Introduction

Many women experience problems such as pain, cramps, and irregular or very heavy bleeding during their period. If a woman has to change tampons or sanitary pads about every one to two hours, her period is probably heavier than normal. Menstrual bleeding is clearly too heavy if it affects your daily life or if the loss of blood leads to iron deficiency and anemia.

About 10 out of 100 women have very heavy periods. A period that lasts longer than 5 to 7 days is considered to be prolonged menstrual bleeding. The medical term for these two problems is menorrhagia. They commonly occur together.

Some women who have heavy periods manage well without treatment. But if the bleeding is causing too many problems or an iron deficiency, then medication to reduce the bleeding may be an option. Certain causes of heavy periods can be treated with surgery.

At a glance

• About 10 out of 100 women have very heavy periods (menorrhagia).
• These are often caused by benign (non-cancerous) growths in or on the womb.
• Changes in hormones during puberty or perimenopause may play a role as well.
• Heavy periods can be painful, affect your daily life and lead to iron deficiency anemia.
• Hormone therapy, painkillers and medication to reduce bleeding can help. Sometimes surgery on the womb is considered.

Symptoms

Although it can feel like a lot more at times, the total amount of blood lost during one period is usually about 60 milliliters (around 2.7 ounces). That's about one-and-a-half shot glasses full. At that rate of bleeding, it takes about four hours for a regular tampon or pad to become fully soaked. But that’s just an average: menstrual flow is typically heavier on the first two days and then lighter after that.

Doctors consider a woman to have heavy periods if she regularly loses more than 80 milliliters (2.7 ounces) of blood during one menstrual period. The loss of that much blood may or may not affect you, depending on your general physical fitness and other individual factors.

The following could be signs of very heavy periods:

• You regularly need to change pads, tampons or period underwear after only one or two hours, or already have to empty your menstrual cup after just a few hours.
• You often feel weak, tired and sluggish when you have your period.
• Your period blood has a lot of large clumps in it.

Causes

When you have your period, the outer layer of the tissue lining your womb (the endometrium) is shed. The muscles in your womb contract and squeeze in order to help loosen this tissue. It can then be flushed out easily together with some blood. If the womb doesn't contract properly, it's harder for the tissue to break away. Then the bleeding is heavier and often lasts longer. The most common cause of this is large benign growths, such as polyps or fibroids. Polyps grow in the lining of the womb, and fibroids develop in the muscle layer of the womb.

Other possible causes include:

• Hormonal changes – for instance, when girls first get their periods, or after women give birth, or during perimenopause (the time leading up to menopause).
• A copper coil (IUD): This usually makes your periods heavier because the coil can cause the tissue lining the womb to become slightly inflamed and irritate the small blood vessels on the surface of the tissue. Hormonal coils (IUDs) can also lead to heavier periods for some time after they are fitted.
• Adhesions (bands of tissue) or inflammations in the womb or on the fallopian tubes: These adhesions may be present from birth, or they may result from surgery or severe endometriosis. Malignant growths such as uterine (womb) cancer or cervical cancer are only rarely the cause of heavy periods.
• Other medical conditions: These include hormonal disorders and problems affecting the heart, kidneys, thyroid gland or liver. But heavy periods are rarely caused by these conditions.

Sometimes no clear cause can be found.

Effects

If a woman loses too much blood (and iron in the blood) during her period, it can lead to iron deficiency. Iron is very important for making red blood cells. Red blood cells carry oxygen to the body's organs in the bloodstream. If the body doesn't have enough iron, it can't make enough red blood cells, which leads to anemia.

If there is a lack of red blood cells in our blood, our bodies get less oxygen, making us feel weak and tired. Other signs of anemia include a pale complexion, and cold hands and feet. More severe anemia can also cause other symptoms, like dizziness, breathing difficulties and a racing heart – particularly following physical activity.

Women who would like to have children sometimes wonder whether heavy periods might make it harder (or impossible) for them to get pregnant. The answer to this question will depend on what's causing the heavy periods. It is a good idea to talk to your doctor if you have any concerns like this.

Diagnosis

First, it's important to find out how much blood you typically lose during your period. Although it may not be possible to measure the exact amount, you can at least estimate it. One way is to count how many pads or tampons you need on the different days of one period, or how often you have to empty your menstrual cup. It can be helpful to keep track for one or two months – for example, by keeping notes in a diary.

To find out what is causing heavy periods, the doctor will usually start by examining your womb. They palpate (feel) the womb and do an ultrasound scan to look at it. Sometimes a hysteroscopy is recommended as well. This is a procedure where a tiny camera is inserted into the womb.

A blood test can show whether the heavy periods have caused anemia. If it's thought that a hormonal imbalance might be part of the problem, the blood can also be tested to measure the amount of certain hormones that affect the lining of the womb and the menstrual cycle.

Your personal situation and the type of symptoms you notice can give your doctor further important clues about possible causes. For this reason, it's also important for the doctor to know about any illnesses you have, illnesses that run in your family, medications you are taking, and any psychological stress that might be affecting you.

Treatment

The treatment options for heavy periods depend on what's causing them:

• Medication: Medications containing tranexamic acid can reduce bleeding. Many women also take painkillers that lower the amount of bleeding a little too. Known as non-steroidal anti-inflammatory drugs (NSAIDs), these medications include ibuprofen and diclofenac. Acetylsalicylic acid (the drug in medicines like Aspirin) is not suitable for treating heavy periods because it decreases blood clotting, which can make your periods even heavier.
• Treatment with hormones: Progesterone tablets and contraceptives like birth control pills or hormonal coils (IUDs) reduce menstrual bleeding by making the lining of the womb grow less.
• Surgery: If heavy periods are causing a lot of problems and you don't want to have any (more) children, the lining of your womb can be removed or destroyed in a procedure known as endometrial resection or ablation. Removing the whole womb (hysterectomy) is a more major operation. This is only considered if a woman's periods are very heavy and a big problem in her daily life. Surgery can be done to remove fibroids, polyps or other non-cancerous growths from the womb, too.

Your treatment options will also depend on whether you want to have (any more) children. The most effective treatments limit a woman's ability to get pregnant – either temporarily, like the pill, or permanently, like surgery to remove the womb (hysterectomy).

Deciding

It is not always easy to decide which treatment would be most suitable for you. Whether it's the pill, painkillers or surgery – all treatment options have their own pros and cons. Many individual factors will play a role in the decision: for example, what's causing the heavy periods, whether you would like to have (more) children and what your treatment goals are. Heavy periods aren't an emergency. There's plenty of time to find out about all the options and weigh their pros and cons.

It can also be helpful to get a second medical opinion. When it comes to hysterectomies, you even have a legal right to a second opinion from a specialist. Your doctor must point this out if they recommend that you have a hysterectomy.

Everyday life

Heavy periods can affect many activities and make you feel tired and weak. The bleeding itself can also be bothersome or embarrassing. But many women find ways to cope with heavy periods in daily life. For instance, on days when the bleeding is particularly bad, you could make sure that you're always close to a toilet, or you could use tampons as well as sanitary pads or period underwear.

Sometimes the people close to you – and even doctors – don't take period problems seriously. But women shouldn't accept distressing problems and blood loss as something "natural" and normal that they just have to put up with. So it's all the more important to get enough information yourself, inform others, and to have the cause of your heavy periods checked out by a doctor.

Further information

When people are ill or need medical advice, they usually go to see their gynecologist or family doctor first. Information about health care in Germany can help you to navigate the German healthcare system and find a suitable doctor. You can use this list of questions to prepare for your appointment.

Sources

• Beckermann MJ, Perl FM. Frauen-Heilkunde und Geburtshilfe. Integration von Evidence Based Medicine in eine frauenzentrierte Gynäkologie. Basel: Schwabe; 2004.
• Bofill Rodriguez M, Dias S, Jordan V et al. Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis. Cochrane Database Syst Rev 2022; (5): CD013180. [PMC free article: PMC9153244] [PubMed: 35638592]
• Bofill Rodriguez M, Lethaby A, Fergusson RJ. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev 2021; (2): CD000329. [PMC free article: PMC8095059] [PubMed: 33619722]
• Institute for Quality and Efficiency in Health Care (IQWiG, Germany). High frequency ablation of the endometrium using a mesh electrode in patients with menorrhagia: Final report; Commission N20-06. 2021. [PubMed: 35544667]
• Institute for Quality and Efficiency in Health Care (IQWiG, Germany). Access routes of hysterectomy - Evidence report for the S3 guideline on diagnosis and treatment of benign diseases of the uterus. Commission V21-08A. 2023. [PubMed: 35133765]
• National Institute for Health and Care Excellence (NICE). Heavy menstrual bleeding: assessment and management (NICE guidelines; No. NG88). 2021.
• Singh S, Best C, Dunn S et al. No. 292 – Abnormal Uterine Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can 2018; 40(5): e391-e415. [PubMed: 29731212]
• Sriprasert I, Pakrashi T, Kimble T, Archer DF. Heavy menstrual bleeding diagnosis and medical management. Contracept Reprod Med 2017; 2: 20. [PMC free article: PMC5683444] [PubMed: 29201425]
• Vitale SG, Riemma G, Mikuš M et al. Quality of Life, Anxiety and Depression in Women Treated with Hysteroscopic Endometrial Resection or Ablation for Heavy Menstrual Bleeding: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Medicina (Kaunas) 2022; 58(11): 1664. [PMC free article: PMC9695759] [PubMed: 36422203]

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