Causes of Prolonged Menses

Introduction to Causes

Prolonged menses are primarily caused by structural abnormalities or non-structural factors, as defined by the PALM-COEIN classification system, according to the American Academy of Family Physicians 1, 2

Endometrial polyps can cause irregular and prolonged bleeding patterns by creating focal areas of endometrial overgrowth, as noted by the American Academy of Family Physicians 1
Adenomyosis, characterized by the presence of endometrial tissue within the myometrium, can lead to heavy and prolonged menstrual bleeding, as reported by the American Academy of Family Physicians 1
Leiomyomas (fibroids) can distort the uterine cavity and endometrial surface, resulting in prolonged bleeding, according to the American Academy of Family Physicians 1, 2
Malignancy and hyperplasia, including endometrial hyperplasia or cancer, can present with abnormal uterine bleeding patterns, including prolonged menses, as stated by the American Academy of Family Physicians 1, 2

Ovulatory dysfunction, including oligo-ovulation and anovulation, is a common cause of prolonged menses, often resulting in irregular and heavy bleeding patterns, as noted by the American Academy of Family Physicians 1, 2
Endometrial causes, such as primary disorders of the endometrium, can lead to abnormal bleeding patterns, according to the American Academy of Family Physicians 1
Iatrogenic causes, including hormonal contraceptives and intrauterine devices, can cause prolonged bleeding, as reported by the Centers for Disease Control and Prevention 3, 4 and the American College of Obstetricians and Gynecologists 5

Adolescence, characterized by an immature hypothalamic-pituitary-ovarian axis, can lead to anovulation and irregular bleeding, as stated by the American Academy of Family Physicians 1, 2
Perimenopause, marked by hormonal fluctuations during the transition to menopause, often causes irregular and prolonged bleeding, according to the American Academy of Family Physicians 1, 2
Hyperandrogenic conditions, such as polycystic ovary syndrome, can cause anovulation, as reported by the American Academy of Family Physicians 1 and the European Society of Human Reproduction and Embryology 7
Hypothalamic dysfunction, often related to stress, excessive exercise, or significant weight changes, can disrupt normal menstrual patterns, as noted by the American Academy of Family Physicians 1 and the European Society of Human Reproduction and Embryology 7

Relative energy deficiency, particularly in athletes, can disrupt normal menstrual patterns, as reported by the British Journal of Sports Medicine 8

Evaluation for structural causes should include assessment through imaging, such as transvaginal ultrasound, sonohysterography, or hysteroscopy, as recommended by the American Academy of Family Physicians 1, 2
Laboratory testing should include pregnancy test, thyroid function tests, prolactin levels, and consideration of coagulation studies when appropriate, according to the American Academy of Family Physicians 1, 2
Endometrial biopsy may be indicated to rule out hyperplasia or malignancy, particularly in women over 40 or those with risk factors, as stated by the American Academy of Family Physicians 1, 2