Heavy Menstrual Bleeding (Menorrhagia)

What is heavy menstrual bleeding (menorrhagia)?

Heavy menstrual bleeding (formerly called menorrhagia) is when your periods are extremely heavy or prolonged. "Heavy" means that your period lasts longer than seven days or that you lose more blood than is typical during menstruation. You may bleed so much that you have to change your tampon or pad every hour for several hours back-to-back. You may pass blood clots the size of a quarter or even larger.

Menstrual bleeding that's so heavy that it interferes with your daily life is never normal. Your provider can recommend treatments to manage heavy blood flow.

How common are heavy periods?

Heavy period bleeding is common, affecting anywhere from 27% to 54% of people who menstruate.

Is heavy menstrual bleeding serious?

Heavy menstrual bleeding can be serious if you lose so much blood that you show signs of anemia. Anemia is a condition arising from having too little iron in your body. Anemia can be life-threatening without treatment.

Also, some of the conditions that can cause heavy period bleeding, like cancer, require early medical intervention. Speak with your healthcare provider to discuss any risks related to your period bleeding.

What are the signs and symptoms of heavy menstrual bleeding?

Signs of heavy menstrual bleeding include:

• Abdominal pain.
• Periods lasting longer than seven days.
• Passing blood clots that are the size of a quarter or bigger. The blood may appear red, pink, brown, or even rust-like.
• Bleeding through 1 or more tampons or pads each hour for more than two consecutive hours.
• Losing more than 80 milliliters of blood during your period instead of what is typical, 35-40 milliliters.
• Anemia symptoms, like feeling exhausted, tired or short of breath.

With anemia, you may also notice signs of a condition called pica. Pica symptoms include hair loss, pale skin, and the urge to eat non-food items (paper, hair, dirt, etc.). See your provider if have these symptoms.

How do you know if you have heavy menstrual bleeding?

Heavy menstrual bleeding interferes with your quality of life. Many people with heavy periods assume that periods are supposed to be inconvenient and uncomfortable. They may have watched people in their families live with heavy periods without seeking care and followed their example. But periods should never cause you to restrict activities or accept inconvenience.

During your period, you should be able to:

• Wear a standard pad or tampon every three to four hours without changing it.
• Wear a single menstrual product without having to double-up (wearing two pads or two tampons at the same time) at any point.
• Leave your home without having to pack extra bags of pads or clothing changes.
• Live your life as usual, without missing work, avoiding going out in public, or skipping activities you enjoy.

If your periods are disrupting your life, it's time to see your provider.

How long does heavy menstrual bleeding last?

Heavy menstrual bleeding is a period that lasts longer than seven days. How long you bleed depends on what's causing your bleeding.

What causes heavy menstrual bleeding?

Heavy menstrual bleeding can have many causes, ranging from hormone-related issues to various medical conditions and even stress.

Hormone imbalances

The hormones that your body produces, like estrogen and progesterone, help regulate your menstrual cycle, including how heavy your periods are. Having a condition that causes your hormones to become imbalanced can lead to heavy period bleeding. Causes include:

• Anovulation.
• Thyroid disease.
• Polycystic ovary syndrome (PCOS).

Weighing more than your ideal body weight can interfere with your body's hormone production and lead to heavy menstrual bleeding, too.

Non-cancerous growths in your uterus

Benign growths in your uterus and conditions that cause cells in your uterus to grow improperly can cause heavy menstrual bleeding, too. Causes include:

• Polyps.
• Fibroids.
• Adenomyosis.

Cancerous growths in your uterus

Conditions that increase your risk of getting cancer, including endometrial hyperplasia, as well as cancers that affect your reproductive system, can cause heavy menstrual bleeding. These include:

• Uterine cancer.
• Cervical cancer.

Infection

Infections, including sexually transmitted infections (STIs) can cause heavy bleeding. These include:

• Trichomoniasis.
• Gonorrhea.
• Chlamydia.
• Chronic endometritis.

Pregnancy complications

Heavy bleeding can be a warning sign of pregnancy complications, such as:

• Miscarriage.
• Ectopic pregnancy.
• C-Section niche. High numbers of cesarean sections can lead to a scar that creates a pocket in your uterus. That pocket can collect blood, which you can later bleed.

Other medical conditions

Heavy menstrual bleeding is a symptom associated with various conditions, including bleeding disorders and non-bleeding disorders. Some common medical conditions that can lead to heavy bleeding are:

• Von Willebrand disease.
• Liver disease.
• Kidney disease.
• Pelvic inflammatory disease (PID).
• Leukemia or platelet disorders.

Medications

Certain medicines can cause heavy menstrual bleeding, too. These include:

• Blood thinners and aspirin.
• Hormone replacement therapy.
• Tamoxifen (breast cancer drug).
• Intrauterine devices (IUDs).
• Birth control pills and injectables (NuvaRing®, Depo-Provera®, Implanon®).

Failing to remove contraceptive devices when needed can also cause abnormal uterine bleeding.

How is heavy menstrual bleeding diagnosed?

Your healthcare provider will ask a series of questions about your medical history and menstrual cycle to diagnose heavy menstrual bleeding.

Your provider may ask about:

• Your age when you got your first period.
• The number of days your period lasts.
• The number of days your period is heavy.
• Family members with a history of heavy menstrual bleeding.
• Your pregnancy history and current birth control methods.
• Current medications you're taking, including over-the-counter ones.

Come prepared to talk about your quality of life, too. Your provider needs to know if you've been doubling up on menstrual products, avoiding activities or placing restrictions on your life in any way because of heavy periods.

What tests will be done to diagnose heavy menstrual bleeding?

Your provider will do a physical exam and a pelvic exam. Many non-invasive procedures are available that can help your provider diagnose what's causing your bleeding, such as:

• A sonohysterogram (saline-infusion sonography) to check for problems in the lining of your uterus. A sonohysterogram allows your provider to see the inside of your uterus while it's filled with saline. It offers higher accuracy and sensitivity when detecting abnormalities in your uterine cavity than an ultrasound without saline.
• A hysteroscopy to check for polyps, fibroids or other irregular tissue in your uterus. Hysteroscopy allows your provider to inspect your vagina, cervix and uterus. Your provider can remove growths that may be causing your bleeding, like fibroids or polyps, during a hysteroscopy.

You may have other tests, depending on your age and how severe your symptoms are. Other tests may include:

• A blood test to check for signs of anemia, clotting issues, or thyroid disease.
• A Pap smear to study cells from your cervix for changes that may indicate cancer.
• An endometrial biopsy to check uterine tissue for cancer cells or other irregularities.
• Transvaginal ultrasound to check the appearance of the organs and tissues in your pelvis.
• Magnetic resonance imaging (MRI) to check for abnormal structures inside your uterus when an ultrasound doesn't provide enough information.
• A cervical culture to test for infection, as indicated by your medical history and the results of your physical exam.

How is heavy menstrual bleeding treated?

Treatment depends on what's causing your bleeding, how severe your bleeding is, your health, age and medical history. Also, treatment depends on your response to certain medicines and your preferences. For instance, you may not want to have a period at all, or you may want to reduce your bleeding. In addition, your plans to get pregnant will affect your treatment options.

Talk with your provider about your health concerns and your goals for treatment.

Medications used to treat heavy menstrual bleeding

• Iron supplements improve your iron stores.
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs) like Ibuprofen® or Aspirin® can ease your cramps and reduce your bleeding.
• Birth control (pills, vaginal ring, patch, IUDs) may help make your periods more regular and lighten your blood flow.
• Hormone therapy (HT) can help balance the amount of estrogen and progesterone in your body so that your menstrual flow isn't as heavy. HT is often recommended for heavy menstrual bleeding associated with perimenopause but comes with risks that you should discuss with your provider.
• Gonadotropin-releasing hormone (GnRH) agonists can temporarily stop or reduce bleeding by preventing ovulation.
• Gonadotropin-releasing hormone (GnRH) antagonists (elagolix®) can manage heavy period bleeding related to fibroids.
• Desmopressin nasal spray can stop bleeding associated with von Willebrand disease by helping your blood clot.
• Antifibrinolytic medicines, like tranexamic acid, prevent clots from breaking down and causing excessive bleeding.

Procedures used to treat heavy period bleeding

Hysteroscopy is often used to diagnose and treat heavy period bleeding. With an operative hysteroscopy, your provider inserts a thin, lighted tube into your vagina that allows them to inspect your uterine cavity. The hysteroscope acts as a precise surgical instrument, too, and can help your provider remove any growths that may be causing your bleeding.

Other procedures include:

• Myomectomy. A procedure that removes fibroids from your uterus.
• Uterine artery embolization (UAE). A procedure that restricts the blood flow from fibroids and tumors.
• Endometrial ablation. A procedure that destroys all or part of the lining of your uterus. Often, your provider will recommend sterilization afterward. Endometrial ablation puts a fetus at risk of serious complications if you become pregnant.
• Hysterectomy. Surgery that removes your uterus and prevents you from having periods or getting pregnant.

How is heavy period bleeding managed?

Treatment may begin with medication and then progress to minor procedures and surgical options. Speak with your provider to decide which options work best for your health and your goals for treatment.

How is heavy period bleeding prevented?

You can't prevent all causes of heavy period bleeding. But talking with your healthcare provider to get diagnosed and treated can help you manage your bleeding so that it doesn't interfere with your quality of life.

What is the prognosis for living with heavy menstrual bleeding?

Left untreated, heavy periods can interfere with your life. In addition, heavy menstrual bleeding can cause anemia and leave you feeling tired and weak. Other health problems can also arise if you don't get help. With proper treatment and assistance from your provider, you can manage heavy periods without compromising your well-being.

When do you call your healthcare provider if you suspect heavy period bleeding?

You should call your provider if you're experiencing the symptoms of heavy menstrual bleeding or anemia, or if your period bleeding has become abnormal. Tracking your periods using a calendar or app can help you identify if your periods are heavier and longer-lasting than usual. Share these notes with your provider.

You should also schedule an appointment if you notice that you're having to double-up on menstrual products or if you're skipping activities you enjoy because of heavy bleeding.

Can heavy menstrual bleeding be life-threatening?

Heavy periods aren’t usually life-threatening, but they can be if you lose too much blood. Bleeding through two or more tampons or pads each hour for two hours in a row is a sign that you should see your provider or seek emergency care immediately.

A note from Cleveland Clinic

Just because heavy periods are common doesn't mean that you have to learn to live with the discomfort they cause. If managing your blood flow is getting in the way of your emotional and physical well-being, speak with your provider. They can provide a care path that will provide relief.