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Date issued: November 2022
For review: November 2024 
Ref:B 464/RMR/Gynae/Heavy Menstrual Bleeding v2

PDF:  Heavy Menstrual Bleeding [pdf] 609KB

What are heavy periods?

A patient may be described as having ‘heavy periods’ if there is excessive menstrual bleeding over several menstrual cycles in a row that interfere with physical, emotional, and social quality of life.

It affects 1 in 10 patients aged 30-49 years old. There are interventions that can improve quality of life.

This leaflet does not cover treatment for women whose heavy periods are caused by endometriosis or Hormone Replacement Therapy (HRT), or whose bleeding is not related to the menstrual cycle.

What are the signs and symptoms of heavy periods?

• Blood loss that requires you to change your sanitary wear (pads or tampons) frequently (every one to two hours or more).

• Having to wear two pads or a pad and a tampon at the same time (double protection).

• Passing large blood clots.

• Feeling tired and drained during and after your period.

• A diagnosis of anaemia (low blood count or low ferritin level).

• ‘Flooding’ (leaking through your clothing).

• Feeling that your periods are interfering in your everyday life.

Causes of Heavy Periods

1. Polyps: these are generally non-cancerous growths of the lining of the womb (Endometrium).

2. Adenomyosis: a condition where there is tissue from the lining of the womb in the muscle layer of the womb, this can cause pain along with the heavy periods.

3. Leiomyomas (Fibroids): these are non-cancerous growths made up of muscle and fibrous tissue.

• Fibroids are very common with around 1 in 3 women developing them.

• Why women get fibroids is not fully understood. It could possibly be due to the hormone oestrogen.

• Most women develop fibroids around the age of 16-50 when oestrogen levels are the highest.

• Fibroids can shrink when oestrogen levels are low, for example when going through the menopause.

• You are more likely to develop them if overweight due to higher oestrogen levels.

• As well as heavy bleeding, fibroids can cause abdominal pain, lower back pain, constipation, the feeling of needing to constantly urinate, pain during sexual intercourse and rarely, problems getting pregnant.

• Fibroids can grow anywhere in the womb:

  • Intramural, inside the muscle (most common)

  • Submucosal, bulge into the womb’s cavity

  • Subserosal, project outside the surface of the womb into the pelvis

• How to treat fibroids depends on where they are, the size and number of them.

• Generally, hormones are used to reduce the heavy bleeding caused by fibroids. This can be either Progesterone only, through the coil (Mirena) or oral tablets, or a combination of Progesterone and Oestrogen in the combined pill.

• Sometimes medication such as Gonadotropin-releasing hormone (GNRH) analogues (decapeptyl) are used to shrink the fibroids, especially prior to surgery. Other options are surgical as listed below.

       4. Dysfunctional uterine bleeding: the womb is normal in appearance and the heavy bleeding is usually hormonal.

       5. Ovulatory disorders: when the ovaries do not produce eggs (cycles with no ovulation) this can lead to the lining of the womb being exposed to more oestrogen,                 becoming thickened and then can cause heavy periods. This is more likely when starting periods in adolescence, around the time of the menopause or if you have             anovulatory cycles with a condition called polycystic ovarian syndrome (PCOS).

       6. Coagulopathy: blood clotting disorders leading to heavy bleeding, the most common is Von Willebrand’s disease. Usually have other symptoms like frequent nose             bleeds.

      7. Medication: bleeding due to hormonal treatments or medication such as, the copper coil and blood thinning medication.

      8. Endometrial hyperplasia and Endometrial cancer: these are rare causes of regular heavy menstrual bleeding and are more likely seen with irregular bleeding or            bleeding post-menopause.

      9. Hypothyroidism: an underactive thyroid.

Do I need any tests?

Medical history

Your clinician will ask some questions about your medical history, the nature of your bleeding and any other related symptoms that you may have. This will help you and the clinician decide what tests are required and what treatment you may need. You will be asked:

• About your menstrual cycle, when your last period was, how many days your period lasts, how often your periods come.

• How often you change your sanitary pads, clots, flooding episodes.

• Bleeding in between periods or after sexual intercourse.

• Your method of contraception and whether you could be pregnant.

• If you experience pelvic pain during your periods and/or pelvic pain during sexual intercourse.

• About your medications, if you have taken any medications for your periods and whether these have helped or not.

• The number of pregnancies you have had and plans for future children.

• Cervical smear history.

• If you bleed for a prolonged period after sustaining a minor cut, going to the dentist or frequent nose bleeds.

• About your family's medical history.

Pelvic examination

Your clinician may ask to perform a pelvic examination. You must give consent for the examination and have the option of a chaperone while the examination is being performed. A pelvic examination includes the following:

• Speculum examination of the vagina and cervix: This uses a device called a speculum (the same instrument that is used when you go for a cervical screening test), which is inserted into the vagina to enable the clinician to inspect your vagina and the cervix (neck of the womb) for evidence of any abnormal changes.

• Bimanual palpation:  An internal examination of your vagina, which involves the clinician inserting two fingers into the vagina to assess whether your womb or ovaries are tender or enlarged.

The tests you may need:

Blood test

• Full blood count (FBC): To detect iron deficiency anaemia. If your blood test shows that you have iron deficiency anaemia, oral iron will be prescribed for you.

• Thyroid function test (TFT)

• Clotting screen: This may be done if your clinician thinks it is appropriate.

Pelvic Ultrasound: This uses ultrasound waves to look for abnormalities within the womb such as fibroids or polyps. It is a painless investigation and can be done either via the abdomen (transabdominal scan) or via the vagina (trans-vaginal scan). The trans-vaginal scan is usually preferred as it produces better images of the womb and ovaries.

Hysteroscopy: This is where a small telescope is inserted into the womb. This can be done awake in clinic or under general anaesthetic. You are more likely to have one recommended if you have ongoing bleeding between periods and or your scan has shown fibroids or polyps within the womb. Polyps and certain fibroids can be treated in an outpatient setting. See our leaflet on hysteroscopy.

Endometrial Biopsy: Occasionally a biopsy from the lining of your womb may need to be taken and sent off to the laboratory. This involves inserting a straw-like tube into the womb. It can cause period pains while it is being taken and may cause some bleeding after the procedure. The results are generally available after a few weeks.

Treatment

1. Levonorgestrel intrauterine system (IUS)

• This is considered as first line treatment for heavy periods.

• It is a small plastic device which releases the hormone progesterone into the womb.

• It lasts for 3 – 5 years depending on the type of progesterone coil you have.

• It can change bleeding to lighter periods or no bleeding.

• It reduces bleeding in 70-100% women and also helps with period pain that can be caused by conditions like endometriosis.

• As a method of contraception, it is 99% effective.

• Once it is removed, you could get pregnant straight away.

• Some women can experience spotting or bleeding between periods, especially in the first 3 to 6 months.

• It is advised to wait at least 6 months to see the benefit of this treatment.

• It can be taken out at any time by a doctor or nurse.

• Some women may experience side effects, such as mood swings, headaches, skin problems or breast tenderness.

• There is no evidence that an IUS will affect your weight or increase the risk of cervical / uterine / ovarian cancer.

• There is a very small risk of getting a hole in the womb when having it fitted (uterine perforation).

• There is a small risk of getting an infection, this is mainly seen initially when first fitted.

• There is a small risk the coil could fall out, this is generally with heavy bleeding and within the first 6 weeks.

• If the IUS fails and you become pregnant, then there is a small risk of an ectopic pregnancy (pregnancy growing in the wrong place).

• It can be uncomfortable when the IUS is put in, but painkillers and the use of local anaesthetic to your cervix can help.

• The IUS can be fitted at any time during your monthly menstrual cycle, as long as you are not pregnant.

• If it's fitted in the first 7 days of your cycle, you'll be protected against pregnancy straight away.

• If it's fitted at any other time, use additional contraception, such as condoms, for 7 days afterwards.

• 3 to 6 weeks after having the coil fitted, arrange a GP appointment to make sure the threads are still visible on speculum examination.

• The IUS does not protect against sexually transmitted infections (STIs), so you may need to use condoms as well.

The IUS may not be suitable if you have:

• Breast cancer, or have had it in the past 5 years.

• Cervical cancer or womb (uterus) cancer.

• Liver disease.

• Arterial disease or a history of serious heart disease or stroke.

• An untreated sexually transmitted infection (STI) or pelvic infection.

    2. Medical

      i. Non-hormonal

       a. Tranexamic acid: This is a tablet that is used during the period only. It can decrease bleeding by 30-50%. You will need to start taking the tablets when the period           starts and stop it when the blood flow is manageable, usually day 3 to 5. This medicine can cause stomach pains and is generally not used if you have previously had         clots in your legs or lungs.

      b. Non-Steroidal Anti-Inflammatory Drugs (NSAIDS): such as mefenamic acid and naproxen may decrease blood flow by 20-40%. These medicines may cause              indigestion and diarrhoea.

ii. Hormonal

• The Combined Oral Contraceptive pill (COCP) this tablet can decrease blood flow by up to 30%. There can be side effects with COCP and strict criteria due to the risk of blood clots.

• Cyclical Progesterone:

  • Norethisterone 5 mg 3 times a day for 10 days or 5 mg twice a day from day 19 to 26 of the cycle (day 1 is the first day of your period). This medication can also be used to stop the bleeding temporarily.

  • Medroxyprogesterone acetate 2.5–10?mg daily for 5–10 days, repeated for 2 cycles, begin treatment on day 16–21 of cycle.

  • Side effects can be weight gain, bloating, breast tenderness, headaches and blood clots with norethisterone.

• Long Term Progesterone: e.g., the progesterone only contraceptive pill which decreases bleeding up to 60%. Other medications such as the contraceptive implant and contraceptive injection may also help your periods but can sometimes cause irregular bleeding.

• GNRH analogues (Decapeptyl injections) This is used to temporarily turn off your ovaries to stop the bleeding. It is also used to shrink fibroids and help pelvic pain, especially before surgery. Up to 90% of women will have no periods but it is generally used as a short-term solution. It is associated with menopause symptoms and bone thinning. Some women will be asked to take Hormone Replacement Therapy alongside the injections.

3. Surgical Treatment

Surgical treatments are generally only considered when medical treatments are not effective. They will have an impact on your fertility and will increase your risks if you were to have a pregnancy. Leaflets are available on surgical treatments which include the following:

1. Endometrial Ablation

2. Uterine artery embolization

3. Myomectomy

4. Hysterectomy

Is there anything you can do to help? Whether or not you decide to have surgical or medical treatment, having a balanced diet that is low in fat and high in iron will help ensure your blood iron level is within normal limits. Other lifestyle habits, such as regular exercise and not smoking, will help to keep you healthy.