Ovulatory dysfunction

How it causes bleeding

After ovulation, the ovary makes progesterone. Progesterone stabilizes the uterine lining, and when it falls, the lining sheds in an orderly period. Without ovulation there is no progesterone. The lining keeps growing under estrogen alone until it breaks down unevenly. Bleeding from this pattern is often irregular and can be heavy. It is usually less painful than ovulatory periods.

Common causes

• Polycystic ovary syndrome (PCOS)
• Thyroid disease, both over- and underactive
• High prolactin, from a pituitary condition or medications such as some antipsychotics
• The first years after a first period, and perimenopause
• Low energy availability from intense exercise, low body weight, or not eating enough
• Significant stress or illness

Why treat it

Treatment controls bleeding. It also protects the lining, because long stretches without progesterone raise the risk of endometrial hyperplasia. And it addresses fertility if pregnancy is a goal.

Diagnosis

Expect a pregnancy test, thyroid and prolactin levels, testosterone and related tests when PCOS is suspected, and a blood count. A pelvic ultrasound is often done. An endometrial biopsy is recommended at 45 and older, and at younger ages with long-standing irregular bleeding plus risk factors such as obesity.

Treatment

• Combined hormonal birth control, which regulates bleeding and protects the lining
• Progestins taken cyclically or continuously, or the levonorgestrel IUD
• Treating the underlying cause, such as thyroid disease or high prolactin
• Ovulation induction, such as letrozole for PCOS, when pregnancy is the goal