What causes prolonged menses?

Causes of Prolonged Menses

Prolonged menses are primarily caused by structural abnormalities (polyps, adenomyosis, leiomyomas, malignancy) or non-structural factors (coagulopathy, ovulatory dysfunction, endometrial disorders, iatrogenic causes, and unclassified conditions) as defined by the PALM-COEIN classification system. 1

Structural Causes

• Polyps: Endometrial polyps can cause irregular and prolonged bleeding patterns by creating focal areas of endometrial overgrowth 1
• Adenomyosis: The presence of endometrial tissue within the myometrium can lead to heavy and prolonged menstrual bleeding 1
• Leiomyomas (fibroids): Both submucosal and intramural fibroids can distort the uterine cavity and endometrial surface, resulting in prolonged bleeding 1
• Malignancy and hyperplasia: Endometrial hyperplasia or cancer can present with abnormal uterine bleeding patterns, including prolonged menses 1

Non-Structural Causes

• Coagulopathy: Bleeding disorders can lead to heavy and prolonged menstrual bleeding; up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder 2
• Ovulatory dysfunction: Oligo-ovulation and anovulation are common causes of prolonged menses, often resulting in irregular and heavy bleeding patterns 1
• Endometrial causes: Primary disorders of the endometrium can lead to abnormal bleeding patterns 1
• Iatrogenic causes: Medications and contraceptive methods can cause prolonged bleeding:
  • Hormonal contraceptives, particularly during the first 3-6 months of use 1
  • Intrauterine devices (both copper and hormonal) commonly cause irregular bleeding patterns, especially during initial use 1, 3
  • Anticoagulants and certain other medications can prolong menstrual bleeding 4
• Not yet classified: Other conditions that don't fit into the above categories 1

Specific Conditions Associated with Ovulatory Dysfunction

• Adolescence: Immature hypothalamic-pituitary-ovarian axis can lead to anovulation and irregular bleeding 1
• Perimenopause: Hormonal fluctuations during the transition to menopause often cause irregular and prolonged bleeding 1
• Lactation: Elevated prolactin levels can suppress ovulation 1
• Pregnancy-related: Incomplete abortion or other pregnancy complications can present as prolonged bleeding 5
• Hyperandrogenic conditions: Conditions like polycystic ovary syndrome can cause anovulation 1
• Hypothalamic dysfunction: Often related to stress, excessive exercise, or significant weight changes 1
• Endocrine disorders:
  • Hyperprolactinemia: Elevated prolactin suppresses GnRH pulsatility 1
  • Thyroid dysfunction: Both hypo- and hyperthyroidism can affect menstrual patterns 1
  • Primary pituitary disease: Disrupts normal hormone signaling 1
• Premature ovarian failure: Early depletion of ovarian follicles leads to hormonal changes 1
• Functional hypothalamic amenorrhea (FHA): Caused by stress, excessive exercise, and weight loss, resulting in reduced GnRH pulsatility 1

Other Contributing Factors

• Relative energy deficiency: Particularly in athletes, inadequate caloric intake relative to energy expenditure can disrupt normal menstrual patterns 1
• Chronic diseases: Conditions such as diabetes, liver and kidney dysfunction can affect menstrual patterns 5
• Obesity: Can cause abnormal estrogen cycling and contribute to anovulation 5

Diagnostic Considerations

• Evaluation should include assessment for structural causes through imaging (transvaginal ultrasound, sonohysterography, or hysteroscopy) 1
• Laboratory testing should include pregnancy test, thyroid function tests, prolactin levels, and consideration of coagulation studies when appropriate 1, 2
• Endometrial biopsy may be indicated to rule out hyperplasia or malignancy, particularly in women over 40 or those with risk factors 1

Understanding the underlying cause of prolonged menses is essential for appropriate management, as treatment approaches vary significantly depending on the etiology 1, 6.