Heavy Periods (Menorrhagia)

What is a normal period, a heavy period, and menorrhagia?

About 1 in 3 women describe their periods as 'heavy'. However, it is often difficult to know if your periods are normal or heavy compared to other women. Some women who feel they have heavy periods actually have an average blood loss. Some women who feel they have normal periods actually have a heavy blood loss. Most of the blood loss (about 90%) usually occurs in the first three days with either normal or heavy periods.

• A 'normal' period is a blood loss between 20 and 60 ml (4-12 teaspoonfuls). Bleeding can last up to eight days, but bleeding for five days is average.
• A 'heavy' period is a blood loss of 60-80 ml or more. This is about half a teacupful or more. However, it is difficult to measure the amount of blood that you lose during a period. For practical purposes, a period is probably heavy if it causes one or more of the following:
  • Flooding through to clothes or bedding.
  • You need frequent changes of sanitary towels or tampons.
  • You need double sanitary protection (tampons and towels).
  • You pass large blood clots.
• Menorrhagia means heavy periods that recur each month. Also, that the blood loss interferes with your quality of life. For example, if it stops you doing normal activities such as going out, working, or shopping. Menorrhagia can occur alone or in combination with other symptoms.

What causes recurring heavy periods?

The cause is not known in most cases

This is called 'dysfunctional uterine bleeding'. In this condition the uterus (womb) and ovaries are normal. It is not a hormone problem. Ovulation is usually normal and the periods are regular. A chemical called prostaglandin may play a part. The amount of prostaglandin in the lining of the uterus is often higher than normal in women with heavy periods. The high level of prostaglandin may affect blood clotting within the uterus. Bleeding then takes longer than normal to stop.

Other causes

These are less common. They include the following:

• Fibroids. These are benign (non-cancerous) growths in the muscle of the uterus. They often cause no problems, but sometimes cause symptoms such as heavy periods. See separate leaflet called 'Fibroids' for details.
• Other conditions of the uterus such as endometriosis (see separate leaflet), infections, polyps, or a previous sterilization ('tubal tie') may lead to heavy periods. Cancer of the lining of the uterus (endometrial cancer) is an uncommon cause. This occurs in a small number of women, usually over the age of 40.
• Hormone problems. Periods can be irregular and sometimes heavy if you do not ovulate every month. For example, this occurs in some women with polycystic ovary syndrome. Women with an underactive thyroid gland may have heavy periods.
• The IUD (Intrauterine Device or 'coil') sometimes causes heavy periods. However, a special hormone-releasing IUD can actually treat heavy periods (see below).
• Warfarin or similar medicines interfere with blood clotting. If you take one of these medicines for other conditions, it may have a side-effect of heavier periods.
• Some drugs used for chemotherapy can also cause heavy periods.
• Blood clotting disorders are rare causes of heavy bleeding. Other symptoms are also likely to develop such as easy bruising or bleeding from other parts of the body.

If you stop taking the contraceptive pill it may appear to cause heavy periods. Some women become used to the light monthly bleeds that occur whilst on 'the pill'. Normal periods return if you stop the pill. These may appear heavier, but are usually normal.

Do I need any tests if I have heavy periods?

• A doctor may want to do an internal (vaginal) examination to check the feel of the uterus for any abnormalities. This is not always necessary, especially in younger women who do not have any symptoms to suggest anything other than dysfunctional uterine bleeding.
• A blood test to check for anaemia is usually advised. If you bleed heavily each month then you may not take in enough iron in your diet needed to replace the blood that you lose. (Iron is needed to make blood cells.) This can lead to anaemia which can cause tiredness and other symptoms. Up to 2 in 3 women with recurring heavy periods develop anaemia.

If the vaginal examination is normal (as it is in most cases), and you are under the age of 40, no further tests are usually needed. The diagnosis is usually 'dysfunctional uterine bleeding' and treatment may be started if required. Further tests may be advised for some women, especially if there is concern that there may be a cause for the heavy periods other than dysfunctional uterine bleeding. For example:

• Women over the age of 40 who develop heavy periods.
• Any woman who has an increased risk of developing cancer of the uterus. For example, older women who have never had children, women with a family history of cancer of the uterus or colon, women taking the drug tamoxifen. See separate leaflet called 'Cancer of the Uterus' for details.
• If treatment for a presumed dysfunctional uterine bleeding does not seem to help.
• Any woman where a doctor detects a large or abnormal uterus, or who has other symptoms which may indicate an underlying problem. For example, if you:
  • Bleed between periods, or have irregular bleeding.
  • Have bleeding or pain during, or just after, sex.
  • Have pain apart from normal period pain.
  • Have any change in your usual pattern of bleeding, particularly if you are over the age of 40.
  • Have symptoms suggesting a hormone problem or blood disorder.

If tests are advised they may include one or more of the following:

• An ultrasound scan of the uterus. This is a painless test which uses sound waves to create images of structures inside your body. The probe of the scanner may be placed on your abdomen to scan the uterus. A small probe is also commonly placed inside the vagina to scan the uterus from this angle. An ultrasound scan can usually detect fibroids, polyps, or other changes in the structure of the uterus.
• Swabs taken from inside the vagina. This may be done if a persistent infection is the suspected cause of the heavy bleeding. A swab is a small ball of cotton wool on the end of a thin stick. It can be gently rubbed in various places to obtain a sample of mucus, discharge, or some cells. The sample can be looked at under a microscope and sent away to the lab for testing.
• Endometrial sampling. This is where a thin tube is passed into the uterus. Gentle suction is used to obtain small samples (biopsies) of the uterine lining (endometrium). This can often be done without an anaesthetic. The samples are looked at under the microscope for abnormalities.
• Hysteroscopy. This is where a doctor can look inside the uterus. A thin 'telescope' is passed into the uterus through the cervix via the vagina. This too can often be done without an anaesthetic. Small samples can also be taken during this test.
• Blood tests. For example, if an underactive thyroid gland or a bleeding disorder is suspected.

Keeping a menstrual diary

It may be worth keeping a diary for a few periods (before and after any treatment). Your doctor may give you a chart which you can fill in. Basically, you record the number of sanitary towels or tampons that you need each day, and the number of days of bleeding. Also, note if you have any flooding or interruption of normal activities. An example of a chart is in another leaflet called 'Period Blood Loss Chart'.

A diary is useful for both patient and doctor to see:

• How bad symptoms are, and whether treatment is needed.
• If treatment is started, to assess if it is helping. Some treatments take a few menstrual cycles to work fully. If you keep a diary it helps you to remember exactly how things are going.

What are the treatment options for heavy periods?

Treatment aims to reduce the amount of blood loss. The rest of this leaflet discusses treatment options for women who have regular but heavy periods with no clear cause (dysfunctional uterine bleeding). This is the majority of cases. If there is an underlying cause, such as a fibroid or endometriosis, treatment options may be different.

Not treating

This is an option if your periods do not interfere too much with normal life. You may be reassured that there is no serious cause for your heavy periods, and you may be able to 'live with them'. A blood test may be advised every so often to check for anaemia. Iron tablets can correct anaemia.

Levonorgestrel intrauterine system (LNG-IUS)

This treatment usually works very well. The LNG-IUS is similar to an intrauterine device (IUD or 'coil'). It is inserted into the uterus and slowly releases a small amount of a progestogen hormone called levonorgestrel. The amount of hormone released each day is tiny but sufficient to work inside the uterus. In most women, bleeding becomes either very light or stops altogether within 3-6 months of starting this treatment. Period pain is usualy reduced too. However, the light periods may become irregular. The LNG-IUS works mainly by making the lining of the uterus very thin.

The LNG-IUS is a long-acting treatment. Each device lasts five years, although it can be taken out anytime. It is particularly useful for women who require long-term contraception as it is also a reliable form of contraception. See separate leaflet called 'The Intrauterine System - IUS' for details.

Tranexamic acid tablets

Tranexamic acid tablets are an option if the LNG-IUS is not suitable or not wanted. Treatment with tranexamic acid can reduce the heaviness of bleeding by almost half (40-50%) in most cases. However, the number of days of bleeding during a period is not reduced, nor is period pain. You need to take a tablet 3-4 times a day, for 3-5 days during each period. Tranexamic acid works by reducing the breakdown of blood clots in the uterus. In effect, it 'strengthens' the blood clots in the uterus lining which leads to less bleeding. Side-effects are usually minor, but may include an upset stomach.

Anti-inflammatory painkillers

There are various types and brands. Most are available only on prescription but you can buy one called ibuprofen from pharmacies. These medicines reduce the blood loss by about a third (20-50%) in most cases. They also ease period pain. You need to take the tablets for a few days each period. They work by reducing the high level of prostaglandin in the uterus lining which seems to contribute to heavy periods and period pain. However, they do not reduce the number of days the period lasts.

Side-effects occur in some people and may include an upset stomach. If you have a history of a duodenal or stomach ulcer, or asthma, you should only take these medicines on a doctor's advice. See separate leaflet called 'Anti-inflammatory Painkillers' for details.

Some women take both anti-inflammatory painkillers and tranexamic acid tablets for a few days over each period.

The contraceptive pill

This reduces bleeding by about a third in most women - sometimes more. It often helps with period pain too. It is a popular treatment with women who also want contraception, but who do not want to use the LNG-IUS. If required, you can take this in addition to anti-inflammatory painkillers (described above), particularly if period pain is a problem. See separate leaflet called 'Combined Oral Contraceptive Pill' for details.

Long acting progestogen contraceptives

The contraceptive injection and the contraceptive implant tend to reduce heavy periods. For example, up to half of women on the contraceptive injection have no periods after a year. They are not given as a treatment just for heavy periods. However, if you require contraception then one of these may be an option for you. See separate leaflets on 'Injectable Contraceptive' and 'Implanon - The Contraceptive Implant' for details.

Norethisterone

Norethisterone is a progestogen medicine. It is not commonly used to treat heavy periods. It is sometimes considered if other treatments have not worked, are unsuitable or are not wanted. If norethisterone is used on a regualar basis to treat heavy periods, please note that it only works if taken on days 5-26 of the menstrual cycle. Strictly speaking, this is longer than the 'licensed' (official) dose, but it is the recommended dose for heavy periods.

The reason why norethisterone is not commonly used as a regular treatment is because many women get side-effects such as bloating, fluid retention, breast tenderness, nausea, headache and dizziness. However, norethisterone is used as a temporary measure to stop very heavy menstrual bleeding (see below).

Other medicines

Other hormone treatments such as gonadotrophin-releasing hormone (GnRH) analogues are occasionally used. However, they are not routine treatments due to various side-effects that commonly occur.

Surgical treatment

This is an option if the above treatments do not help or are unsuitable.

• Removing or 'stripping' the lining of the uterus is an option. This is called endometrial ablation or resection. An instrument is passed into the uterus via the vagina. The aim is to remove as much of the uterus lining as possible. This can be done by various ways such as by using heat, microwaves, and cryotherapy.
• Hysterectomy is the traditional operation where the uterus is totally removed. However, hysterectomy is done much less commonly these days since endometrial ablation became available in the 1990s.

Emergency treatment to rapidly stop heavy bleeding

Some women have very heavy bleeding during a period. This can cause a lot of blood loss, and distress. One option as an emergency treatment is to take a course of norethisterone tablets. Norethisterone is a progestogen medicine. Progestogens act like the body's natural progesterone hormones - they control the buildup of cells lining the womb.

So, if a period is very heavy or prolonged, your doctor may advise that you take norethisterone tablets. A dose of 5 mg three times daily for 10 days is the usual treatment. Bleeding usually stops within 24-48 hours of starting treatment. If bleeding is exceptionally heavy then 10 mg three times daily may be needed (although, strictly speaking, this dose is not licensed). This should then be tapered down to 5 mg three times daily for one week only, once bleeding has stopped.

A note for teenagers with heavy periods

Heavy periods due to 'dysfunctional uterine bleeding' seems to be more common in the first few years after starting periods (and in the months running up to the menopause). If you are a teenager and have heavy periods, you have a good chance that they will 'settle down' over a few years and become less heavy. So, for example, if you take treatment for heavy periods whilst a teenager or young adult, you may not need it after a few years.

Further help and information

Women's Health Concern

Whitehall House, 41 Whitehall, London, SW1A 2BY
Helpline: 0845 123 2319 (local rate) Web: www.womens-health-concern.org
Provides advice to women on a wide variety of women's health issues including periods.