An Overview of Heavy Menstrual Bleeding

The Causes, Symptoms, and Diagnosis

Menorrhagia—excessive menstrual bleeding—can be a cause of medical issues, and it can cause serious complications. You should make an appointment to see your gynecologist if you have heavy periods. Sometimes heavy bleeding is an emergency that warrants prompt medical attention.

causes of heavy menstrual bleeding
Verywell / Brianna Gilmartin

Symptoms

The easiest way to know if you are experiencing heavy menstrual bleeding is to take note of how often you are soaking through a pad or tampon.

If your period is heavy enough to require changing a pad or tampon every hour for several hours, or if you have vaginal bleeding that lasts more than a full week, you are experiencing heavy menstrual bleeding.

Other signs of heavy menstrual bleeding include:

  • Wearing more than one pad at a time in order to control the bleeding
  • Having to change your tampon or pad in the middle of the night
  • If your menstrual blood contains clots that are the size of a quarter or bigger

When Menstrual Bleeding Is an Emergency

Go to the nearest emergency room if you experience severe, acute bleeding in which you soak through four or more pads or tampons in a two-hour period. If you are pregnant, seek immediate medical care if you have any menstrual bleeding.

Causes

There are a number of different causes of heavy menstrual bleeding—including benign (noncancerous) growths, like fibroids, or malignant growths, like cancer of the uterus or cervix. Hormone changes or blood clotting disorders can cause menorrhagia too.

Other, less common causes of heavy menstrual bleeding include endometriosis and having an intrauterine device (IUD) like the ParaGard, which may cause excessive bleeding, especially during your first year of use.

But the list does not stop there. This emphasizes the importance of seeing your healthcare provider for a proper diagnosis and evaluation.

Ovulatory Dysfunction

The most common cause of heavy menstrual bleeding is ovulatory dysfunction during adolescence or perimenopause. During this time, ovulation (releasing an egg) can be irregular—which means it might not happen every month. This can lead to thickening of the endometrium (uterine lining) and heavy periods.

Oral contraceptives can usually regulate your bleeding during adolescence, and hormone therapy can help during menopause.

Beyond the normal hormonal changes that occur with puberty or menopause, hormonally-induced ovulatory dysfunction can also occur with hypothyroidism, polycystic ovary syndrome (PCOS), and premature ovarian insufficiency. Getting treated for your underlying problem is important, and it can help restore regular ovulation and normalize your periods.

Uterine Fibroids

Fibroids are growths that develop from the muscle of the uterus, usually between ages 30 to 49.

Uterine fibroids are estrogen-dependent. Hormonal birth control methods, like birth control pills, can help reduce heavy menstrual bleeding from fibroids.

If your symptoms are not severe or troublesome, you might not need treatment for your fibroids—it's often sufficient to take a “wait and see” approach. During menopause, fibroids typically shrink and disappear without treatment.

Progestin-release intrauterine devices (IUDs) can decrease menstrual bleeding but do not reduce fibroid size. Injectable gonadotropin-releasing hormone agonists can decrease the size, but can only be used for a short time due to their side effects.

Endometrial ablation (the lining of the uterus is destroyed) is a procedure that can be used for the treatment of small fibroids. Surgical options include myomectomy (removal of the fibroid) and uterine artery embolization (the blood supply is cut off to the fibroid).

In the most severe cases, a hysterectomy may be warranted, in which the whole uterus is removed, with or without the ovaries.

Uterine Polyps

Endometrial polyps are typically noncancerous, grape-like growths that protrude from the lining of the uterus. They can develop before and after menopause. The cause of endometrial polyps is unclear, though research suggests a link between hormone therapy and obesity.

Treatment of small polyps is unnecessary unless you're at risk of uterine cancer. If you are, your healthcare provider might recommend a polypectomy, in which the polyp would be removed for microscopic examination. Large polyps are routinely removed and examined as a precaution.

Uterine Adenomyosis

Uterine adenomyosis is a condition in which the endometrial uterine cells grow into the muscular wall of the uterus, causing uterine enlargement and painful, heavy bleeding. Hormonal birth control methods can help control the condition, and the definitive treatment for adenomyosis is a hysterectomy.

Pelvic Inflammatory Disease (PID)

PID is most often caused by an untreated sexually transmitted infection (STI), however, it can sometimes occur following childbirth, abortion, or other gynecological procedures. In PID, one or more reproductive organs can be infected—including the uterus, fallopian tubes, and/or cervix. The recommended treatment for PID is antibiotic therapy.

Cervical or Endometrial Cancer

Cervical cancer, which can be caused by human papillomavirus (HPV) (an asymptomatic STI), can invade other parts of the body. Treatment for cervical cancer includes surgery, chemotherapy, and/or radiation therapy.

Endometrial cancer occurs when abnormal cells in the endometrium grow into the uterus and/or other organs. While the cause of endometrial cancer is unknown, the most common age for diagnosis is the mid 60's.

Treatment for endometrial cancer is usually a hysterectomy, possibly followed by chemotherapy and/or radiation treatments.

Early diagnosis is key to the effective treatment of cancer. In addition to regular Pap screening for cervical cancer, the American Cancer Society recommends that women at high risk of endometrial cancer have an annual endometrial biopsy.

Bleeding Disorders

While there are several types of bleeding disorders, the most common type in women is von Willebrand disease (VWD). Treatments for von Willebrand disease involve the release of stored clotting factors in the blood or, in extreme cases, replacing the clotting factor with an intravenous treatment or with a prescribed nasal spray.

Other bleeding issues that can lead to heavy menstrual bleeding include having a low platelet count (platelets are involved in the clotting process and are produced in the bone marrow) or taking a blood thinner like aspirin or Coumadin (warfarin sodium).

Diagnosis

It's important that you get a diagnosis for the cause of your heavy menstrual bleeding. Before your appointment, try to jot down your period pattern in the last few months.

For instance, how many days did you bleed each month? How many pads or tampons do you go through on the days of your heaviest menstrual flow?

Make sure you have a list of all your medications, including hormonal birth control, hormone therapy, and any vitamins or over-the-counter supplements.

You might have diagnostic tests, such as:

  • A pregnancy test (if you are premenopausal)
  • Blood tests (for example, a complete blood count, iron levels, and thyroid hormones)
  • An ultrasound of your pelvis

Your healthcare provider may also do a hysteroscopy which is a diagnostic procedure that is used to visualize the inside of your uterus. They may also do an endometrial biopsy to sample your uterine tissue for microscopic examination.

A Word From Verywell

Getting to the bottom of your heavy menstrual bleeding is important for your quality of life and for your overall health. Heavy blood loss, regardless of the cause, can cause iron-deficiency anemia, which can make you short of breath, tired, and dizzy.

Once both the bleeding and the root cause of your bleeding are addressed and treated, you can move forward and feel well—you deserve it.

Frequently Asked Questions

  • How is heavy menstrual bleeding treated?

    If bleeding is hormonal in nature, prostaglandin inhibitors (non-inflammatory drugs), birth control pills, and progesterone may help. For issues involving the endometrium, treatment options include ablation, resection (removal) of the uterine lining, or hysterectomy. In May 2020, the Food and Drug Administration (FDA) approved Oriahnn (elagolix, estradiol, and norethindrone acetate capsules; elagolix capsules) for heavy bleeding due to fibroids.

  • Can heavy menstrual bleeding be treated without drugs or surgery?

    There are no Food and Drug Administration-approved natural remedies for heavy periods, but a number have been studied. Among those that show promise are:

    • Ginger capsules
    • Myrtle fruit syrup
    • Punica granatum flower (pomegranate) capsules
    • Plantain syrup

    Check with your healthcare provider before taking any supplement.

  • Should I take iron supplements if I have heavy periods?

    Possibly. In studies, women who had anemia due to menorrhagia experienced a number of positive benefits from taking iron supplements: more energy and physical activity, a more robust social life, and less anxiety and depression. See your healthcare provider to find out if you're anemic and if they think iron supplements may help.

  • How is heavy menstrual bleeding treated in the emergency room?

    A number of measures may be taken depending on the cause, the amount of blood loss, and any complications, such as:

    • Intravenous (IV) fluids to replace lost fluid
    • A blood transfusion
    • IV estrogen
    • Insertion of a balloon catheter into the uterus that is expanded to put pressure on bleeding blood vessels
    • Treatment for hemorrhagic shock, should that occur
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