Heavy periods are common. In most cases no cause can be found. In some cases a cause is found such as endometriosis, fibroids and other conditions. There are a number of ways of improving heavy periods and making them more manageable. Options include medication to reduce bleeding, a type of intrauterine system - sometimes called a coil - placed in the womb (uterus), or an operation.
What is a normal period, a heavy period, and menorrhagia?
Many women describe their periods as heavy. However, it is often difficult to know if your periods are normal or heavy compared with other women. Some women who feel they have heavy periods actually have an average blood loss. Some women who feel they have normal periods actually have a heavy blood loss. Most of the blood loss usually occurs in the first three days with either normal or heavy periods.
It is difficult to measure blood loss accurately. Some medical definitions of blood loss during a period are:
- A normal period is a blood loss between 30 and 40 ml (six to eight teaspoonfuls) per month. Bleeding can last up to eight days but bleeding for five days is average.
- A heavy period is a blood loss of 80 ml or more. This is about half a teacupful or more. However, it is difficult to measure the amount of blood that you lose during a period.
- For practical purposes, a period is probably heavy if it causes one or more of the following:
- Flooding through to clothes or bedding.
- You need frequent changes of sanitary towels or tampons.
- You need double sanitary protection (tampons and towels).
- Soaking of bedclothes.
- You pass large blood clots.
- Restriction to your normal lifestyle because of heavy bleeding.
- Menorrhagia means heavy periods that recur each month. Also, that the blood loss interferes with your quality of life. For example, if it stops you doing normal activities such as going out, working or shopping. Menorrhagia can occur alone or in combination with other symptoms.
What are the causes of heavy periods?
Often no specific cause for heavy periods is found. In other cases, something causes the heavy periods.
When the cause is unknown, this is called dysfunctional uterine bleeding or idiopathic menorrhagia. This is the case about half the time. In this condition, the womb (uterus) and ovaries are normal. It is not a hormonal problem. Ovulation is often normal and the periods are usually regular. It is more common if you have recently started your periods or if you are approaching the menopause. At these times you may find your periods are irregular as well as heavy.
These are less common. They include the following:
- Fibroids. These are non-cancerous (benign) growths in the muscle of the womb. They often cause no problems, but sometimes cause symptoms such as heavy periods.
- Other conditions of the womb - for example:
- Infections involving the womb.
- Small fleshy lumps (called polyps).
- Cancer of the lining of the womb (endometrial cancer).
- Hormonal problems. Periods can be irregular and sometimes heavy if you do not ovulate every month. For example, this occurs in some women with polycystic ovary syndrome. Women with an underactive thyroid gland may have heavy periods.
- The intrauterine contraceptive device (IUCD, or coil). Sometimes an IUCD causes heavy periods. However, a special hormone-releasing IUCD called the intrauterine system (IUS) can actually treat heavy periods (see 'Levonorgestrel intrauterine system (LNG-IUS)' in the treatment section below).
- Pelvic infections. There are different infections that can sometimes lead to heavy bleeding developing. For example, chlamydia can occasionally cause heavy bleeding. These infections can be treated with antibiotics. See separate leaflet called Pelvic Inflammatory Disease.
- Warfarin or similar medicines interfere with blood clotting. If you take one of these medicines for other conditions, heavier periods may be a side-effect.
- Some medicines used for chemotherapy can also cause heavy periods.
- Blood clotting disorders are rare causes of heavy bleeding. Other symptoms are also likely to develop, such as easy bruising or bleeding from other parts of the body.
If you stop taking the contraceptive pill it may appear to cause heavy periods. Some women become used to the light monthly bleeds that occur whilst on the pill. Normal periods return if you stop the pill. These may appear heavier but are usually normal.
Do I need any tests if I have heavy periods?
See your doctor if your periods change and become heavier than previously. For most women, the cause is unclear and there is no abnormality of the womb (uterus) or hormones. However, it is very important to get it checked out properly.
A doctor may want to do an internal (vaginal) examination to examine your neck of the womb (cervix) and also to assess the size and shape of your womb. However, an examination is not always necessary, especially in younger women who do not have any symptoms to suggest anything other than dysfunctional uterine bleeding.
A blood test to check for anaemia may be performed. If you bleed heavily each month then you may not take in enough iron in your diet, needed to replace the blood that you lose. (Iron is needed to make blood cells.) This can lead to anaemia which can cause tiredness and other symptoms. Up to 2 in 3 women with recurring heavy periods develop anaemia.
If the vaginal examination is normal (as it is in most cases) and there are no other associated symptoms, no further tests may be needed. The diagnosis is usually dysfunctional uterine bleeding and treatment may be started if required. Further tests may be advised for some women, especially if there is concern that there may be a cause for the heavy periods other than dysfunctional uterine bleeding. For example, if you:
- Bleed between periods, or have irregular bleeding.
- Have bleeding or pain during, or just after, sex.
- Have pain apart from normal period pains.
- Have a vaginal discharge.
- Have any change in your usual pattern of bleeding.
- Have symptoms suggesting a hormonal problem or blood disorder.
If tests are advised then they may include one or more of the following:
- An ultrasound scan of your womb. This is a painless test which uses sound waves to create images of structures inside your body. The probe of the scanner may be placed on your tummy (abdomen) to scan the womb. A small probe is also often placed inside the vagina to scan the womb from this angle. An ultrasound scan can usually detect any fibroids, polyps, or other changes in the structure of your womb.
- Internal swabs. This may be done if an infection is the suspected cause of the heavy bleeding. A swab is a small ball of cotton wool on the end of a thin stick. It can be gently rubbed in various places to obtain a sample of mucus, discharge, or some cells. A swab is usually taken from the top of your vagina and also from your cervix. The samples are then sent away to the laboratory for testing.
- Endometrial sampling. This is a procedure in which a thin tube is passed into the womb. Gentle suction is used to obtain small samples (biopsies) of the uterine lining (endometrium). This is usually done without an anaesthetic. The samples are looked at under the microscope for abnormalities.
- A hysteroscopy. This is a procedure in which a doctor can look inside the womb. A thin telescope is passed into your womb through your cervix via the vagina. This too can often be done without an anaesthetic. Small samples can also be taken during this test.
- Blood tests. These may be taken if, for example, an underactive thyroid gland or a bleeding disorder is suspected.
Clinical Editor's note
March 2018 - Dr Hayley Willacy recommends reading the recently released National Institute for Health and Care Excellence (NICE) guideline dealing with the assessment and management of heavy menstrual bleeding; see Further reading below. NICE wants this guideline to make a difference to women with heavy menstrual bleeding by making sure that:
- Doctors take your symptoms seriously, ask the right questions and use the best tests to find the cause of your heavy periods sooner.
- You can see a healthcare professional with specialist knowledge of diagnosing and treating heavy periods if you need to.
- You are given information about the full range of treatments that could help and what they involve, and support to choose one that is right for you.
Keeping a menstrual diary
It may be worth keeping a diary for a few periods (before and after any treatment). Your doctor may give you a period blood loss chart which you can fill in. Basically, you record the number of sanitary towels or tampons that you need each day and the number of days of bleeding.
A diary is useful for both patient and doctor to see:
- How bad symptoms are and whether treatment is needed.
- If treatment is started, whether it is helping. Some treatments take a few menstrual cycles to work fully. If you keep a diary it helps you to remember exactly how things are going.
What are the treatment options for heavy periods?
Treatment aims to reduce the amount of blood loss. The rest of this leaflet discusses treatment options for women who have regular but heavy periods with no clear cause . This is the majority of cases. If there is an underlying cause, such as a fibroid or endometriosis, treatment options may be different. See the relevant leaflets to read about treatment for these conditions.
This is an option if your periods do not interfere too much with normal life. You may be reassured that there is no serious cause for your heavy periods and you may be able to live with them. A blood test may be advised every so often to check for anaemia. Iron tablets can correct anaemia.
Levonorgestrel intrauterine system (LNG-IUS)
The LNG-IUS treatment usually works very well. The LNG-IUS is similar to an IUCD, or coil. It is inserted into the womb (uterus) and slowly releases a small amount of a progestogen hormone called levonorgestrel. The amount of hormone released each day is tiny but sufficient to work inside the womb. In most women, bleeding becomes either very light or stops altogether within 3-6 months of starting this treatment. Period pain is usually reduced too. The LNG-IUS works mainly by making the lining of the womb very thin.
The LNG-IUS is a long-acting treatment. Each device lasts for five years, although it can be taken out at any time. It is particularly useful for women who require long-term contraception, as it is also a reliable form of contraception. It is not usually suitable if you do not need long-term (for at least one year) contraception. See separate leaflet called Intrauterine System for more details.
Tranexamic acid tablets
Tranexamic acid tablets are an option if the LNG-IUS is not suitable or not wanted. Treatment with tranexamic acid can reduce the heaviness of bleeding by almost half in most cases. However, the number of days of bleeding during a period is not reduced and neither is period pain. You need to take a tablet 3-4 times a day, for 3-5 days during each period. Tranexamic acid works by reducing the breakdown of blood clots in the womb. In effect, it strengthens the blood clots in the lining of the womb, which leads to less bleeding. If side-effects occur they are usually minor but may include an upset stomach.
There are various types and brands. Most are available only on prescription but you can buy one called ibuprofen from pharmacies. Your doctor may prescribe others such as mefenamic acid or naproxen. These medicines reduce the blood loss by about a quarter in most cases. They also ease period pain. You need to take the tablets for a few days during each period. They work by reducing the high level of prostaglandin in the lining of the womb. This is a chemical which seems to contribute to heavy periods and period pain. However, they do not reduce the number of days the period lasts.
Side-effects occur in some people and may include an upset stomach. If you have a history of a duodenal or stomach ulcer, or asthma, you should only take these medicines on a doctor's advice. See separate leaflet called Anti-inflammatory Painkillers for more details.
Many women take both anti-inflammatory painkillers and tranexamic acid tablets for a few days over each period, as they work in different ways. This combination of tablets can be really effective for many women with heavy periods.
The combined oral contraceptive (COC) pill
This reduces bleeding by at least a third in most women. It often helps with period pain too. It is a popular treatment with women who also want contraception but who do not want to use the LNG-IUS. If required, you can take this in addition to anti-inflammatory painkillers (described above), particularly if period pain is a problem. See separate leaflet called The Combined Oral Contraceptive (COC) Pill for more details. Other options which work in a similar way are combined hormonal contraceptive rings or patches.
Long-acting progestogen contraceptives
The contraceptive injection and the contraceptive implant also tend to reduce heavy periods. For example, up to half of women on the contraceptive injection have no periods after a year. They are not given as a treatment just for heavy periods. However, if you require contraception then one of these may be an option for you. See separate leaflets called Contraceptive Injection and Contraceptive Implant for more details.
Norethisterone is a hormone (progestogen) medicine. It is not commonly used to treat heavy periods. It is sometimes considered if other treatments have not worked, are unsuitable or are not wanted. Norethisterone is given to take on days 5-26 of your menstrual cycle (day 1 is the first day of your period). Taking norethisterone in this way does not act as a contraceptive.
The reason why norethisterone is not commonly used as a regular treatment is because it is less effective than the other options. Also many women develop side-effects. However, norethisterone may be used as a temporary measure to stop very heavy menstrual bleeding (see 'Emergency treatment to rapidly stop heavy bleeding', below).
Other hormonal treatments, such as gonadotrophin-releasing hormone (GnRH) analogues, are occasionally used by specialists in hospital. However, they are not routine treatments, due to various side-effects that commonly occur.
Having surgery is not a first-line treatment. It is an option if the above treatments do not help or are unsuitable.
Removing or destroying the lining of the womb is an option. This is called endometrial ablation. This can be done in a number of ways, using heat, laser or energy waves. It can be done by passing an instrument into the womb through the vagina, or can be done through the tummy, using ultrasound or magnetic resonance imaging (MRI) scans to guide the energy waves to the right place. The aim is to remove as much of the lining of the womb as possible. Usually this is very successful but sometimes it needs to be repeated as it is not permanent. See separate leaflet called Menorrhagia Surgery which discusses surgical treatment options for heavy vaginal bleeding.
Hysterectomy is the traditional operation where the womb is totally removed. However, hysterectomy is done much less commonly these days since endometrial ablation became available in the 1990s. It is a more major operation, with more possible problems and a longer recovery time. It may be considered if all other treatment options have not worked for you. See separate leaflet called Hysterectomy.
Menorrhagia Management Options
Each treatment option for Menorrhagia has various benefits, risks and consequences. In collaboration with health.org.uk, we've put together a summary decision aid that encourages patients and doctors to discuss and assess what's available.
Emergency treatment to rapidly stop heavy bleeding
Some women have very heavy bleeding during a period. This can cause a lot of blood loss, and distress. One option as an emergency treatment is to take a course of norethisterone tablets. Norethisterone is a progestogen medicine. Progestogens act like the body's natural progesterone hormones - they control the build-up of cells lining the womb (uterus).
So, if a period is very heavy or prolonged, your doctor may advise that you take norethisterone tablets. A dose of 5 mg three times daily for 10 days is the usual treatment. Bleeding usually stops within 24-48 hours of starting treatment. If bleeding is exceptionally heavy then 10 mg three times daily may be given. This should then be tapered down to 5 mg three times daily for a week, once your bleeding has stopped.
A note for teenagers with heavy periods
Heavy periods due to dysfunctional uterine bleeding seem to be more common in the first few years after starting periods. (This is also the case in the months running up to the menopause.) If you are a teenager and have heavy periods, you have a good chance that they will settle down over a few years and become less heavy.
So, for example, if you take treatment for heavy periods whilst a teenager or young adult, it is very likely you will not need it after a few years. On a practical note, there is no reason why a teenager should not use tampons. It can take a bit of practice to learn how to use a tampon but it may make heavy periods easier to manage.
Further reading and references
Heavy menstrual bleeding: assessment and management; NICE guideline (March 2018)
Menorrhagia; NICE CKS, December 2017 (UK access only)
Duckitt K; Menorrhagia. BMJ Clin Evid. 2015 Sep 182015. pii: 0805.
Fibroids; NICE CKS, June 2017 (UK access only)
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