Gynecological Exams / Tests
Heavy Menstrual Bleeding
What counts as heavy
The old definition was more than eighty millilitres. Women do not measure this at home. The useful questions are these: does she get up at night, is a double pad not enough, are clots bigger than the palm of a hand, does the bleeding last longer than a week. If any of these is true, the amount is heavy. Tiredness, shortness of breath and hair loss are the language of iron deficiency. No one should say “you'll get used to it” before a blood count is done.
Regular but very heavy bleeding is not the same condition as irregular bleeding that spills into the days in between. The second is covered on the menometrorrhagia page. This page is about bleeding where the timing is roughly normal but the amount has increased. The two can come together. Then both are recorded.
How can you tell if menstrual bleeding is heavy? (animation)
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- In a normal period, the pad becomes moderately stained over several hours.
- The pad fills completely every hour for several hours in a row.
- One pad is not enough; two pads are worn together.
- You get up at night to change the pad.
- The clot is larger than the coin next to it.
- Bleeding lasts longer than seven days.
- If any of these signs is present, see a doctor.
This is an illustrative animation. The criteria are based on the CDC's description of heavy menstrual bleeding; the number of pads and the amount of staining in a normal period vary from person to person.
List of causes
| FIGO heading | How it shows in heavy periods |
|---|---|
| Polyp | Spotting between periods and clots; if the stalk is inside, ultrasound may not be enough |
| Adenomyosis | Painful, heavier bleeding; the womb is tender |
| Fibroid | Especially the submucosal type that faces the cavity |
| Cancer and precancer | After forty-five, not responding to treatment, after menopause |
| Clotting disorder | Heavy bleeding since the first period, gums, nose |
| Cycles without ovulation | Irregular build-up in teenagers and around menopause |
| Medication and coil | A copper coil can increase the amount; a hormonal one reduces it |
A copper intrauterine device can increase bleeding. A hormonal device reduces it in most women. The two are not lumped together as “the coil makes you bleed”. Blood thinners and some hormones change the amount. The cause is not settled without asking for a list of medications.
Age changes the picture
In the early years, heavy bleeding comes with clotting disorders and cycles without ovulation. Von Willebrand disease comes to mind in a girl who has had to change pads every hour since her first period. After forty, fibroids, adenomyosis and thickening of the womb lining come to the fore. Bleeding after menopause is not the topic of this page. That spotting, however light, is not dismissed without checking inside the womb.
The wish to become pregnant changes the treatment. Before the womb is removed, this wish is asked about. Not every fibroid gets surgery just because there is no wish for pregnancy.
What is checked at the examination
A pregnancy test, a blood count and ferritin come first. NICE says a cause should be looked for when bleeding harms quality of life. A speculum shows a polyp and changes on the cervix. Transvaginal ultrasound reads fibroids, signs of adenomyosis and the lining of the womb. If the lining is thick and the bleeding has gone on, a biopsy or hysteroscopy is discussed. Hysteroscopy is a separate route for a polyp on a stalk that ultrasound misses.
Thyroid and prolactin are not ordered as a routine panel for every woman. They are requested if there is hair loss, feeling cold or milk from the breast. If there is a history of clotting problems, haematology is discussed.
Treatment depends on the cause
Iron is started even before the bleeding stops. Tranexamic acid reduces the amount on bleeding days; it is not used if pregnancy is suspected. Ibuprofen cuts both the pain and the amount in some women. If there is a stomach ulcer, the choice changes. The pill and progestins make periods lighter if there is no wish to become pregnant. A hormonal intrauterine device clearly reduces the amount in suitable women. It may cause spotting in the first months.
Submucosal fibroids and polyps do not shrink with medication. Removal is discussed. In adenomyosis, removing the womb is an option if the wish for children is over and medication has not been enough. Ablation is not for every woman. It is not done unless the sample from the womb lining is clear.
When to go the same day
If a pad fills in twenty to thirty minutes, or there is fainting, shortness of breath or a suspected pregnancy, do not wait. This is not a case for a next-day appointment at the practice. An ectopic pregnancy or a miscarriage can look like a heavy period.
Our approach at SoftCare
Heavy periods are not a continuation of the frequent periods page. First, pregnancy is ruled out and a blood count is done. Ultrasound tells apart fibroids and signs of adenomyosis. A copper coil can increase the amount; a hormonal device can reduce it. After forty-five, a sample from the womb lining is discussed when bleeding does not respond. Iron is not postponed until a plan for the bleeding is in place. Surgery is not recommended without asking about the wish to become pregnant.
Frequently asked questions
How much bleeding is too much?
A pad every hour, large clots, flow lasting more than a week or an amount that disrupts life.
Could I be pregnant?
If a late period and bleeding come together, a test is checked first.
Is a fibroid always to blame?
No. The type that faces the cavity increases the amount more.
Isn't ultrasound enough?
A polyp's stalk can be missed. Hysteroscopy is discussed separately.
Do I need iron?
Yes, if there is anaemia or low ferritin. It is started even while the bleeding continues.
Does a hormonal coil reduce bleeding?
In most women, yes. There may be spotting in the first months.
Does a copper coil cause bleeding?
It can increase the amount. It is not the same as a hormonal device.
Does every heavy bleed mean surgery?
No. Your wishes, the cause and the response to medication decide.
Listing these sources does not mean SoftCare wrote those texts.
References
- Heavy menstrual bleeding: assessment and management (NICE guideline NG88). National Institute for Health and Care Excellence (NICE), 2018.
- The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Munro MG, Critchley HOD, Fraser IS. International Journal of Gynecology & Obstetrics 143(3), 2018.
- Committee Opinion No. 557: Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women. American College of Obstetricians and Gynecologists (ACOG). Obstetrics & Gynecology 121(4), 2013.
- Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. American College of Obstetricians and Gynecologists (ACOG). Obstetrics & Gynecology 120(1), 2012.
- Committee Opinion No. 785: Screening and Management of Bleeding Disorders in Adolescents With Heavy Menstrual Bleeding. American College of Obstetricians and Gynecologists (ACOG). Obstetrics & Gynecology 134(3), 2019.
Medically reviewed by Op. Dr. Şükrü Sanus, Obstetrician & Gynecologist · Last medical review: