Periods are not supposed to ruin your life. Some discomfort is common, but heavy bleeding, severe pain, or unpredictable cycles can signal an underlying issue. What’s “normal” also changes across life stages — from the first period to menopause. This guide breaks down the most common menstrual complaints by age group, their likely causes, and how doctors evaluate and manage them.
What Counts as “Normal”?
A typical cycle is about 24–38 days long, bleeding lasts up to about 7 days, and flow shouldn’t stop you from daily activities. It’s normal to have more irregular cycles right after your first period and again in the years leading up to menopause.
Age Group 1: Early Adolescence (Menarche to ~19)
Common Complaints
- Irregular cycles (skipping months, unpredictable timing)
- Heavy menstrual bleeding (HMB)
- Painful periods (dysmenorrhea)
- Mood changes, bloating, breast tenderness (PMS-like symptoms)
Common Causes / Diseases
- Anovulatory cycles (immature hormonal axis): In the first 2–3 years after the first period, ovulation may not happen regularly, causing irregular or heavy bleeding.
- Bleeding disorders: If periods are heavy from the very beginning or there’s easy bruising or family history, conditions like von Willebrand disease should be considered.
- Primary dysmenorrhea: Cramping pain without disease, caused by prostaglandins — very common in teens.
- Endometriosis: Can begin in adolescence; suspect if pain is severe, worsening, or not responding to basic treatment.
Prevention & General Management
- Track cycles on an app or calendar to spot patterns.
- Start NSAIDs (like ibuprofen/naproxen) at onset or 1 day before bleeding for cramps.
- Eat iron-rich foods; take iron supplements if heavy bleeding causes fatigue.
- Hormonal therapy (combined pills or progestins) may regulate cycles and reduce pain/flow.
- Sleep, exercise, and stress control can noticeably improve cramps and PMS symptoms.
Red Flags in Teens
- Soaking more than 1 pad/tampon per hour for 2+ hours
- Large clots repeatedly
- Dizziness, fainting, shortness of breath, racing heartbeat
- Pain worsening every cycle or causing school absence
- Bleeding between periods or after sex
Age Group 2: Reproductive Years (~20–39)
Common Complaints
- Painful periods
- Heavy or prolonged bleeding
- Irregular or missed periods
- Bleeding between periods (spotting)
- Moderate to severe PMS/PMDD
Common Causes / Diseases
Abnormal uterine bleeding (AUB) is often described using the PALM–COEIN system:
Structural Causes (PALM)
- Polyps – spotting, bleeding after sex
- Adenomyosis – heavy, painful periods with enlarged tender uterus
- Leiomyomas (fibroids) – heavy flow, prolonged bleeding, pelvic pressure
- Malignancy/hyperplasia – less common under 40 but important if persistent
Non-Structural Causes (COEIN)
- Coagulopathy – inherited/acquired bleeding issues
- Ovulatory dysfunction – stress, weight shifts, thyroid disease
- Endometrial causes – local lining problems
- Iatrogenic – contraception, anticoagulants
- Not otherwise classified
Two very common diagnoses in this age group are:
- PCOS: irregular ovulation + acne/hair growth + possible insulin resistance.
- Endometriosis: cyclic pelvic pain, pain during sex, infertility, bowel/bladder pain during periods.
Prevention & General Management
- Maintain metabolic health (weight, insulin control) — especially for PCOS.
- First-line heavy-bleeding options:
- Hormonal IUD (LNG-IUS)
- Tranexamic acid during periods
- NSAIDs if pain is also present
- For suspected endometriosis: NSAIDs + hormonal suppression are standard first-line therapy.
- For PMS/PMDD: lifestyle + CBT; SSRIs or hormonal strategies if severe.
Red Flags in 20–39
- Sudden heavy bleeding after years of normal cycles
- Bleeding after sex
- Persistent spotting between periods
- Pelvic mass/bloating, unintended weight loss
- Severe pain not improving with medications
Age Group 3: Perimenopause (~40 to Menopause)
Common Complaints
- Cycles becoming shorter then longer
- Heavy or prolonged bleeding
- Spotting between cycles
- Worsening PMS or mood swings
Common Causes / Diseases
- Hormonal instability/anovulation (very common in this phase)
- Fibroids and polyps (structural causes increase with age)
- Adenomyosis
- Endometrial hyperplasia/cancer risk rises after 40
Prevention & General Management
- Same heavy-bleeding tools apply: LNG-IUS, tranexamic acid, NSAIDs.
- Treat iron deficiency early.
- Procedures (polyp removal, fibroid treatment, ablation, hysterectomy) may be options depending on cause.
Important: persistent AUB around or after age 45 often needs endometrial evaluation.
Age Group 4: Post menopause (No Period for 12+ Months)
Any bleeding after menopause is abnormal. Most causes are benign, but cancer must be ruled out.
Common Causes
- Vaginal/endometrial atrophy
- Polyps
- Endometrial hyperplasia or cancer
- Hormone therapy effects
- Cervical disease
What Happens in Diagnosis?
- Pelvic exam
- Transvaginal ultrasound
- Endometrial biopsy depending on thickness/risk profile
How Doctors Investigate Menstrual Problems
1) History
- Cycle length, duration, volume (pads/day, clots)
- Pain pattern and severity
- Pregnancy or STI risk
- Medication use (contraception, blood thinners)
- Stress, weight change, exercise, eating patterns
- Family history of fibroids, endometriosis, cancers, bleeding disorders
2) Exam
- Vitals and anemia signs
- Abdominal and pelvic exam as appropriate
3) Labs
- Pregnancy test (reproductive age)
- CBC and ferritin
- TSH
- Coagulation studies if bleeding-disorder suspected
- PCOS workup (androgens, glucose, lipids) if indicated
4) Imaging / Procedures
- Transvaginal ultrasound (first-line)
- Hysteroscopy for suspected polyps/fibroids inside the uterus
- Endometrial biopsy if age ≥45 or risk factors/persistent AUB
- MRI/laparoscopy if endometriosis is strongly suspected
Prevention Tips for Everyone
- Track your cycle and symptoms consistently.
- Don’t normalize disabling pain or exhaustion.
- Prioritize iron-rich foods and check ferritin if flow is heavy.
- Exercise and sleep regularly for cramps and PMS.
- Manage metabolic health (especially PCOS and perimenopause).
- Keep up with routine gynecologic screening.
How to Start a Healthy Conversation About Periods (Mothers & Teachers)
Talking about periods early and calmly makes a huge difference. Girls who understand menstruation before menarche experience less fear, less shame, and better health awareness. The goal isn’t one big “talk.” It’s lots of small, normal conversations over time.
From a Mother’s Perspective
- Start before her first period: bring it up around ages 8–10 in simple, calm language.
- Keep it casual: a normal tone teaches it’s a normal topic.
- Use a body-positive explanation: “The uterus builds a lining each month; if there’s no pregnancy, it sheds.”
- Teach practical prep: show her pads/tampons, how often to change, and help her pack a small period kit.
- Validate pain but don’t normalize suffering: mild cramps can be common, but disabling pain needs care.
- Leave the door open: short check-ins work better than one long lecture.
- Avoid shame-loaded phrases: skip “dirty,” “don’t tell boys,” or “now you’re a woman.”
From a Teacher’s Perspective
- Teach menstruation as biology: factual language reduces stigma.
- Avoid singling girls out: keep the topic inclusive and respectful.
- Offer quiet support: believe students who ask for washroom breaks frequently.
- Normalize access to pads: clearly mention where they are without making it dramatic.
- Watch for red flags gently: recurring absences or severe pain may need medical evaluation.
- Build respect among boys too: one clear rule helps reduce stigma and bullying.
Conversation Starters
- “You might notice bleeding once a month soon — that’s called a period.”
- “Some cramps or mood changes are common; we’ll figure out what helps you.”
- “If your flow is very heavy or pain is extreme, tell me — you don’t have to suffer.”
- “You can ask me anything about this anytime.”
Why this matters: Healthy conversations reduce panic at first periods, prevent shame and secrecy, and help girls seek early care for heavy bleeding, anemia, PCOS, or endometriosis.
References
- FIGO PALM–COEIN classification of abnormal uterine bleeding and modern terminology.
- ACOG Committee Opinion: Menstruation in Girls and Adolescents — using the menstrual cycle as a vital sign (education before menarche, normal ranges).
- American Academy of Pediatrics / ACOG joint guidance endorsing anticipatory counseling on menstruation in adolescence.
- ACOG Committee Opinion: Dysmenorrhea and Endometriosis in the Adolescent.
- NICE Guideline NG88: Heavy menstrual bleeding assessment and management (LNG-IUS, tranexamic acid, NSAIDs, structural workup).
- International evidence-based guideline for the assessment and management of PCOS (Rotterdam criteria).
- ACOG guidance for perimenopausal and postmenopausal bleeding evaluation.
- UNICEF “Period lesson plan” and Menstrual Health & Hygiene guidance (talk early, dignity, school support, normalize resources).
- UNESCO Puberty Education & Menstrual Hygiene Management resources for educators and parents (reduce stigma through structured puberty education).
- WHO/UNICEF 2024 report on menstrual health in schools highlighting stigma reduction through open conversation and teacher preparedness.
Disclaimer: This article is for education only and does not replace medical advice.