Date issued:September 2020
For review:September 2022
Ref:B 464/RMR/Gynae/Heavy Menstrual Bleeding
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 with your periods 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.
- Passing blood clots during periods.
- Feeling tired and drained during and just after your period.
- A diagnosis of anaemia (low blood count).
- ‘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 growth on 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 tummy pain, lower back pain, constipation, the feeling of needing to constantly urinate, pain/ discomfort during sexual intercourse and rarely, problems getting pregnant.
– Fibroids can grow anywhere in the womb:
? Intramural, inside the muscle (the most common)
? Submucosal, bulge into the womb’s cavity
? Subserosal, project outside the womb into the pelvis
– How to treat fibroids depends on where they are, the size and number of them.
– If a fibroid is under 3 cm and not affecting the cavity of the womb a progesterone coil is the first line treatment.
– If the fibroid is over 3 cm then a progesterone coil is still an option for treatment but it depends on the size and number of fibroids.
– If a fibroid is over 3 cm you may need additional investigations such as MRI or hysteroscopy.
– You can still have medical treatment as listed below and sometimes medication such as Gonadotropin-releasing hormone (GNRH) analogues (decapeptyl) to shrink the fibroids. Other options are surgical as listed below.
4. Dysfunctional uterine bleeding: the womb is normal and no cause for the excessive bleeding is discovered.
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 and 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.
6. Coagulopathy: blood clotting disorders, the most common is Von Willebrand’s disease.
7. Medication: bleeding due to hormonal treatments or medication such as, the copper coil (IUD) and blood thinning drugs.
8. Endometrial hyperplasia and Endometrial cancer: these are rare causes of regular heavy menstrual bleeding
9. Hypothyroidism: an underactive thyroid.
Do I need any tests?
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, flooding.
How your periods are affecting your life.
Bleeding in between periods or after sexual intercourse.
Your method of contraception and whether you could be pregnant now.
If you experience pelvic pain during your periods and/or pelvic pain during sexual intercourse.
About your medication, 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 or going to the dentist.
About your family's medical history.
Your clinician may ask to perform a pelvic examination for a number of reasons, for example to check for fibroids. 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 gently 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:
- Full blood count (FBC): To detect iron deficiency anaemia. If your blood test shows that you have iron deficiency anaemia, a course of iron medicine 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 create images of structures within the body and in particular 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 image of the womb.
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 a small amount of spotting after the procedure. The results are generally available after a few weeks.
1. Levonorgestrel intrauterine system (progesterone coil or IUS)
- ? This is considered as first line treatment which means it is a good one to start with.
- ? It is a little plastic device which releases a small amount of the hormone progesterone to the lining of 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 sometimes it can go over 6 months.
- ? It is advised to wait at least 6 cycles to see the benefit of this treatment.
- ? It can be taken out at any time by a specially trained doctor or nurse.
- ? Some women may experience side effects, such as mood swings, headaches, skin problems or breast tenderness.
- ? There's no evidence that an IUS will affect your weight or increase the risk of cervical cancer, cancer of the uterus or ovarian cancer.
- ? An uncommon side effect of the IUS is that some women can develop small fluid-filled cysts on the ovaries, these usually disappear without treatment.
- ? There is a very small risk of getting a hole in the womb when having it fitted.
- ? There is a small risk of getting an infection after it's been fitted.
- ? 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 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 everything is fine.
- ? 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.
- a. Tranexamic acid: This is a tablet that is used during the period; 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 3 to 5 days. 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 can cause indigestion and diarrhoea.
- ? The Combined Oral Contraceptive pill (COCP) this tablet can decrease blood flow by up to 30%. You will need to have a follow up with you GP. There can be side effects with COCP.
- ? Cyclical Progesterone’s:
- – 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. – 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’s: 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 cause some irregular bleeding.
- ? GNRH analogues (Decapeptyl)
- – This is used to see if stopping your periods will help prior to other treatments; it can also shrink fibroids and help pelvic pain. Up to 90% of women will have no periods but it is generally used as a short-term solution.
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 having regular exercise and avoiding smoking, will help to keep you healthy. You should also only have the recommended units of alcohol.