fertility awareness.^[54] Wearable devices integrating BBT with heart rate variability further enhance accuracy, allowing for personalized insights that can guide lifestyle adjustments to foster regularity. Regular use of these tools has been associated with better self-management of mild irregularities, though they should complement, not replace, professional evaluation. Natural remedies, such as herbal supplements, are sometimes explored for progesterone support in irregular menstruation, but evidence remains limited and requires caution due to variable efficacy and potential interactions. Vitex agnus-castus (chasteberry), traditionally used for cycle regulation, shows promise in addressing hyperprolactinemia-related irregularities; clinical studies report improvements in menstrual frequency (up to 79%) and reduced pain in women with cycle disorders after 3-6 months of use at standardized doses (20-40 mg/day of extract).^[55] However, systematic reviews highlight inconsistent results for broader menstrual irregularities, with benefits more established for premenstrual syndrome than for cycle length variations, and long-term safety data are sparse.^[56] Consultation with a healthcare provider is essential before initiating such remedies to avoid adverse effects like nausea or hormonal imbalances.

Pharmacological and procedural interventions

Hormonal therapies form the foundation of pharmacological management for irregular menstruation, targeting ovulatory dysfunction and endometrial instability. Combined oral contraceptives (COCs), containing estrogen and progestin, regulate cycle length by inhibiting ovulation and promoting consistent endometrial shedding, effectively normalizing irregular patterns in conditions such as anovulation or polycystic ovary syndrome (PCOS).^[57] Clinical consensus supports their use for menstrual suppression and cycle stabilization, with extended regimens minimizing breakthrough bleeding.^[58] Progestin-only challenges, typically involving medroxyprogesterone acetate (10 mg daily for 5-10 days), induce withdrawal bleeding to evaluate estrogen status and restore cycling in hypoestrogenic or anovulatory states, confirming responsiveness in up to 80% of cases without structural pathology.^[35] This approach aids in differentiating causes and initiating therapy for oligomenorrhea or amenorrhea.^[59] Non-hormonal options include tranexamic acid and nonsteroidal anti-inflammatory drugs (NSAIDs), which reduce blood loss by 30-50% in heavy menstrual bleeding.^[60] Condition-specific pharmacological interventions address underlying etiologies to restore menstrual regularity. In PCOS, metformin targets insulin resistance, enhancing ovulatory function and improving menstrual regularity (e.g., more cycles per 6 months), as shown in meta-analyses of randomized trials (very low certainty evidence).^[61] ^[62] For hypothyroidism-induced irregularities, levothyroxine replacement normalizes thyroid-stimulating hormone levels, thereby reinstating ovulatory cycles and potentially improving menstrual patterns.^[63] In endometriosis, gonadotropin-releasing hormone (GnRH) agonists like leuprolide acetate suppress pituitary gonadotropin secretion, inducing a hypoestrogenic state that halts menstruation and regresses lesions, alleviating associated dysmenorrhea and irregular bleeding in 70-90% of patients during 3-6 months of treatment.^[64] Procedural interventions provide targeted relief for acute heavy bleeding or cases refractory to medications. Dilation and curettage (D&C) involves cervical dilation and mechanical removal of the endometrium, offering immediate hemostasis and diagnostic tissue sampling for unexplained menorrhagia.^[60] Guidelines endorse D&C for acute abnormal uterine bleeding unresponsive to initial pharmacotherapy, though it is not a long-term solution.^[65] For persistent irregularities, endometrial ablation techniques—such as radiofrequency or thermal balloon methods—destroy the endometrial lining, achieving significant reduction in bleeding (70-90% satisfaction) or amenorrhea (up to 50%) in women with benign heavy menstrual bleeding.^[66] ^[67] Hysterectomy, entailing surgical removal of the uterus, serves as a definitive option for refractory cases where fertility preservation is not desired, eliminating menstruation entirely but reserved due to its invasiveness.^[1] Recent advancements in long-acting reversible contraceptives (LARCs), notably the levonorgestrel-releasing intrauterine system (LNG-IUS), have enhanced options for cycle regulation. Inserted intrauterinely, the LNG-IUS delivers localized progestin to thin the endometrium, reducing bleeding volume by 82% overall and promoting predictable light or absent menses in 70-95% of users with abnormal uterine bleeding, per 2023-2024 clinical data.^[68] These devices offer sustained efficacy for up to 5-8 years, outperforming oral therapies in quality-of-life improvements for heavy or irregular patterns.^[69]

Complications

Reproductive health impacts

Irregular menstruation often stems from ovulatory disorders, such as anovulation, which disrupts the release of eggs necessary for conception and leads to subfertility in affected individuals. Chronic anovulation accounts for approximately 25% to 30% of female infertility cases and is frequently manifested as irregular menstrual cycles, including oligomenorrhea or amenorrhea.^[70] Polycystic ovary syndrome (PCOS), a leading endocrine disorder, contributes significantly to this association, as it underlies up to 70% of anovulation cases and commonly presents with irregular periods that impair ovulation and fertility.^[71] Women with PCOS face a substantially elevated infertility risk due to these hormonal disruptions, with studies estimating that ovulatory dysfunction from PCOS affects fertility in 70% to 80% of untreated cases.^[72] Population-level data underscore the scale of this impact, with irregular menstrual cycles linked to heightened infertility risk compared to regular cycles, primarily arising from inconsistent ovulation, making natural conception challenging without intervention. Beyond infertility, irregular menstruation elevates pregnancy risks once conception occurs, particularly in untreated cases of oligoamenorrhea. Women with these patterns experience higher rates of miscarriage due to endometrial irregularities and hormonal imbalances that compromise implantation and early fetal development.^[73] Additionally, a history of irregular cycles signals underlying hormonal disruptions that independently predict type 2 diabetes mellitus, increasing its risk by up to 2.5-fold through mechanisms like insulin resistance.^[74] For individuals facing premature ovarian insufficiency (POI)—a condition often heralded by progressive irregular menstruation—fertility preservation strategies are crucial to mitigate reproductive loss. Egg freezing, or oocyte cryopreservation, offers a viable option for those at risk or in early stages of POI, allowing retrieval and storage of viable eggs before ovarian function declines further, thereby preserving future conception possibilities via assisted reproductive technologies.^[75] Guidelines from reproductive medicine societies emphasize counseling on such preservation for women with POI risk factors, as spontaneous ovulation ceases in most cases, rendering natural fertility improbable without prior intervention.^[44]

Systemic health risks

Untreated irregular menstruation can lead to significant metabolic disturbances, particularly through insulin resistance commonly observed in polycystic ovary syndrome (PCOS), a frequent cause of cycle irregularities. This insulin resistance promotes hyperinsulinemia and impaired glucose tolerance, elevating the risk of type 2 diabetes by 5- to 10-fold compared to women without PCOS.^[76]^[77] Additionally, these metabolic changes contribute to dyslipidemia, visceral obesity, and hypertension, collectively heightening cardiovascular risks such as coronary heart disease and nonfatal stroke.^[72]^[78] Hypoestrogenism associated with amenorrhea, an extreme manifestation of irregular menstruation, impairs bone health by accelerating resorption and reducing formation, thereby increasing osteoporosis risk. Women experiencing functional hypothalamic amenorrhea, for instance, exhibit annual bone mineral density (BMD) losses of 2.4% at the hip and 2.6% at the spine, reflecting estrogen's critical role in maintaining skeletal integrity.^[79] This progressive BMD decline, if prolonged, can result in irreversible fragility fractures and reduced quality of life in later years.^[80] Chronic anovulation underlying many cases of irregular menstruation results in unopposed estrogen exposure, which stimulates endometrial proliferation and elevates cancer risk. This mechanism drives a 2- to 3-fold higher incidence of endometrial cancer in affected women, as the absence of progesterone fails to counter estrogen's mitogenic effects, often leading to hyperplasia as a precursor lesion.^[81]^[82] Screening guidelines from authoritative bodies recommend endometrial biopsy or transvaginal ultrasonography for women with persistent anovulatory bleeding, especially those over 45, obese, or with PCOS, to detect early hyperplasia or malignancy.^[83]^[84] Irregular menstruation correlates with elevated mental health burdens, including anxiety and depression, through disruptions in estrogen-mediated neuroendocrine regulation. Recent cohort studies indicate that 20-30% of women with menstrual irregularities experience clinically significant mood disorders, often bidirectional with underlying stress or hypothalamic dysfunction exacerbating cycle variability.^[5]^[85] These associations underscore the need for integrated psychological screening in affected individuals to mitigate long-term emotional impacts.^[86]

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We found a U-shaped pattern of association between body weight changes and menstrual irregularity among obese women in the general Korean population.Missing: poor | Show results with:poor
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Jan 31, 2023 · As a combination of factors are often involved in its pathophysiology, including sustained low weight, excessive exercise, poor nutritional ...
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May 23, 2022 · Despite regular menses generally being considered an indicator of ovulation, they can, in fact, be associated with anovulation (3). Therefore, ...
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Results Among all athletes, 18.2%, 23.5%, and 21.8% met the criteria for disordered eating, menstrual irregularity, and low bone mass, respectively. Ten girls ( ...
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### Summary: How Uterine Fibroids Cause Irregular Menstruation or Abnormal Bleeding
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### Summary: How PID Causes Abnormal Uterine Bleeding or Irregular Periods
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Endometriosis - Symptoms and causes
### Summary: How Endometriosis Causes Irregular or Painful Periods
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### Summary: Does Type 2 Diabetes Cause Irregular Periods?
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Celiac disease - Symptoms and causes
### Summary: Does Celiac Disease Cause Irregular Menstruation?
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Birth control: Your questions, answered
### Side Effects of Contraceptives on Menstrual Cycles
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The Effects of Antipsychotics on Prolactin Levels and Women's ...
Some studies support that a high percentage of menstrual irregularity and estrogen deficiency cannot be fully explained by antipsychotic induced prolactin ...
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Your periods may end, but you may still ovulate and have cramps each month. After a supracervical (partial) hysterectomy, you may continue to have some monthly ...
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Abnormal Uterine Bleeding
### Summary of Cycle Length Variations from ACOG FAQ on Abnormal Uterine Bleeding
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Primary dysmenorrhea is the cramping pain that comes before or during a period. This pain is caused by natural chemicals called prostaglandins that are made in ...
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Clotting Factor Deficiencies as an Underlying Cause of Abnormal ...
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The purpose of this document is to provide evidence-based management guidelines for the evaluation of the reproductive-aged patient with AUB. A secondary ...
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Apps can be useful tools for tracking and accomplishing health goals [1, 2]. A segment of these health apps is used to track menstrual cycles.
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3 types of oral contraceptive pills are broadly prescribed: combined estrogen-progesterone, progesterone-only, and continuous or extended-use pills.Continuing Education Activity · Indications · Administration · Adverse Effects
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The purpose of this document is to review currently available management options, general principles, and counseling approaches for reproductive-aged patients ...
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The pelvic examination also will determine the amount and intensity of bleeding and will identify any uterine enlargement or irregularity, which can be ...
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Heavy menstrual bleeding (HMB), which is the preferred term for menorrhagia, affects ∼90% of women with an underlying bleeding disorder and ∼70% of women on ...
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The goal of endometrial ablation is to reduce how much you bleed during periods, also called menstrual flow. In some people, menstrual flow may stop completely.
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Dec 6, 2023 · Overall effectiveness of LNG-IUD in reducing menstrual bleeding was 82%. The proportion whose bleeding decreased was 95.50% in the endometrial ...
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Disorders of ovulation account for about 30% of infertility and often present with irregular periods (oligomenorrhoea) or an absence of periods (amenorrhoea).
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: PCOS is a common condition that causes 70% of anovulation cases. PCOS ... In general, the diagnosis of anovulation is having irregular periods. Your ...
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The guideline group recommends the following diagnostic criteria: disordered menstrual cycles (spontaneous amenorrhea or irregular menstrual cycles) for at ...
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Also, patients at risk of premature ovarian insufficiency (POI) could benefit from the preservation of fertility due to cryopreservation of reproductive ...
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You may first have a transvaginal ultrasound exam. This exam measures the thickness of the endometrium and the size of the uterus. A thicker endometrium means ...
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