Introduction
Heavy periods, also called menorrhagia, are when a woman loses an excessive amount of blood during several consecutive periods.
A period is part of a woman's menstrual cycle. The menstrual cycle is the time from the first day of a woman’s period to the day before her next period. A period is a bleed from the uterus (womb) that is released through the vagina. It happens approximately every 28 days, although anywhere between 24-35 days is common.
Periods can begin when girls are between the ages of 8-16 years, but they usually start around the age of 12. They continue every month until the menopause (when a woman’s periods stop) which usually occurs between 45 -55 years of age.
What is menorrhagia?
Menorrhagia is the medical name for heavy periods. Menorrhagia can occur by itself, or in combination with other symptoms, such as menstrual pain (dysmenorrhoea).
Heavy bleeding does not necessarily mean that there is anything seriously wrong, but it can affect a woman physically, emotionally and socially, and cause disruption to everyday life.
How much is heavy bleeding?
The amount of blood that is lost during a woman's period can vary considerably for each woman, so it is difficult to define exactly what a heavy period is.
Doctors can measure blood loss during a period and heavy menstrual bleeding is considered to be 60-80 mL (millilitres) or more per cycle. The average amount of blood that is lost is 30-40 mL, and 90% of women lose less than 80 ml. However, it is rarely necessary to measure the blood loss so accurately.
Most women have a good idea about how much bleeding is normal for them during their period, and can tell when this amount increases or decreases.
If your periods are causing disruption to your everyday life, or they are heavier than usual, you should speak to your GP about it. A good indication that your blood loss is excessive is if:
- you feel that you are using an unusually high number of tampons or pads
- you experience flooding (heavy bleeding) through to your clothes or bedding
- you need to use tampons and towels together
How common are heavy periods?
It is difficult to measure exactly how many women have heavy periods. This is because different women have different ideas of what ‘heavy’ bleeding is. However, some estimates suggest that one woman in ten has heavy periods.
Outlook
There are several different medications that can be used to treat heavy periods. Surgery may also be an option. See Heavy periods - treatment for more information.
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Diagnosis
If you feel that your periods are unusually heavy you should see your GP. Your GP will be able to investigate the problem and offer treatments to help.
Menorrhagia (heavy periods) are diagnosed when both you and your GP agree that your menstrual bleeding is heavy, after details about your periods and medical history have been taken.
Medical history
To establish the cause of your heavy periods, your GP will ask you some questions about:
- your medical history
- the nature of your bleeding
- any related symptoms that you have
Your GP will ask you about your periods, they may ask:
- how many days your period usually lasts for
- how much bleeding you have
- how often you have to change your tampons (or sanitary pads)
- whether or not you experience flooding (heavy bleeding through to your clothes or bedding)
- what impact that your heavy periods have on your everyday life
Your GP will ask you about whether you have any bleeding between periods (inter-menstrual bleeding) or after sexual intercourse (post-coital bleeding), and if you experience any pelvic pain. To help find the cause of your heavy bleeding, you may have a physical examination, particularly if you have pelvic pain, bleeding between periods, or bleeding after sex.
You may be asked about the contraception that you currently use, whether you are considering changing the type of contraception that you use, and whether you have any future plans to have a baby. The last time you had a cervical screening test will also be noted.
Your GP may ask you about your family history in order to identify whether there is a possibility that a hereditary condition may be responsible for your heavy bleeding. For example, a coagulation disorder (condition that affects the blood's ability to clot properly), such as von Willebrand disease, which can run in families.
Further testing
Depending on your medical history and the results of your initial physical examination, the cause of your heavy bleeding may need to be investigated further. For example, if you experience inter-menstrual or post-coital bleeding, or you have pelvic pain, you will need to have some further tests in order to rule out serious illness, such as an underlying cancer (which is very rare).
If you need to have a pelvic examination, your GP will ask for a female assistant to be present at the time. A pelvic examination may include:
- a vulval examination - an examination of your vulva (external sexual organs) for evidence of external bleeding and signs of infection, such as a vaginal discharge
- a speculum examination of your vagina and cervix (neck of the womb) - a speculum is a medical instrument that is used for examining the vagina and cervix
- bimanual palpation - an internal examination of your vagina using the fingers to identify whether your uterus, or ovaries are tender or enlarged.
Pelvic examinations should only be carried out by health professionals who are qualified to perform them, such as a GP or gynaecologist (a specialist in the female reproductive system).
Before carrying out a pelvic examination, the health professional will explain the reasons why the examination is required, and they will also explain the procedure to you. You should ask about anything that you are unsure about. A pelvic examination should not be carried out without your consent (permission) first being obtained.
In some cases of menorrhagia, a biopsy may be needed in order to establish a cause. This will be carried out by a specialist and involves a small sample of your womb lining being removed for closer examination under a microscope.
Blood tests
A full blood count is usually carried out for all women who have heavy periods. A blood test can detect iron deficiency anaemia, which is often caused by a loss of iron following prolonged heavy periods.
If you have iron-deficiency anaemia, you will usually be prescribed a course of medication. Your GP will be able to advise you about the type of medication that is most suitable for you, and how long you need to take it for.
See the Health topic about Iron deficiency anaemia for more information.
Ultrasound scan
If you have heavy menstrual bleeding and following tests the cause is still unknown, an ultrasound examination of your womb may be used to look for abnormalities such as fibroids (non-cancerous growths), or polyps (harmless growths). Ultrasound can also be used to detect some forms of cancer.
A trans-vaginal scan is often used which involves a small probe being inserted into the vagina to take a close-up image of the womb.
See the Health topic about Ultrasound scans for more information.
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Treatment
As the amount of blood that is lost during a woman's period varies considerably from one person to another, menorrhagia (heavy periods) is not always diagnosed.
If menorrhagia is diagnosed, your GP will discuss all the possible treatment options with you. Your GP will inform you about:
- the effectiveness of treatments
- the likelihood of any adverse effects following treatments
- whether contraception will be required
- the implications of treatment on fertility
The aims of treating menorrhagia are:
- to reduce or stop excessive menstrual bleeding
- to prevent or correct iron deficiency anaemia due to heavy menstrual bleeding
- to use surgical treatments for women who may benefit
- to improve the quality of life of women with heavy menstrual bleeding
Medication
Pharmaceutical treatment (medication) is recommended as the first type of treatment for use in cases of menorrhagia for women who:
- have no symptoms or signs that suggest a serious underlying cause
- are waiting for the results of further investigations
If a particular medication is not suitable for you, or if you try a medication and it does not work, another one may be recommended. Some medications make your periods lighter and others may stop bleeding completely. Some medicines are also contraceptives. Your GP will explain how each type of medicaton works, and any possible side effects. This will help you and your GP decide which is the most suitable treatment.
The different types of medications that are used to treat menorrhagia are outlined below. They are listed in the order that the National Institute for Clinical Excellence (NICE) recommends they are are tried (as long as they are considered suitable for you).
Levonorgestrel-releasing intrauterine system (LNG-IUS)
The levonorgestrel-releasing intrauterine system (LNG-IUS) is a small plastic device that is placed in your womb and slowly releases the hormone progestogen. It prevents the lining of your womb from growing quickly, and is also a form of contraceptive. This medication does not affect your chances of getting pregnant after you stop using it.
Possible side effects of using the LNG-IUS include:
- irregular bleeding that may last for more than six months
- breast tenderness
- acne
- headaches - although they tend to be minor and short lived, and
- no periods at all (amenorrhoea).
The LNG-IUS has been shown to reduce blood loss by between 71-96% and is the preferred first choice of treatment for women with menorrhagia, provided that long term contraception using an intrauterine device is appropriate (it is usually used for a minimum of 12 months).
Tranexamic acid
If LNG-IUS is unsuitable, for example, if contraception is not desired, tranexamic acid tablets may be considered. The tablets have been shown to reduce blood loss by between 29-58%, and work by helping the blood in your womb to clot.
Two or three tranexamic acid tablets are taken once heavy bleeding has started. They are taken three or four times a day, for a maximum of 3-4 days. Usually, the lower end of this dosing range will be recommended - that is, two tablets, three times a day for four days. Treatment should be stopped if your symptoms have not improved within three months.
Tranexamic acid tablets are not a form of contraception and will not affect your chances of becoming pregnant. If necessary, tranexamic acid can be combined with a non-steroidal anti-inflammatory drug (NSAID) (see below).
Possible side effects include
- indigestion,
- diarrhoea
- headaches (although they are not very common)
Non-steroidal anti-inflammatory drugs (NSAIDs)
Non-steroidal anti-inflammatory drugs (NSAIDs) are also used to treat menorrhagia as a second choice of treatment if LNG-IUS is not appropriate. NSAIDs have been shown to reduce blood loss by between 20-49%. They are taken in tablet form, from the start of your period (or just before) and for the duration of bleeding, until it has stopped. As with tranexamic acid, treatment should be stopped if your symptoms have not improved within three months.
The NSAIDs that are recommended as a treatment for menorrhagia are:
- mefenamic acid
- naproxen
- ibuprofen
These are usually taken three or four times a day.
NSAIDs work by reducing your body's production of a hormone-like substance, called prostaglandin, which is linked to heavy periods. NSAIDs are also painkillers but they are not a form of contraceptive. However, if necessary, they can be used in conjunction with the combined oral contraceptive pill (see below).
Common side effects include indigestion and diarrhoea.
NSAIDs can be used for an indefinite number of menstrual cycles, as long as they are relieving symptoms of heavy blood loss and are not causing significant adverse side effects. However, if NSAIDs are found to be ineffective, treatment should be stopped after three months.
See the Health topic about NSAIDs for more information about this type of medication.
Combined oral contraceptive pill
Combined oral contraceptive pills, often referred to as the pill, can be used to treat menorrhagia. They contain the hormones oestrogen and progestogen. One pill is taken every day for 21 days, before stopping for seven days. This cycle is then repeated.
The benefit of using combined oral contraceptives as a treatment for menorrhagia is that it offers a more readily reversible form of contraception than the LNG-IUS. It also has the benefit of regulating your menstrual cycle and reducing menstrual pain (dysmenorrhoea).
The combined oral contraceptive is a contraceptive that works by preventing your ovaries from releasing an egg each month. As long as you are taking the pills correctly, they should prevent you from becoming pregnant.
Common side effects of the combined oral contraceptive pill include:
- mood changes
- headaches
- nausea (feeling sick)
- fluid retention
- breast tenderness
See the Health topic about the Combined contraceptive pill for more information.
One study looked at using gonadotropin releasing hormone analogue (GnRH-a) as well as the combined oral contraceptive pill. It found that women who were treated with both had significantly reduced blood loss compared with women who only used the combined contraceptive pill.
GnRH-a is a type of hormone that is usually used to treat fibroids (non-cancerous growths in the womb). Although more research is needed, GnRH-a may be a possible treatment in the future for women with particularly heavy periods.
Oral norethisterone
Oral norethisterone is a man-made progestogen (one of the female sex hormones). It is another form of medication for treating menorrhagia. It is taken in tablet form 2-3 times a day from days 5-26 of your menstrual cycle, counting the first day of your period as day one.
Oral norethisterone works by preventing the lining of your womb from growing quickly. It is not an effective form of contraception. Oral progestogen can have unpleasant side effects including:
- weight gain
- bloating
- breast tenderness
- headaches
- acne (which does not usually last for long)
Oral progestogens, such as norethisterone, are not as effective as tranexamic acid. However, if bleeding is very heavy or has been continuing for a while, a high dose of oral norethisterone can stop bleeding in 24 to 48 hours.
Injected progestogen
A type of progestogen, is also available as an injection (called medroxyprogesterone acetate) and is sometimes used to treat menorrhagia. It works by preventing the lining of your womb from growing quickly, and is a form of contraception. However, it does not prevent you becoming pregnant after you stop using it, although there may be a delay after you take it before you are able to get pregnant (see below).
Common side effects of injected progestogen include:
- weight gain
- irregular bleeding
- absence of periods (amenorrhoea)
- a delay in being able to become pregnant of between 6-12 months after stopping the injection
- premenstrual symptoms, such as bloating, fluid retention and breast tenderness.
You will need to have this form of progestogen injected once every twelve weeks, for as long as treatment is required.
Surgical procedures
If the above medications do not prove effective in treating menorrhagia, your specialist may suggest surgery.
There are several types of operation that can be used to treat menorrhagia. Two are only suitable if your heavy periods are caused by fibroids (non-cancerous growths in the womb). These are:
- uterine artery embolisation (UAE)
- myomectomy
Uterine artery embolisation (UAE)
Uterine artery embolisation (UAE) is a minimally invasive procedure that can be carried out through a small tube inserted into your groin. Through this tube, small plastic beads are injected into the arteries supplying blood to the fibroid. This blocks the arteries and causes the fibroid to shrink over the subsequent six months.
People who have UAE may suffer pain after the blood supply is removed, and strong painkillers are needed for about eight hours. There are some other complications that your specialist will be able to tell you about.
The advantage of UAE is that:
- it is successful in 95% of people who have heavy periods caused by fibroids
- serious complications are rare
- you only need to spend one night in hospital
- your womb and ovaries are not removed, so if you still want children this is possible
Further research needs to be carried out into the success rate of pregnancy after UAE. Sometimes, further embolisations or other procedures are needed after UAE. Your specialist will discuss this with you.
Myomectomy
Sometimes, the fibroids can be removed using a surgical procedure known as a myomectomy. However, the operation is not suitable for every type of fibroid. Your gynaecologist (specialist in the female reproductive system) will be able to tell you whether a myomectomy is possible and what the complications are.
When they are possible, myomectomies are very effective operations. However, in a quarter to a third of all people who have a myomectomy, the fibroids grow back again.
See the Health topic about Fibroids - treatment for more information.
If your heavy periods are caused by something other than fibroids, there are several surgical procedures that can be carried out. Your specialist will be able to discuss them with you, including the benefits and any associated risks.
Common surgical procedures for treating heavy periods that are not caused by fibroids include:
- endometrial ablation: where the womb lining is destroyed
- hysterectomy: surgical removal of the womb, which may sometimes also involve the removal of the cervix (neck of the womb), fallopian tubes and ovaries (oophorectomy)
Endometrial ablation
There are different techniques that can be used for endometrial ablation. These include:
- microwave endometrial ablation: in which a probe that uses microwave energy (a type of radiation) is inserted into the womb to heat up and destroy the womb lining
- thermal balloon ablation: in which a balloon is inserted into your womb and is inflated and heated to destroy the womb lining
These procedures can be carried out under local anaesthetic (painkilling medication) or general anaesthetic (where you are unconscious). They are fairly quick to perform, taking around 20 minutes, and you can often go home the same day.
You may experience some vaginal bleeding for a few days after endometrial ablation which is similar to a light period. Use sanitary towels rather than tampons. Some women can have bloody discharge for three or four weeks.
You may also experience tummy cramps, similar to period pains, for a day or two. These can be treated with painkillers, such as paracetamol.
More information about endometrial ablation is available from the Royal College of Obstetricians and Gynaecologists who have produced a leaflet called information for you after an endometrial ablation.
Hysterectomy
A hysterectomy (surgical removal of the womb) will stop any future periods, but it should only be considered after other options have been tried or discussed. The hysterectomy operation and recovery time are longer than for other surgical techniques for treating heavy periods.
Hysterectomy is only usually used to treat menorrhagia following a thorough discussion with your specialist to outline the benefits and disadvantages of the procedure. See the Health topic about Hysterectomies for more information.
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