Menorrhagia (Heavy Menstrual Bleeding)

What counts as heavy menstrual bleeding

Doctors now focus on how bleeding affects your life rather than measuring blood loss. Signs your period is heavy include:

• soaking through one or more pads or tampons every hour for several hours in a row
• needing to double up on protection, or change it during the night
• bleeding for more than 7 days
• passing clots the size of a quarter (about 2.5 cm) or larger
• flooding through clothes or bedding
• limiting daily activities because of bleeding
• symptoms of anemia: tiredness, breathlessness, pale skin

The research definition is losing more than 80 ml per cycle (a normal period loses about 30 to 40 ml).

What idiopathic menorrhagia means

"Idiopathic" means without a known cause. Idiopathic menorrhagia describes heavy, regular periods in which tests find no fibroids, polyps, hormone problems, bleeding disorders or other explanation. It is common. Research suggests it results from subtle changes in the uterine lining itself, such as increased local clot-dissolving activity and an imbalance of prostaglandins, which control blood vessel tone. In the international PALM-COEIN system, this is called AUB-E (endometrial disorder). The treatments that target these mechanisms, tranexamic acid and NSAIDs, work well for it.

Causes

The FIGO PALM-COEIN system groups causes into structural (PALM) and non-structural (COEIN):

Bleeding disorders are found in up to about 1 in 5 women with heavy periods, and in a higher share of teenagers with heavy periods from their first cycle, according to ACOG.

Diagnosis

• History: pattern and duration of bleeding, clots, pain, contraception, medicines, family history of bleeding, and symptoms of anemia or thyroid disease.
• Examination, including a pelvic exam.
• Blood tests: full blood count and ferritin (iron stores), pregnancy test, thyroid function, and bleeding disorder tests if suggested by history.
• Transvaginal ultrasound to check for fibroids, polyps and adenomyosis.
• Endometrial biopsy for people over 45, or younger with risk factors for endometrial cancer or persistent irregular bleeding.
• Hysteroscopy or saline ultrasound to look for polyps and fibroids inside the cavity.

Treatment

Medicines

• Levonorgestrel IUD (hormonal IUD): the most effective medical treatment, reducing blood loss by roughly 70 to 95% over months. Also contraceptive.
• Tranexamic acid: taken only during heavy days, reduces bleeding by about 30 to 55%. Non-hormonal. Not used by people with a history of blood clots.
• NSAIDs (ibuprofen, naproxen, mefenamic acid): taken during the period, reduce bleeding by about 20 to 40% and ease cramps.
• Combined hormonal contraceptives: pills, patch or ring, which lighten and regulate periods.
• Progestin-only options: oral progestins, injection or implant.
• GnRH antagonists with add-back hormones for fibroid-related bleeding.
• Iron supplements to correct deficiency, or IV iron for severe anemia.

Procedures and surgery

• Endometrial ablation: destroys the lining to reduce bleeding, for people who have finished having children.
• Polypectomy or hysteroscopic myomectomy for polyps and fibroids inside the cavity.
• Uterine artery embolization or myomectomy for fibroids.
• Hysterectomy: a definitive option when other treatments fail.

Acute heavy bleeding

Very heavy, ongoing bleeding is treated in hospital with IV estrogen, tranexamic acid, fluids and sometimes blood transfusion or a procedure.

Frequently asked questions

What does idiopathic menorrhagia mean?

Idiopathic menorrhagia means heavy menstrual bleeding with no identifiable cause after investigation. There are no fibroids, polyps, hormone problems or bleeding disorders. It is thought to result from changes in the uterine lining that affect clotting and blood vessels, and responds well to treatment.

How heavy is too heavy for a period?

Your period is too heavy if you soak through a pad or tampon every hour for several hours, need to double up or change protection at night, bleed for more than 7 days, pass clots larger than a quarter, or feel tired and breathless from blood loss.

What causes heavy periods?

Common causes include fibroids, polyps, adenomyosis, hormonal imbalances (such as PCOS, thyroid problems or perimenopause), bleeding disorders such as von Willebrand disease, copper IUDs and blood thinners. Sometimes no cause is found, called idiopathic menorrhagia.

What is the best treatment for menorrhagia?

The hormonal (levonorgestrel) IUD is the most effective medical treatment for many people. Tranexamic acid and NSAIDs reduce bleeding without hormones. Hormonal pills help regulate cycles. Procedures such as ablation or surgery are options when medicines do not help.

Can heavy periods cause anemia?

Yes. Heavy periods are the most common cause of iron deficiency anemia in women of reproductive age. Symptoms include tiredness, weakness, breathlessness, pale skin, and craving ice. A blood test can check iron levels, and iron supplements correct the deficiency.