Heavy periods: you don't have to just live with it

Common causes include polyps (benign growths of the uterine lining, often with heavier or intermenstrual bleeding), fibroids (benign muscle nodules – depending on location and size causing very heavy or prolonged bleeding with a feeling of pressure), adenomyosis (endometrium-like tissue growing into the muscular wall of the uterus – typically causing heavy and simultaneously painful periods, often around age 40) and hormonal changes in perimenopause with absent ovulation. Less commonly, an underactive thyroid, blood thinners, a copper IUD or – if the period has been very heavy since the first menstruation – a congenital clotting disorder (for example von Willebrand disease) play a role. Very rarely, changes in the uterine lining are the cause – which is why we also assess the lining, especially in and after perimenopause.

Risk factors

• –Perimenopause
• –Known fibroids, polyps or adenomyosis
• –Tendency to bleed since the first period, easy bruising, nosebleeds
• –Copper IUD
• –Blood-thinning medication
• –Thyroid dysfunction

Frequency

Heavy menstrual bleeding is one of the most common reasons for a gynaecology visit – and one of the most treatable.

Typical symptoms

• –Changing pads or tampons every one to two hours
• –Extra or double protection at night, waking up to change
• –Bleeding through clothing or bedding
• –Larger blood clots (about coin-sized or bigger)
• –Bleeding lasting longer than seven days
• –Fatigue, paleness, shortness of breath
• –Planning daily life around the bleeding

Common incidental findings

• –Rough guide: more than about 5 fully soaked pads/tampons per day
• –Known iron deficiency or anaemia
• –Heavy and simultaneously painful period (suggests adenomyosis)

When is it detected?

For very heavy bleeding with dizziness, palpitations or weakness (circulatory symptoms), seek medical help or the emergency department promptly. Bleeding after menopause (more than 12 months without a period) is no longer a 'heavy period' and should always be investigated.

The first step is a detailed conversation (how long does the bleeding last, how much do you use, are there clots, are you tired, since when has it been heavier, is there a wish to have children), a blood count with ferritin (checks for anaemia and iron stores) and an ultrasound (shows polyps, fibroids, adenomyosis, the thickness of the uterine lining and cysts). Depending on suspicion, we add targeted tests – for example thyroid function (TSH) or, for heavy bleeding since the first period, a coagulation work-up. Especially in perimenopause or with risk factors, we assess the uterine lining with hysteroscopy, with a tissue sample if needed.

Examinations

• –Detailed conversation & bleeding history
• –Blood count and ferritin
• –Transvaginal ultrasound
• –Targeted lab values (e.g. TSH)
• –Coagulation work-up if suspected
• –Hysteroscopy with biopsy if needed

What do the findings mean?

In many cases, the combination of conversation and ultrasound is already enough to narrow down the cause. A broad, untargeted hormone panel is usually not necessary for this.

Watchful waiting

Treatment is based on the cause, your age, your family planning and your wishes. Whether hormonal or not, we decide together – based on your symptoms, not on a lab value.

Medication

Surgery

Polyps and fibroids can often be removed during a brief hysteroscopy or surgical procedure; depending on findings, this can permanently improve bleeding. For adenomyosis, hormonal treatment – often the hormonal IUD – often helps. If family planning is complete, endometrial ablation or, as a last option, hysterectomy may also be considered.

• –Record bleeding pattern and usage with an app or calendar
• –Have a blood count and ferritin checked if you feel tired or your performance drops
• –If the period is heavy and painful at the same time, specifically check for adenomyosis
• –Always have bleeding after menopause investigated
• –Consider a clotting disorder if there is a bleeding tendency since the first period
• –Keep cancer screening up to date

• Iron infusion→

  Ferritin work-up and iron infusion for bleeding-related anaemia, from CHF 270.

• Painful periods→
• Irregular periods→
• IUD (coil)→
• Bioidentical hormone therapy→

• ↗NICE NG88 – Heavy menstrual bleeding
• ↗ACOG – Heavy Menstrual Bleeding
• ↗FIGO PALM-COEIN classification