Heavy periods

Heavy periods have a medical name – menorrhagia. It’s not always a red flag symptom. Still, they can affect your physical and emotional state and become a cause of disruption of your everyday life¹. Around 30% of women with heavy menstrual bleeding have iron deficiency, and 60% have iron-deficiency anaemia². Menorrhagia can be normal for some ladies¹. But sometimes, heavy or prolonged bleeding can affect the quality of life³. Talk to your doctor if you dread your period because of such heavy menstrual bleeding. There are many effective ways to treat menorrhagia⁴.  

What’s normal, what’s not

Menstrual flow might occur every 21 to 35 days and last from 2 to 7 days. 

The main rule is that the menstrual cycle might be regular, meaning the same length every month. Typically the amount of blood lost is small and varies from 20 to 80 ml per day (2 to 3 tablespoons)^3,5.  

Periods can sometimes be heavy at different times, like when you first start your periods or after pregnancy¹. Also, the menstrual cycles shorten and become more regular as you age. When you get close to menopause, your cycle might become irregular again⁶. 

How do you know if the bleeding is heavy? If you need to change your tampon or pad after less than 2 hours or you pass clots the size of a quarter or larger, that is heavy bleeding. If you have this type of bleeding, you should see a doctor³. 

Signs 

Signs of heavy menstrual bleeding include^1,3,7: 

• Abdominal pain  
• The menstrual flow with blood clots larger than a quarter, or more than usual. The blood may appear red, pink, brown, or even rust-like 
• Menstrual periods last more than 7 days. You are bleeding through one or more tampons or pads each hour for more than two consecutive hours, or, if you need to change pads or tampons during the night. Pay attention if you are losing more than 80 ml of blood during your period instead of the typical amount which is between 35 and 40 ml  
• Spotting or bleeding between periods 
• Heavy menstrual bleeding after pregnancy 
• Heavy menstrual bleeding after menopause 
• Anaemia symptoms. Tiredness, lack of energy, or shortness of breath and if heavy menstrual flow keeps you from doing what you usually would 

The symptoms of menorrhagia may appear to be similar to other conditions or medical problems. Always consult with your healthcare provider for a diagnosis⁸. 

Causes

Sometimes, heavy periods can be caused by^1,4: 

• Endometriosis 
• Polycystic ovary syndrome 
• Fibroids 
• Pelvic inflammatory disease 
• Dysfunction of the ovaries 
• Polyps 
• Adenomyosis 
• Uterine cancer or cervical cancer  
• Some medicines and treatments 
• Stress and depression 
• Hormone imbalance 
• Intrauterine device 
• Pregnancy complications 
• Inherited bleeding disorders 

Diagnosis 

To find out if you have menorrhagia, your doctor will ask you about your medical history and menstrual cycles. The doctor may ask you the following questions³: 

• How old were you when you got your first period? 
• How long is your menstrual cycle? 
• How many days does your period usually last? 
• How many days do you consider your period to be heavy? 
• How do your periods affect your quality of life? 

You might want to track your periods by writing down the dates and how heavy you think your flow is (maybe by counting how many pads or tampons you use). Do this before visiting the doctor so you can give the doctor as much information as possible³. 

Your doctor might tell you that one or more of the following tests will help find out if you have a bleeding problem³: 

• Blood test. To check for anaemia, thyroid, or blood clotting problems 
• Pap test. For this test, cells from your cervix will be taken and examined to determine if you have an infection, inflammation, or changes in your cells 
• Endometrial biopsy. Tissue samples will be taken from the inside lining of your uterus (or endometrium as it is known) to determine if you have cancer or other abnormal cells  
• Ultrasound. A painless test using sound waves and a computer shows your blood vessels, tissues, and organs
    

Using the results of these examinations, your doctor might recommend more tests, including³: 

• Hysteroscopy. A procedure to examine the inside of the uterus with a tiny instrument to see if you have fibroids, polyps, or other problems that may be causing bleeding  
• Sonohysterogram. This ultrasound scan is performed after fluid is injected via a tube into the uterus through the vagina and cervix. This allows your doctor to look for problems in the uterine lining 

Treatment 

The treatment advised will depend on the cause of your bleeding and how serious it is. Your doctor will also consider your age, general health, and medical history; how well you respond to certain medicines, procedures, or therapies; and your wants and needs. For example, some women want to reduce the amount of bleeding, and some want to make sure they can still have children in the future. Others want to relieve the pain more than they want to reduce the amount of bleeding. Some treatments are ongoing, and others are one-time. It is best if you discuss your options with your doctor to decide which is best for you³.  

Medical therapy for menorrhagia may include⁹: 

• Nonsteroidal anti-inflammatory drugs (NSAIDs) that can help reduce menstrual blood loss 
• Tranexamic acid can help reduce menstrual blood loss, but it should only be taken during the time when you are bleeding 
• Hormonal therapy can help balance the hormones in your body so that your menstrual flow is reduced and becomes less heavy
• Iron supplements can be taken to help replace the iron you lose due to heavy bleeding

You may need surgical treatment for menorrhagia if medical therapy is unsuccessful. Treatment options can include³: 

• Dilation and Curettage.  The top layer of the uterus lining is removed to reduce menstrual bleeding. This method might need to be repeated over time 
• Operative hysteroscopy. A surgical approach that uses a special tool to view the inside of the uterus. It helps remove polyps and fibroids, correct uterus abnormalities, and remove the uterus lining to manage the heavy menstrual flow 
• Endometrial ablation or resection. These are two different surgical techniques that remove all or part of the uterus lining to control menstrual bleeding. While some patients will stop menstruating completely, others may continue to menstruate but have a lighter menstrual flow than before 
• Hysterectomy. A major surgical intervention requiring hospitalization that involves surgically removing the entire uterus. After this procedure, a woman can no longer become pregnant and will stop having her periods altogether 

Heavy bleeding is one of the most common issues women report to their doctors. But many women do not know they can get help for it, and others do not get help because they are too embarrassed to talk with a doctor about their problem. Talking sincerely with your doctor is very important for a correct diagnosis and to get the right treatment. Remember that therapy can help if heavy periods are affecting your daily life³.