Differential Diagnosis of Prolonged Menstruation

Introduction to Causes

Prolonged menstruation (>7 days) requires systematic evaluation for structural, hormonal, coagulopathic, iatrogenic, and systemic causes, with pregnancy and malignancy being the most critical to exclude immediately, as recommended by the American College of Obstetricians and Gynecologists 1, 2

Uterine fibroids (leiomyomas), particularly submucosal fibroids that distort the endometrial cavity, can cause prolonged menstruation, according to the American College of Obstetricians and Gynecologists 2
Endometrial or cervical malignancy must be excluded, especially in women >35 years or with risk factors, as recommended by the American College of Obstetricians and Gynecologists 2
Intrauterine device (IUD) complications, particularly copper IUD displacement or malposition, can cause prolonged menstruation, as reported by the Centers for Disease Control and Prevention 3, 2

Polycystic ovary syndrome (PCOS) can cause chronic anovulation with prolonged unopposed estrogen, leading to prolonged menstruation, according to the Endocrine Society 4
Relative Energy Deficiency in Sport (RED-S) can paradoxically cause both amenorrhea and irregular prolonged bleeding in female athletes, as reported by the International Olympic Committee 5, 4

Von Willebrand disease is the most common inherited bleeding disorder, present in up to 20% of women with heavy menstrual bleeding, according to the National Hemophilia Foundation 2
Platelet dysfunction or thrombocytopenia requires complete blood count with platelet assessment, as recommended by the American College of Obstetricians and Gynecologists 2

Hormonal contraceptives, particularly progestin-only methods (implants, IUDs), can cause irregular bleeding patterns, as reported by the Centers for Disease Control and Prevention 6, 7
Anticoagulant therapy, such as warfarin and NOACs (rivaroxaban particularly associated with prolonged menstrual bleeding), can cause prolonged menstruation, according to the European Society of Cardiology 8
Intrauterine devices, particularly copper IUDs, commonly cause heavy/prolonged bleeding, especially in the first 3-6 months, as reported by the Centers for Disease Control and Prevention 3, 2

Pregnancy complications, such as incomplete spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease, must be excluded, as recommended by the American College of Obstetricians and Gynecologists 2

Pelvic inflammatory disease (PID) from sexually transmitted infections can cause endometritis, leading to prolonged menstruation, according to the Centers for Disease Control and Prevention 1, 2

Always rule out pregnancy first by performing hCG testing in all reproductive-age women before pursuing other diagnoses, as recommended by the American College of Obstetricians and Gynecologists 2
Don't overlook coagulopathies - obtain detailed bleeding history and consider coagulation studies when clinically indicated, as recommended by the American College of Obstetricians and Gynecologists 2