Abnormal Bleeding: Causes and When to Worry

What counts as abnormal bleeding

Everyone bruises and bleeds sometimes. Bleeding is more likely to be abnormal when:

• bruises appear without a bump, are larger than a coin, or appear on the trunk
• nosebleeds last more than 10 minutes despite pressure or happen often
• gums bleed easily without gum disease
• periods are very heavy or long, especially since the first period
• a tooth extraction, cut or surgery bleeds for hours or starts bleeding again
• bleeding happens in several different places
• blood relatives have similar problems

Two main patterns of bleeding

Where and how you bleed points to the type of problem.

Causes of abnormal bleeding

Medicines and supplements

The commonest cause in adults. Anticoagulants (warfarin, apixaban, rivaroxaban, dabigatran), antiplatelets (aspirin, clopidogrel), NSAIDs (ibuprofen, naproxen) and some antidepressants (SSRIs) all increase bleeding. Fish oil, ginkgo, garlic and vitamin E supplements can add to the effect. See anticoagulant-associated bleeding.

Low platelets (thrombocytopenia)

Thrombocytopenia has many causes:

• immune thrombocytopenia (ITP), where the immune system destroys platelets
• viral infections, pregnancy and some medicines
• heavy alcohol use and an enlarged spleen
• bone marrow problems, including leukemia and chemotherapy

Inherited bleeding disorders

• Von Willebrand disease: the commonest inherited bleeding disorder, affecting up to about 1 in 100 people, many undiagnosed. Heavy periods, nosebleeds and bleeding after dental work are typical.
• Hemophilia A and B: mainly in males. Causes bleeding into joints and muscles and prolonged bleeding after injury.
• Rarer factor deficiencies and platelet function disorders.

Liver disease and vitamin K deficiency

The liver makes most clotting factors. Cirrhosis and other liver disease cause easy bruising and bleeding, often with low platelets. Vitamin K deficiency, from poor diet, malabsorption or long antibiotic courses, causes similar problems. Newborns receive vitamin K at birth to prevent dangerous bleeding.

Blood cancers and serious illnesses

Leukemia can cause bruising, petechiae and bleeding gums with tiredness, infections, fever and bone pain. Severe infections (sepsis) can trigger disseminated intravascular coagulation (DIC), where clotting and bleeding happen at once.

Kidney disease and other causes

Advanced kidney disease impairs platelet function. Scurvy (very low vitamin C), Cushing's syndrome, long-term steroid use and aging skin cause easy bruising from fragile vessels rather than a clotting problem.

Bleeding from one site

Bleeding from one place is often a local problem rather than a bleeding disorder: gum disease, nasal dryness, hemorrhoids, a stomach ulcer, a urinary stone, fibroids or polyps. A bleeding tendency makes these bleed more.

When to worry about abnormal bleeding

Get prompt medical advice if you have:

• new bruising or petechiae without injury
• bleeding from several sites, such as gums and nose together
• bleeding with fever, tiredness, weight loss or bone pain
• bleeding while taking a blood thinner
• heavy periods causing tiredness or breathlessness (signs of anemia)

How doctors investigate abnormal bleeding

Your doctor will ask about the bleeding pattern, how long it has happened, past surgery and dental work, period history, medicines and supplements, alcohol and family history. Standard bleeding questionnaires help score how significant symptoms are.

Initial tests:

• Complete blood count with platelet count and a blood smear
• PT/INR and aPTT: measure how long blood takes to clot
• Fibrinogen
• Liver and kidney function
• Iron studies if bleeding has been heavy or long-standing

Further tests, often by a hematologist, include von Willebrand factor levels, specific clotting factor levels and platelet function testing. Von Willebrand levels can vary, so tests are sometimes repeated.

Treatment

Treatment depends on the cause:

• Medicine review: stopping or adjusting NSAIDs, aspirin or supplements, and adjusting anticoagulants (never stop a prescribed blood thinner without medical advice, because of the risk of stroke or clots)
• Reversal agents for life-threatening bleeding on anticoagulants
• Treating the underlying condition: for example steroids or other medicines for ITP, or vitamin K for deficiency
• Desmopressin (DDAVP): releases stored von Willebrand factor in many people with von Willebrand disease and mild hemophilia A
• Tranexamic acid: helps clots hold, used for heavy periods, nosebleeds and dental procedures
• Clotting factor concentrates for hemophilia and severe von Willebrand disease
• Platelet transfusion for very low platelets with bleeding
• Iron to replace losses
• Hormonal treatments for heavy menstrual bleeding

Living with a bleeding tendency

• Tell every doctor and dentist before procedures.
• Use acetaminophen (paracetamol) rather than aspirin or NSAIDs for pain unless told otherwise.
• Use a soft toothbrush and an electric razor.
• Carry a medical alert card or bracelet if you have a diagnosed bleeding disorder or take anticoagulants.
• For nosebleeds, sit up, lean forward and pinch the soft part of the nose firmly for 10 to 15 minutes.

Frequently asked questions

What causes abnormal bleeding?

The commonest causes are blood thinners, aspirin and NSAIDs. Others include low platelets, inherited disorders such as von Willebrand disease and hemophilia, liver disease, vitamin K deficiency and, less often, leukemia. Bleeding from one site may be a local problem such as gum disease, hemorrhoids or fibroids.

What are the signs of a bleeding disorder?

Easy or unexplained bruising, frequent or long nosebleeds, bleeding gums, very heavy or long periods, and prolonged bleeding after cuts, dental work, childbirth or surgery. A family history of similar bleeding makes an inherited disorder more likely.

When is bleeding an emergency?

Bleeding that will not stop with 10 to 15 minutes of firm pressure, vomiting blood, black stools, a sudden severe headache, or heavy bleeding with dizziness or fainting all need emergency care. People on blood thinners should have a low threshold for being seen after any head injury.

Can heavy periods be a sign of a bleeding disorder?

Yes. Many women with von Willebrand disease are first diagnosed after years of heavy periods, especially when they have been heavy since the first period or come with nosebleeds or bruising. Ask your doctor about testing if this sounds familiar.