When are periods too heavy, and what can be done?

Heavy means it disrupts your life, not that it passes a set amount

Many women cannot tell whether their periods are heavy, particularly if they have been this way since the teenage years. NICE guidance does not rely on measuring blood loss; it asks whether the bleeding interferes with your quality of life.

Signs that often go with heavy periods:

• Flooding through a pad or tampon onto clothes or bedding.
• Changing protection every hour or two, including at night, or using a pad and a tampon together.
• Passing clots larger than a coin.
• Bleeding for longer than usual, or for more than about a week.
• Planning work, travel or social life around the heaviest days.
• Tiredness or breathlessness that can point to low iron (anaemia).

Heavy periods are common and worth mentioning to a doctor. On their own, they do not mean something serious is wrong.

Often no cause is found; sometimes the womb, thyroid or clotting explains it

In many women, examination and tests find nothing abnormal. The bleeding is still real and treatable.

When a cause is found, it is usually in the womb. Fibroids are non-cancerous growths in the womb muscle. Polyps are small overgrowths of the lining, usually non-cancerous. In adenomyosis, tissue like the lining grows into the muscle wall, often making periods painful as well as heavy.

Less often the cause lies elsewhere: an underactive thyroid, or an inherited bleeding tendency such as von Willebrand disease. A bleeding disorder is more likely if periods have been heavy since they began, or if you or close relatives bruise easily or bleed heavily after dental work or surgery. Blood-thinning medicines and the copper coil can also make periods heavier.

Bleeding after the menopause, between periods or after sex is different from heavy periods. It is rarely an emergency, but it should be checked by a doctor promptly, as occasionally it comes from changes in the lining of the womb or the cervix that need treatment.

What an assessment for heavy periods may include

Much of the assessment is conversation: how long your periods last, how often you change protection, clots, pain, bleeding between periods or after sex, your medicines, contraception and pregnancy plans. Notes kept over two or three cycles help.

NICE recommends a full blood count for every woman with heavy periods, to check for anaemia, which is treated with iron. Thyroid or clotting tests are added when your history suggests them; hormone tests are not usually needed.

An examination, sometimes including an internal one, is usual if there is pain, pressure or bleeding between periods, and before a hormonal coil is fitted; you can ask for a chaperone. An ultrasound scan follows if fibroids or adenomyosis are suspected, and a hysteroscopy (a thin camera passed through the cervix) if polyps or changes in the lining are possible. When nothing points to a structural problem, NICE supports starting treatment without a scan.

Medicines usually come before procedures, and every option has trade-offs

The choice depends on what the assessment finds, whether you need contraception or hope for a pregnancy, your health and your preferences. When no cause is found, fibroids are small or adenomyosis is suspected, NICE suggests considering the hormonal coil ahead of other options.

• Hormonal coil: releases a progestogen inside the womb, thinning the lining, and prevents pregnancy. Irregular spotting is common in the months after fitting, and some women notice breast tenderness or acne. Fitting can be uncomfortable; occasionally the coil comes out, and rarely it passes through the wall of the womb.
• Tranexamic acid: tablets taken on the heavy days that help the blood to clot. It is not a contraceptive, can upset the stomach and may not suit women who have had blood clots.
• Anti-inflammatory painkillers such as mefenamic acid: these ease bleeding and period pain, but can irritate the stomach and may not suit women with stomach ulcers, kidney problems or some types of asthma.
• Combined pill, patch or ring: these can make bleeds lighter and more regular, but slightly raise the risk of blood clots and do not suit everyone, for example women who have migraine with aura.
• Progestogen tablets: these can reduce bleeding, but may cause bloating, mood changes or spotting.

Procedures are considered when medicines have not helped or do not suit you, or when larger fibroids are the cause. Endometrial ablation destroys the womb lining; it is meant for women whose families are complete, as a pregnancy afterwards carries serious risks. Fibroids can be removed, or their blood supply blocked. Hysterectomy ends periods and fertility, and carries the risks of any major operation, including bleeding, infection, blood clots and injury to nearby organs.

If an option does not help or its side effects are hard to live with, another can usually be tried.