Illustrations by Emma Günther
What is a heavy period?
Find out whether you’re experiencing heavy menstrual bleeding.
Top things to know:
Heavy menstrual bleeding is when excessive bleeding negatively impacts a person’s quality of life.
Symptoms include frequently soaking through menstrual products, large blood clots, and periods lasting longer than eight days.
Most individuals with heavy menstrual bleeding are iron deficient, and many have iron deficiency anemia; circumstances that typically negatively impact cognitive and physical function.
Potential causes include bleeding disorders (like von Willebrand Disease), adenomyosis, certain types of fibroids, and changes to the uterus’ ability to stop bleeding.
Treatment options vary depending on the cause of the heavy menstrual bleeding, the degree and severity of iron deficiency, and someone’s immediate and future desires regarding pregnancy.
For many people, periods are manageable with minor inconveniences. But for others, heavy periods can impact work, school, relationships, and daily life, especially if they result in iron deficiency (ID) or its more severe form, iron deficiency anemia (IDA). Heavy menstrual bleeding (HMB) is actually a set of symptoms known collectively as abnormal uterine bleeding (AUB). AUB also includes disruptions to the frequency, duration, and regularity of menstrual bleeding (1).
HMB isn’t defined by a healthcare provider but by you, if the volume of your periods adversely impacts the activities and quality of your daily life (2). It's a common problem, affecting up to five out of ten women during their reproductive years (3). The good news is that effective treatments for HMB and ID/IDA exist and are readily available (4,5).
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What is heavy menstrual bleeding?
While periods vary from person to person, determining whether you have HMB is as simple as evaluating the impact of your period bleeding volume on your daily life (6). Occasional periods can indeed be heavy and bothersome, but if most of your periods adversely affect your quality of life, you probably have HMB (4,6). Another component of menstruation that can adversely affect your quality of life is the amount of pain associated with the period, called dysmenorrhea (7). While not HMB, there are also many simple and effective ways to treat dysmenorrhea, many of which also treat heavy bleeding (depending on the underlying cause)(2).
The following list outlines symptoms that might suggest you’re losing more blood than expected (5,6,8):
Your menstrual bleeding lasts for more than eight days
You soak through your tampons or pads every one to two hours
You use more than one pad at a time to manage your menstrual flow
You have to use two menstrual products simultaneously, like a pad and a tampon, because you soak through
You must change pads or tampons throughout the night or frequently wake up to empty your menstrual cup
You need to empty your menstrual cup more regularly than the packaging suggests
You pass blood clots that are larger than the size of a quarter or 10p coin during your menstrual period
Your heavy menstrual flow interferes with your daily activities, such as exercise, or causes you to take time off work or school
You feel tired, lack energy, or have shortness of breath throughout the month, including during your periods
You feel heaviness or pain in your abdomen and lower back
Your sleep is disrupted by heavier, unpredictable periods (9)
Your heavy period disrupts work, school, or your social activities (10,11)
Your heavy menstrual bleeding has an emotional impact - you feel stressed, anxious, or depressed due to the physical discomfort and lifestyle disruptions it causes (12,13)
Your libido is reduced and you engage in sexual activity less due to the physical discomfort and bleeding associated with HMB (14)
If any of these experiences sound familiar or happen regularly, you might have HMB. It may be a good idea to speak to your healthcare provider. They can help you determine what may be causing it and discuss potential treatment options (2). Keeping track of your period and associated experiences can help you understand HMB (15).
Causes of heavy menstrual bleeding
If you’re worried about how much you bleed on your period, getting a check-up with a healthcare provider is important, as it may have an underlying cause (6,15). Sometimes, heavy periods can result from medical conditions affecting your uterus, ovaries, hormones, and other health problems (6).
The potential causes of abnormal uterine bleeding or heavy menstrual bleeding are described in the table below (2,5,6,16,17,18):
Iron deficiency and iron deficiency anemia
Prolonged heavy periods usually lead to iron deficiency (ID) and, subsequently, to iron deficiency anemia (IDA) (10). This happens when you lose more blood than you can replace with the iron you get from your diet, even if you take oral supplements.
Iron is essential to many bodily processes, including supporting muscular and brain function. Consequently, fatigue, difficulty concentrating, and reduced physical function may occur even when someone is at the ID stage and not yet with IDA (10,19). Once anemic, the symptoms can worsen including shortness of breath due to a lack of essential oxygen-carrying red blood cells (10,20).
Your healthcare provider will likely prescribe iron therapy to treat ID or IDA. In most instances, people will receive tablets they take daily or every other day. Some people who have very low iron levels or can’t take medication orally may need to receive intravenous iron (where iron is given directly into the bloodstream via a vein)(10).
What can I do about heavy menstrual bleeding?
Living with heavy periods can be difficult, but having these experiences doesn't mean you have to accept a lower quality of life. While HMB impacts one or more of your physical health, emotions, relationships, and daily activities, support and treatment options are available.
The first step is being open with your healthcare provider about your experience and the impact your period might be having on your life. To determine the underlying cause of the HMB, your healthcare provider may perform steps including (2,5,21):
A pelvic examination to ensure that the bleeding is coming from the uterus
Blood tests to check several markers, including your iron levels
A pelvic ultrasound
For those at risk for endometrial cancer, an endometrial biopsy, where they take a sample of tissue from the uterine lining. As previously noted, this is necessary for a minority of women, most of whom are in their later reproductive years
Based on the results, your healthcare provider may recommend additional tests to help understand the cause of your HMB and help guide your treatment (21). These could include a hysteroscopy (where a small camera is used to check the inside of your uterus) or further scans such as a magnetic resonance imaging (MRI)(5).
How is heavy menstrual bleeding treated?
The treatment for HMB depends on the cause. After your healthcare provider has evaluated your situation and found the potential cause or causes, treatment can be started. For most people, medical options are available that are often simple, safe, and effective, while for others, surgery is an option.
For those with a suspected endometrial condition, there are common and often over-the-counter options, such as nonsteroidal analgesics (“NSAIDS”) or prescribed tranexamic acid, that can be effective and are taken only during the period (22).
On the other hand, an individual with a leiomyoma (fibroid) affecting the lining of the uterus (the endometrium) may benefit from a surgical procedure that can often be performed without incisions with a simple day-care procedure called hysteroscopic myomectomy (23).
For those with PCOS, hormonal therapy may be prescribed to help regulate or reduce bleeding. This is often achieved by using hormonal birth control that contains both estrogen and progestin (22).
When to see your healthcare provider
Generally speaking, it’s a good idea to consult your healthcare provider if your menstrual flow affects your quality of life, as, by definition, you have HMB. Your symptoms may extend outside the days of your period. Most people with HMB will have iron deficiency and may be anemic, meaning you could feel tired and have difficulty concentrating throughout the month.
Additionally, if you notice bleeding between your regular periods, after having sex, or after menopause, schedule an appointment with your healthcare provider.
If you’re pregnant or think you could be pregnant, it’s important to speak to your healthcare provider if you experience an episode of what you think might be HMB. Bleeding in pregnancy should always be investigated, as it possibly indicates problems that could include a miscarriage or an ectopic pregnancy, where the pregnancy may be present outside the uterus, which can be life-threatening (24). Consequently, getting advice from your healthcare provider if you experience a sudden change in bleeding pattern or volume is important.
If you experience sudden and unusually heavy bleeding, this could be acute AUB. Acute AUB refers to an episode of heavy bleeding that is heavy enough to require immediate intervention to prevent further blood loss (25). It can happen as an isolated event or may occur in someone who has an ongoing history of heavy and/or irregular bleeding. The possible causes of acute AUB are the same as listed above. Acute AUB is typically treated with medication first, but in some cases, surgery may be required, depending on the cause (26).
Heavy menstrual bleeding is treatable
Dealing with heavy menstrual bleeding can be frustrating and may make you feel isolated. But you don't have to cope with it alone. The good news is that help is available, and the causes and consequences of HMB are generally highly treatable.
If you have HMB, reaching out to your healthcare provider for guidance may be a good place to start. Identifying the underlying condition causing the heavy menstrual flow is the first step in getting the appropriate treatment to improve your quality of life.
Tracking your menstrual cycle more closely with the Clue app can help you gather helpful insights to share with your healthcare provider. You can track details about how heavy your bleeding is, from ‘light’ to ‘super heavy’, and use tags to add details about extra symptoms like blood clots. Being open and providing as much information as possible with your healthcare provider can help you get the answers and support you may need.
