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Heavy periods (menorrhagia)

Do I have heavy periods?

Heavy periods are common and are medically defined as any of the following:

  • During your period, you lose more than 80 ml of blood (more than 5 tablespoons) and/or 
  • You have periods that last more than seven days

On average most periods last up to five days (range from 4 to 7 days), with a blood loss between 30 and 40 ml (about 2 to 2.5 tablespoons) per month. 

As it is not practical to measure the exact amount of blood that you lose during your periods, an easier way to understand if you may be bleeding heavily is if you experience any of the following: 

  • You need to change your sanitary products (for example pads or tampons) every one to two hours 
  • You pass large blood clots during your period (more than 2.5cm – about the size of a 10p coin)
  • You need to use double protection sanitary products (for example both tampons and pads)
  • Your menstrual flow (blood) soaks through onto your bedding or clothing
  • Your menstrual flow is interfering with your physical, social, emotional and/or quality of life e.g. you are unable to do your usual activities such as working or going out
  • You are finding it difficult to manage your menstrual blood loss each month

A term called ‘Menorrhagia’ is used in the medical field to describe heavy periods that: 

  • Recur each month and
  • Interferes with your quality of life (as described above)

Menorrhagia can occur with other symptoms for example painful periods (dysmenorrhoea).

You should speak to a GP if you experience any of the above or if you are concerned about heavy periods or changes in your periods.

What are the causes?

There are various causes for heavier periods, but in half of all cases, no cause is found. When this is the case it is referred to as ‘idiopathic menorrhagia or dysfunctional uterine bleeding’. 

Dysfunctional uterine bleeding (Idiopathic menorrhagia)

  • No cause is found
  • Accounts for 50% of all cases of heavy periods
  • The womb (uterus), ovaries and hormones all appear normal
  • Periods are usually regular
  • Ovulation (when your ovary releases an egg each month) is often normal 
  • It is more common in the first few years after starting periods and during the perimenopausal period (the months running up to the menopause: when your periods stop).

Known causes

Endometriosis: This is where the tissue that lines the womb (endometrium) is found outside the womb, for example in the fallopian tubes (the tubes that connect the ovaries to the womb) or ovaries. Periods tend to be painful

Fibroids: These are benign (non-cancerous) growths that can develop in the wall of the womb (the muscular part called the myometrium). Periods can be both painful and heavy

Adenomyosis: This is where the tissue from the lining of the womb grows in the myometrium. Periods tend to be both painful and heavy

Pelvic inflammatory disease (PID): This is a condition where there is damage and scarring overtime to the womb and fallopian tubes. It is caused by an infection (most commonly chlamydia). Symptoms may include lower pelvic (tummy) pain, bleeding, or pain during or after sex or between periods

Polycystic ovary syndrome (PCOS): This is a condition that affects how the ovaries work. Periods tend to be irregular and can be heavy when they occur. Other symptoms include excessive hair growth and acne

Endometrial polyps: These are benign small growths that appear in the lining of the womb or cervix (neck of the womb)

Endometrial cancer (cancer of the womb): The main symptom is abnormal bleeding, for example between periods or after the menopause

Blood clotting disorders: Your blood clots to stop you from dangerously bleeding. Some disorders interfere with this process such as Haemophilia. This can result in easy bruising, excessive and prolonged bleeding (not just during your period, for example if you cut yourself)

Underactive Thyroid Gland (Hypothyroidism): The thyroid gland produces hormones, some of which are involved in helping to regulate periods. When it is underactive it does not produce enough hormones. This can result in heavier periods, weight gain, and feeling tired

Intrauterine Contraceptive Device (the copper coil): This can make periods heavier, longer, and more painful

Medication: Blood thinning medication for example Warfarin and some chemotherapy medication

Herbal Supplements: Some herbal supplements such as Ginseng, Ginkgo and Soya may affect periods due to changes they cause in your hormones

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What other signs and symptoms are there for heavy periods?

  • You wake up during the night to change your pads or tampons
  • Pain in the lower part of the abdomen (pelvic pain) during your periods
  • Tiredness, lacking energy, or shortness of breath:
    • These may indicate that you are anaemic 
    • Anaemia – is when you have low red blood cells due to excessive blood loss, which is associated with low iron levels

You can keep a menstrual diary for a few of your periods, both before and after any treatment. You should write down:

  • How many tampons or sanitary towels that you use each day 
  • How many days your period lasts
  • Any other associated symptoms for example period pain

What are the causes?

There are various causes for heavier periods, but in half of all cases, no cause is found. When this is the case it is referred to as ‘idiopathic menorrhagia or dysfunctional uterine bleeding’. 

Dysfunctional Uterine Bleeding (Idiopathic Menorrhagia)

  • No cause is found
  • Accounts for 50% of all cases of heavy periods
  • The womb (uterus), ovaries and hormones all appear normal
  • Periods are usually regular
  • Ovulation (when your ovary releases an egg each month) is often normal 
  • It is more common in the first few years after starting periods and during the perimenopausal period (the months running up to the menopause: when your periods stop).

Known causes

  • Endometriosis: This is where the tissue that lines the womb (endometrium) is found outside the womb, for example in the fallopian tubes (the tubes that connect the ovaries to the womb) or ovaries. Periods tend to be painful

  • Fibroids: These are benign (non-cancerous) growths that can develop in the wall of the womb (the muscular part – called the myometrium). Periods can be both painful and heavy

When should you see your GP?

  • Your periods are heavy or heavier than usual
  • You are worried about changes to your periods
  • Your periods are painful
  • You are more tired than usual

You should see your GP urgently if:

  • You experience extreme tiredness
  • You have pain or vaginal bleeding during or after sex, or between your periods
  • You are concerned about a pelvic infection
  • You have vaginal bleeding after the menopause

You should seek IMMEDIATE MEDICAL ATTENTION if you experience severe symptoms, which may include, but are not limited to the following:

  • Difficulty in breathing for example shortness of breath
  • Fainting
  • Extremely heavy vaginal bleeding
    • This can lead to acute severe blood loss
    • This is where you lose a significant amount of blood in a short period of time
    • You may need emergency treatment quickly to stop the heavy bleeding
  • Severe pelvic (lower tummy) pain
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​Important symptoms to look out for that suggest a kidney infection

  • Severe pain in the stomach (abdomen) or back
  • Back pain especially on either side underneath the ribs
  • Fevers or temperatures

How are heavy periods diagnosed?

To help identify the cause of your heavy periods your GP should:

  • Take a detailed history from you – which involves asking you about your symptoms
  • Examine you, including a pelvic examination
  • Review your menstrual diary if you have one (or your GP may give you a period blood loss chart to fill in, which is similar to a menstrual diary)

Your GP will then determine the likely cause of your heavy periods and tailor any necessary tests based on this.

As is seen in most cases, if your examination is normal and you have no other associated symptoms, further tests may not be necessary. The diagnosis of ‘dysfunctional uterine bleeding’ can usually be made and appropriate treatment started.

Your GP may suspect that you do not have ‘dysfunctional uterine bleeding’, if you:

  • Have pain or vaginal bleeding during or after sex, or between your periods
  • Have irregular or changes in your vaginal bleeding
  • Have pelvic pain that is not during your period
  • Have a vaginal discharge
  • Have vaginal bleeding after the menopause
  • Have symptoms that may suggest that you have a problem with your blood clotting or hormones

If you have any of these, then your GP will refer you for further investigations. If they suspect a more serious cause of your symptoms for example cancer, you will be referred urgently for investigations and to see a specialist. 

What tests are available?

Blood Tests

  • Your GP may request your full blood count and iron levels. This will include your red blood cell levels to check if you are anaemic
  • Thyroid function – if you have signs or symptoms suggesting an underactive thyroid gland
  • Tests for blood clotting disorders – if you have symptoms or a personal/family history of a bleeding disorder

Vaginal or Cervical Swabs

  • The aim is to obtain discharge and cells for testing
  • Your GP may request this if an infection such as Chlamydia is suspected

Imaging (scans)

  • Transvaginal or Transabdominal Ultrasound:
    • This is a where a small probe is placed into the vagina or over the abdomen
    • The probe uses sound waves to create images of your womb and ovaries, which at the same time can be visualised on a screen
    • This can help assess for various abnormalities including fibroids or polyps

Procedures

  • Endometrial sampling:
    • This is where a thin tube is passed through the vagina into the womb.
    • Gentle suction is then used to obtain small biopsies (tissue samples) of the womb lining, the samples are then analysed for any abnormalities
    • Usually, no general anaesthetic (when you are asleep) is needed
  • Hysteroscopy:
    • This is where a narrow telescope that has both a camera and light is passed through the vagina into the womb to examine the inside of the womb
    • Samples may be taken to be analysed for any abnormalities

This can often be done without any general anaesthetic

How are heavy periods treated?

Overall treatments available will depend on the underlying cause for your heavy periods. In all cases, you should discuss with your doctor and be provided with the following:

  • Information about heavy periods
  • All the possible available treatments, including:
    • No treatment
    • The benefits and risks of various options
    • Suitable treatments if you are trying for a baby
  • Whether you want to ensure your fertility is not affected by any treatment

You should then come to a shared decision together.

No Active Treatment (watchful waiting)

If there is no serious cause and you feel that your periods do not impact your everyday life and you are managing them well, this may be an option.

Treatment for Anaemia

  • Iron tablets can help to resolve this
  • There are various options you can discuss with your GP and most are available over the counter via a pharmacist

Medication

Levonorgestrel – Intrauterine System (IUS)

  • A small device that slowly releases a hormone called ‘progestogen’
  • Progestogens work by thinning the lining of the womb
  • It is inserted in your womb by a healthcare professional

An example includes the ‘Mirena coil’

Devices typically last for 3 – 5 years (but can be removed before this)

Suitability and benefits

Offered as a first line treatment for:

  • Dysfunctional uterine bleeding
  • If you have fibroids less than 3 cm (and not affecting the inner part of your womb)
  • Adenomyosis

This is successful in most women, with periods becoming very minimal or absent within 3-6 months

Period pain also tends to reduce

It is an effective contraception

Possible risks and side effects

Irregular bleeding patterns, especially in the first few cycles

Not suitable if you are actively trying for a baby

Rare complications during/after fitting include:

  • Pelvic infection
  • Incorrect placement through the uterine wall (1 in 1000 fittings)
  • The IUS falls out (50 in 1000 fittings)

Combined oral contraceptive pill

Contains both oestrogen and progestogen hormones

There are various options available and usually involves taking a daily tablet for three weeks, then stopping for a 7-day break and then repeating

Suitability and benefits

Can be used for those in whom an IUS is not suitable

Reduces blood flow by up to 40% 

Often reduces period pain and the duration bleeding

An effective contraception

Possible risks and side effects

Not suitable if you are actively trying for a baby

Small associated risks e.g. increase in blood clots, breast, and cervical cancer

Side effects can include acne; bloating, headaches, nausea, and weight gain

The ‘mini’ contraceptive pill

Contains the progestogen hormone only

Suitability and benefits

Can be used for those in whom an IUS is not suitable

Often reduces blood flow, period pain and the duration of bleeding

An effective contraception

Possible risks and side effects

Irregular bleeding patterns, especially in the first few cycles

Side effects include bloating, breast tenderness and acne

Not suitable if you are actively trying for a baby