Heavy menstrual bleeding is either when you lose a lot of blood or you bleed for a longer period of time. This can be associated with the passage of blood clots and pain, and is known medically as menorrhagia. All in all, it can cause a considerable disruption to everyday life and a toll on your mental wellbeing. It’s hard to know what’s “normal”, so signs that you are bleeding more heavily than others may include that you soak through a sanitary towel or tampon at least every hour, that you need double protection (towel and pad), that you need to change in the middle of the night. It may also include bleeding for more than 7 days, passing large blood clots, and generally a disturbance to your daily activities, work, studies or relationship from bleeding.
In half the cases, there’s no particular identifiable cause. It may run in the family, and it’s more common with age, so those women aged 30 to 49. Particular causes are considered if you have other symptoms or risk factors, and confirmation may guide further treatment. Causes include hormone imbalances such as low thyroid or PCOS (polycystic ovary syndrome), fibroids or adenomyosis which can both cause both heavy menstrual bleeding and painful periods, polyps, which are small non-cancerous growths that occur around the uterus and cause heavy bleeding. Heavy bleeding can be a sign of a miscarriage and can sometimes occur when pregnant due to complications. Contraceptives such as the copper coil (intrauterine device) or the mini pill (progestogen-only pill), or medications to thin the blood, such as anticoagulants, can cause dysfunctional bleeding. Cancer of the uterus or cervix can also cause excessive bleeding.
If you have recognised the signs of heavy bleeding, experience severe abdominal cramps, or if you bleed between your periods or after sex, you should contact your doctor. You should make an urgent appointment if you have vaginal bleeding after you have reached the menopause. It’s common for women with menorrhagia to become anaemic. You may experience symptoms such as tiredness, dizziness, fatigue or shortness of breath, especially with exertion. Your doctor may send you for a blood test to check your blood count.
Your doctor will ask about your symptoms, and they may offer an examination of your vaginal area to see if there are any abnormalities that may be causing your symptoms. With your permission, this may be with an instrument called a speculum, to visualise the vaginal passage, and an internal exam, to feel for any masses or pain around the pelvic organs. They can arrange for your smear test, if it's due. You should ensure you have this taken in between periods. Blood tests can be arranged to check for hormonal imbalances, anaemia and thyroid problems. If the diagnosis is unclear, a pelvic ultrasound can help to show any abnormalities in the womb area.
If you have iron deficiency anaemia or are symptomatic in the presence of heavy menstrual bleeding, your doctor may recommend that you start iron supplements. If pain accompanies the symptoms, a medication called tranexamic acid can also be trialled. With excessive bleeding, medications may be offered to try to bring a period to a close. One example is non-steroidal anti-inflammatory drugs (NSAIDs), such as tranexamic acid or ibuprofen. Norethisterone, a type of high-dose progestogen, may also offer a similar relief for a few cycles - your doctor will need to prescribe this. In the longer term, they may offer medication to help regulate your bleeding. Options include the Mirena coil, a device inserted in your uterus that contains progestogen, or if that is unsuitable, the combined oral contraceptive pill, which contains oestrogen and progestogen. Depending on the cause, you may be referred to a gynaecologist, who can consider other treatments, including other medications or surgery.