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What are heavy periods?

A woman may be described as having ‘heavy periods’ if she has excessive menstrual bleeding over several menstrual cycles in a row that interfere with her physical, emotional and social quality of life. The amount of blood that is lost during a woman’s period varies a lot from one person to another, making it difficult to give a general description of heavy periods. The amount of blood lost can also vary at different times in a woman’s life and if she has had surgery or takes medication.

What are the signs and symptoms of heavy periods?

A woman with heavy periods can experience one or more of the signs and symptoms described below:

Blood loss with your periods that requires you to change your sanitary wear (pads or tampons) frequently (every one to two hours or more), especially when you are using large sanitary pads, super plus tampons or night time towels.

Having to wear two pads or a pad and a tampon at the same time to control the flow.

Periods that last more than eight days.

Passing blood clots during periods.

Feeling tired and drained during and just after your period.

A diagnosis of anaemia.

‘Flooding’– when bleeding is so heavy that seating or sheets become soaked with blood while sitting or lying down.

Feeling that your periods are interfering in your everyday life.

What causes heavy periods?

In women from 25 to 40 years of age, over three-quarters (80%) with heavy periods have no underlying cause. However, the conditions listed below can sometimes be the cause of heavy periods:

Endometrial polyps or uterine fibroids – Benign (non-cancerous) growths in the womb (uterus). Fibroids are usually bigger than polyps.

Endometriosis – The cells that line the inside of the womb are called the endometrium. Endometriosis is when these cells are present outside the womb, such as on the ovaries or fallopian tubes. This may cause heavy periods associated with

period pain, painful sex and chronic pelvic pain.

Intra-uterine device (IUD) – The coil inserted into the womb as a method of contraception can increase blood loss during periods by almost half (40 to 50%).

Chronic pelvic inflammatory disease (PID) – An ongoing infection in the pelvic area of the body.

Polycystic ovarian syndrome (PCOS) – A condition of having multiple cysts (small, usually non-cancerous lumps) in the ovaries, causing heavy, irregular periods, and sometimes an increase in weight and facial hair.

Endometrial hyperplasia – When the endometrium is thicker than usual in response to an excess of oestrogen.

Coagulation disorders – Blood clotting disorders, for example, von Willebrand disease.

Hypothyroidism – An under-active thyroid gland. Some other disease conditions, such as liver or renal disease.

Medications – There are some medications (such as warfarin) which are used to thin blood, and which can make periods heavier.

Cancer of the lining of the womb – This is very rare, but can also cause heavy periods.

Do I need any tests to confirm the diagnosis?

There are a number of tests that can be carried out to find the cause of heavy periods. These are normally taken after you have had a full assessment with a member of your healthcare team.

1. Medical history

Your doctor or specialist will ask some questions about your concerns, medical history, the nature of your bleeding and any other related symptoms that you may have. You will be asked:

2. Pelvic examination

Your doctor or specialist may ask to perform a pelvic examination for a number of reasons, such as to check for an enlarged womb, which may indicate fibroids. Your clinician must obtain your consent and give you the option of having someone with you (a chaperone) while the examination is being performed. A pelvic examination includes the following:

Vulva examination – This involves an inspection of your external sexual organs for evidence of external bleeding and signs of infection.

Speculum examination of the vagina and cervix – This uses a device called a speculum (the same instrument that is used when you go for a cervical screening test), which is gently inserted into the vagina to enable the clinician to inspect your vagina and the cervix (neck of the womb) for evidence of any abnormal changes.

Bimanual palpation – An internal examination of your vagina, which involves the clinician inserting two fingers into the vagina while using the other hand to gently press on your abdomen. This helps to assess whether your womb or ovaries are tender or enlarged, and to identify the presence of conditions such as fibroids.

3. Blood test

Your doctor or specialist  may do one or a number of the following blood tests:

Full blood count (FBC) – To detect iron deficiency anaemia, which is often caused by loss of iron following prolonged heavy periods. If your blood test shows that you have iron deficiency anaemia, a course of iron medicine will be prescribed for you.

Thyroid function test (TFT) – This test may be used to detect whether or not a thyroid hormonal imbalance may be the reason for your heavy periods.

Clotting screen – This may be done to determine whether a problem with your blood clotting mechanism may be responsible for your heavy periods.

FSH/LH – These are hormones that control the menstrual cycles. Their levels in the blood may be checked if there has been some irregular bleeding.

The results of your blood test are usually available within one week. You will be given a date and a telephone number/email address to contact for the results of your blood test.

4. Pelvic scan

This is an examination of the womb using ultrasound waves to create images of structures in the pelvis. It is a painless investigation and can be done either via the abdomen (transabdominal scan) or via the vagina (trans-vaginal scan). The trans-vaginal scan is usually preferred as it produces better image of the womb.

5. Endometrial biopsy

If a pelvic scan shows that the endometrium is thicker than normal, an endometrial biopsy (a small sample of the endometrium) can be taken for laboratory tests to find out the reason for the thickness. The biopsy involves inserting a straw-like tube via the vagina into the womb to obtain the sample. This procedure may cause you to have a crampy pain (like a period pain) while it is being taken, and a small amount of spotting after the procedure. Endometrial biopsy can be done on its own or after a hysteroscopy.

6. Hysteroscopy

A hysteroscopy is a procedure which uses a fine telescope, called a hysteroscope, to examine the lining and shape of the womb to look for fibroids, polyps and an overgrowth of the lining (hyperplasia) of the womb.

What treatments are available?

The treatment that is recommended for you will depend on your medical history and on the results of your tests and investigations. If a reason for the bleeding (such as a fibroid) is found, then this will be treated. Sometimes, no cause for heavy periods can be found. In these cases, heavy periods can be treated by drugs or by surgery with the aim of decreasing the amount of bleeding. Some treatments may stop your periods completely and others may have an impact on your fertility. Your doctor will discuss any proposed treatments with you in detail. The following treatments may be recommended:

Drug treatments

The drug treatments below are listed in the order they will be recommended. If the first

treatment is unsuitable for you; we will try the next treatment on the list. All the drug treatments can be used for as long as you need them.

1. Levonorgestrel intrauterine system (Mirena IUS) – This is a small plastic device that is inserted into the womb and slowly releases a small amount of the progesterone hormone. The device is implanted during an outpatient appointment at the hospital. The Mirena IUS can reduce menstrual bleeding by up to 90%, and acts as a contraceptive as well. However, it can cause irregular bleeding when first inserted.

2. Tranexamic acid tablets – These pills can reduce the heaviness of period bleeding by almost half (40 to 50%). They work by reducing the breakdown of blood clots in the womb. Tablets are taken for three to five days during each period. Side effects are usually minor and may include stomach upset. These tablets are not a contraceptive and can be taken by women who wish to conceive.

3. Non-steroidal anti-inflammatory drugs (NSAIDs) – These come in various types, with mefenamic acid being the most commonly prescribed. NSAIDS can reduce period bleeding by 20 to 50%. They work by reducing the body’s production of a hormone-like substance, called prostaglandin, which is linked to heavy periods. NSAIDs are also painkillers and can help reduce period pain. Common side effects include indigestion and diarrhoea. These tablets are not a contraceptive and can be taken by women who wish to conceive.

4. Combined oral contraceptive pill (COC) – This reduces period bleeding by almost a third (30%) in some women.

5. Long-acting progesterone contraceptives – This includes the contraceptive injection and the contraceptive implant. They are helpful in treating heavy periods, as most women do not have any period bleeding after a few months. However, some women can have prolonged bleeding.

6. Oral progesterone – This is taken two to three times a day from days five to 26 of your menstrual cycle, counting the first day of your period as day one. It works by preventing the endometrium from growing quickly. Some common, short-term side effects of oral progesterone include weight gain, bloating, breast tenderness, and headaches. Oral progesterone is not licensed as a contraceptive, but may have some effect on preventing conception. This means that it may not be a suitable option for women looking to conceive. It also means that additional methods of contraception should be used to protect against pregnancy.

7. Gonadorelin analogues – These medications work by putting you into a temporary induced menopause, and therefore stopping the menstrual cycle. They are not suitable for long-term use, as there are menopausal side effects and they can also lead to thinning of the bones (osteoporosis).

Surgical treatments

You doctor or specialist will explain what surgical treatment will entail. Surgical treatments are only considered when medical treatments are not effective, and should only be undertaken when there is no desire for a future pregnancy. Below is a list of the surgical options available.

1. Endometrial ablation – This involves the destruction of the endometrium. To do this, an Instrument is passed through the vagina into the womb. There are different techniques available. The aim is to prevent the endometrium from thickening.

2. Hysterectomy – The surgical removal of the womb. Hysterectomy is not commonly used to treat heavy periods.

3. If you have fibroids there are other surgical treatments, such as fibroid removal,myomectomy or uterine artery embolization.

What happens if I do not get treatment?

Not treating heavy periods is an option if there is no serious reason for your heavy bleeding and your periods do not interfere too much with your normal life. However, if the cause of your heavy period is not treated, continued heavy periods over a length of time could lead to you having a very low blood iron level (anaemia) which can lead to dizziness, breathlessness, tiredness and occasionally sudden collapse that may require a blood transfusion.

Is there anything I can do to help?

Whether or not you decide to have surgical or medical treatment, having a balanced diet that is low in fat and contains food items that have a high iron content, such as red meat, spinach and fortified breakfast cereal, will help ensure your blood iron level is within normal limits. Other lifestyle habits, such as having regular exercise and avoiding smoking, will help to keep you healthy.