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Seek same-day evaluation: Soaking through a pad or tampon every hour for 2+ consecutive hours Passing clots larger than a golf ball Bleeding continuously for more than 14 days without stopping Severe pelvic pain (more than typical cramping) that doesn't respond to ibuprofen Dizziness, lightheadedness, or fainting with heavy bleeding (suggests anemia or hypovolemia) Schedule evaluation within 1 week: Periods that remain irregular (more than 35 days apart or less than 21 days apart) beyond 6 months at stable dose New-onset severe cramping that wasn't present before starting Zepbound Bleeding after menopause (any bleeding, any amount) Missed period with negative pregnancy test and no history of irregular cycles Schedule routine evaluation (within 1 month): Periods heavier than baseline persisting beyond 6 months Persistent spotting between periods after the first 16 weeks Change in cycle length (more than 7 days longer or shorter than baseline) persisting beyond 6 months Why these matter: Heavy or prolonged bleeding can cause iron-deficiency anemia

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Chiu CK et al., J Neurol Sci 2011 High-dose methylcobalamin in ALS