Heavy Periods: What Is Normal and When to Investigate

Heavy menstrual bleeding affects a large proportion of women at some point, and a great deal of it goes unmentioned because there is no clear sense of what counts as too much. Many women assume their experience is normal because it is all they have known, and because heavy periods are treated as something to be endured.

They are a medical problem with effective treatments, and they are one of the commonest causes of iron deficiency anaemia in Indian women.

What counts as heavy

Clinically, heavy menstrual bleeding is bleeding that interferes with physical, social, emotional or material quality of life. In practical terms:

• Needing to change a pad or tampon every one to two hours
• Needing double protection
• Bleeding through to clothes or bedding
• Passing clots larger than a rupee coin
• Periods lasting longer than seven days
• Having to plan work, travel or social life around bleeding
• Symptoms of anaemia: fatigue, breathlessness, palpitations, pallor

If any of these apply, it is worth assessment regardless of what anyone else’s periods are like.

What normal looks like

• Cycle length 24 to 38 days
• Bleeding for 4 to 8 days
• Total blood loss around 30-40 ml, which is difficult to measure but corresponds to moderate use of protection
• Some cramping, manageable with ordinary painkillers

Cycles are often irregular in the first two years after periods begin and in the years before menopause.

Common causes

• Fibroids: benign muscle growths in the uterus, extremely common, and a frequent cause of heavy bleeding and pressure symptoms
• Adenomyosis: endometrial tissue growing within the uterine muscle, causing heavy and painful periods
• Polyps: small growths in the uterine lining
• Hormonal imbalance: particularly around puberty and perimenopause, where cycles without ovulation cause irregular heavy bleeding
• Thyroid disorder: both underactive and overactive thyroid affect bleeding
• Bleeding disorders: von Willebrand disease is under-diagnosed and often presents as heavy periods from the very first cycle
• Copper intrauterine device
• Medication: anticoagulants
• Endometrial hyperplasia or, less often, cancer, especially after 45 or with risk factors such as obesity, PCOS or long gaps between periods

What assessment usually involves

• A careful history, including how bleeding affects daily life
• Haemoglobin and ferritin, since iron deficiency is very common and often severe
• Thyroid function
• Pelvic ultrasound, which detects fibroids, adenomyosis and polyps
• Endometrial biopsy where there are risk factors, abnormal thickening, or bleeding after 45
• Coagulation screening where bleeding has been heavy since the first period, or there is a family history

Treatment options

Treatment depends on the cause, on whether pregnancy is desired, and on how much the bleeding affects life.

Non-hormonal:

• Tranexamic acid, taken only on heavy days, reduces blood loss substantially and does not affect the cycle
• NSAIDs such as mefenamic acid reduce both bleeding and pain

Hormonal:

• The levonorgestrel intrauterine system (hormonal IUD) is the most effective medical treatment, reducing bleeding dramatically and often stopping periods altogether. It is also contraceptive and is frequently the first recommendation in guidelines.
• Combined oral contraceptives regulate and lighten bleeding
• Progestogens, oral or injectable

Procedures:

• Endometrial ablation, for women who have completed their family
• Myomectomy, removing fibroids while preserving the uterus
• Uterine artery embolisation for fibroids
• Hysterectomy, definitive but a last resort

Alongside any of these: correcting iron deficiency matters in its own right. Many women feel dramatically better once ferritin is restored, even before the bleeding is fully controlled.

When to see a doctor promptly

• Bleeding that soaks through protection hourly, or with dizziness and breathlessness
• Any bleeding between periods or after intercourse
• Any bleeding after menopause, which always needs investigation
• Periods that have become suddenly and clearly heavier
• Severe pain not controlled by ordinary painkillers
• Heavy bleeding with easy bruising or frequent nosebleeds

This article is general health information. Persistent heavy bleeding should be assessed by a gynaecologist, and post-menopausal bleeding always needs prompt investigation.