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Bleeding after 7days of menstrutation

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"abnormal uterine bleeding" causes management

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I now have comprehensive information from multiple authoritative textbooks. Here is a thorough answer:

Bleeding After 7 Days of Menstruation

Menstrual bleeding lasting more than 7 days is defined as abnormal uterine bleeding (AUB) - previously called menorrhagia or dysfunctional uterine bleeding (terms no longer recommended). Normal menstruation lasts 4-8 days with blood loss of 35 mL on average; >80 mL or >7 days is abnormal.
  • Rosen's Emergency Medicine, p. 539: "It is considered abnormal to bleed for more than 7 days."
  • Sabiston Textbook of Surgery, p. 2937: "A normal menstrual cycle...duration of flow between 4 and 8 days."

Causes - The PALM-COEIN Classification (FIGO 2011)

Since 2011, the American College of Obstetricians and Gynecologists (ACOG) uses the PALM-COEIN system to categorize causes:

๐Ÿ”ด PALM - Structural Causes (visible on imaging/biopsy)

CauseDetails
P - PolypsEndometrial or cervical polyps cause irregular, prolonged bleeding
A - AdenomyosisEndometrial glands within the myometrium; causes heavy, prolonged periods
L - Leiomyoma (Fibroids)Submucosal fibroids especially prone to heavy/prolonged bleeding (increased endometrial surface area, impairs uterine contractions)
M - Malignancy/HyperplasiaEndometrial cancer or hyperplasia - must always be excluded, especially age >45

๐ŸŸก COEIN - Non-structural Causes

CauseDetails
C - CoagulopathyVon Willebrand disease, ITP, platelet disorders; suspect if heavy bleeding since menarche
O - Ovulatory DysfunctionMost common (~50% of cases). No ovulation = no progesterone = unopposed estrogen = unstable, thick endometrium that sheds irregularly
E - EndometrialPrimary endometrial disorders (e.g., endometritis, altered prostaglandin production)
I - IatrogenicHormonal contraceptives (especially progestin-only, IUDs), anticoagulants, tamoxifen
N - Not classifiedNo obvious etiology found

Common Causes by Age Group

Age GroupMost Likely Causes
AdolescentsAnovulation (immature HPO axis), coagulopathy (von Willebrand disease)
Reproductive ageFibroids, polyps, anovulation, pregnancy complications, contraceptive use
PerimenopauseAnovulation (incipient ovarian failure), fibroids, hyperplasia
PostmenopauseEndometrial atrophy (most common), malignancy, polyps

Diagnostic Workup

The initial evaluation should include:
  1. Detailed history - duration, amount, associated symptoms, medications, family history of bleeding disorders
  2. Pregnancy test - always first to exclude pregnancy-related bleeding
  3. Pelvic examination - tenderness, masses, uterine enlargement
  4. Laboratory tests:
    • Complete blood count (assess for anemia)
    • Thyroid function tests (hypothyroidism causes menorrhagia)
    • Coagulation studies / von Willebrand screen (if heavy since menarche, family history)
    • Prolactin level, fasting glucose
    • STI screening if indicated
  5. Pelvic ultrasound - assess for fibroids, polyps, adenomyosis, endometrial thickness
  6. Endometrial biopsy - indicated for:
    • Women โ‰ฅ45 years with AUB
    • Women <45 with risk factors: obesity, prolonged anovulation, persistent/refractory AUB, family history of endometrial cancer

Treatment

Medical (First-line)

  • Combined oral contraceptives (OCP) - regularize cycles, reduce flow
  • Progestins (medroxyprogesterone acetate, norethindrone) - especially for anovulatory bleeding
  • Levonorgestrel-releasing IUD (LNG-IUS) - highly effective for heavy menstrual bleeding
  • NSAIDs (mefenamic acid, ibuprofen) - reduce blood loss by ~30%
  • Tranexamic acid - antifibrinolytic, reduces blood loss
  • Conjugated estrogens IV - for acute severe anovulatory bleeding (25 mg every 4 hours up to 3 doses)

Surgical (Second-line)

  • Endometrial ablation - destroys the endometrial lining; not 100% effective
  • Hysteroscopic polypectomy - for polyps
  • Myomectomy / UAE - for fibroids
  • Hysterectomy - definitive treatment for refractory cases or confirmed malignancy

When to Seek Urgent Care

See a doctor promptly if you experience:
  • Bleeding that soaks through a pad/tampon every hour for 2+ consecutive hours
  • Signs of anemia: dizziness, fatigue, pallor, shortness of breath
  • Pelvic pain or pressure
  • Bleeding in a postmenopausal woman (always requires evaluation)
  • Suspected pregnancy
Bottom line: Bleeding beyond 7 days is not normal and warrants medical evaluation. The most common cause in reproductive-age women is anovulatory dysfunction (no ovulation leading to unopposed estrogen), but structural causes like fibroids, polyps, and - importantly - malignancy must be excluded through proper workup. - Goldman-Cecil Medicine, p. 1525; Sabiston Textbook of Surgery, pp. 2937-2945
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