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Health condition · Clinically reviewed

Heavy periods, PALM-COEIN causes, medical first, surgery when needed.

Up to one in four women live with heavy periods at some point. Modern UK care starts with a proper work-up and the Mirena coil, and only reaches for surgery when it needs to.

Jump to treatment
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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE NG88, FIGO PALM-COEIN and RCOG standards you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK gynaecology including the Mirena IUS as first-line and minimally invasive alternatives to hysterectomy.

Key facts

Heavy menstrual bleeding at a glance.

The essentials, in plain English: what it is, how it is classified and how it is treated in the UK today.

  • What it is

    Excessive menstrual blood loss - more than 80 mL per cycle, or heavy enough to interfere with physical, social or emotional quality of life.

  • How common

    Affects up to one in four women of reproductive age at some point - and is a leading reason for gynaecology referral in the UK.

  • Classification

    FIGO PALM-COEIN splits causes into structural (polyp, adenomyosis, leiomyoma, malignancy) and non-structural (coagulopathy, ovulatory, endometrial, iatrogenic, not otherwise classified).

  • First-line therapy

    The levonorgestrel intrauterine system (Mirena) is NICE-recommended first-line where structural disease is absent or fibroids are under 3 cm.

  • Iron matters

    Iron-deficiency anaemia is common - ferritin and full blood count should be part of every work-up, and iron replaced early.

  • Definitive options

    Endometrial ablation, uterine artery embolisation, myomectomy and hysterectomy remain effective when medical therapy fails.

Why this guide matters

Common, treatable, and often undertreated.

Heavy periods are still too often normalised. The three points below shape everything else on this page.

  • Cause matters

    PALM-COEIN sorts causes into structural and non-structural. Treatment is chosen accordingly, not by guessing.

  • Medical therapy is now excellent

    The Mirena IUS, tranexamic acid and hormonal options resolve most cases without surgery.

  • Surgery is a choice, not a default

    Ablation, embolisation and myomectomy preserve the uterus. Hysterectomy remains an option when nothing else fits.

How the diagnosis is made

From a first appointment to a clear plan.

The NICE NG88 work-up your GP or gynaecologist will normally follow, in order, so you know what to expect and why.

  1. 01

    Assessing

    Structured menstrual history

    Cycle length, flow volume, flooding, clot size, sanitary product change and the impact on daily life, work and sleep.

  2. 02

    Assessing

    Bleeding tendency and family

    Postpartum haemorrhage, easy bruising, epistaxis or a family history raise suspicion of von Willebrand disease or a platelet disorder.

  3. 03

    Assessing

    Medication and device review

    Anticoagulants, hormonal treatments and the copper IUCD can all contribute - and change the treatment ladder.

  4. 04

    Confirming

    Abdominal and pelvic exam

    Abdominal palpation, speculum and bimanual examination look for uterine size, tenderness and cervical pathology.

  5. 05

    Confirming

    Full blood count and iron studies

    FBC, ferritin and iron studies quantify anaemia; thyroid and coagulation panels are added when the history points that way.

  6. 06

    Confirming

    Transvaginal ultrasound

    A transvaginal ultrasound scan is the first-line imaging test for structural causes - polyps, fibroids and adenomyosis. See /treatments/transvaginal-ultrasound-scan/.

  7. 07

    Sampling

    Endometrial sampling and scope

    Endometrial biopsy and hysteroscopy are offered for women over 45, persistent intermenstrual bleeding or treatment failure. See /treatments/endometrial-biopsy/ and /treatments/hysteroscopy/.

Typical timeline: a first visit to a settled plan in weeks, not months.

Symptoms

What heavy periods actually feel like.

Bleeding is only part of the picture. Anaemia, fatigue, pain and the impact on daily life often matter more than blood-volume estimates.

  • Heavy, prolonged periods

    Soaking through sanitary products every hour or two, or bleeding beyond seven days per cycle.

  • Flooding and large clots

    Sudden gushes of blood, clots larger than a 10p coin and the need for double protection.

  • Iron-deficiency anaemia

    Low haemoglobin and ferritin - the commonest complication and often the first clue on a routine blood test.

  • Fatigue and breathlessness

    Tiredness, breathlessness on exertion, palpitations and reduced exercise tolerance driven by anaemia.

  • Reduced quality of life

    Time off work, restricted social activity, anxiety about accidents and disrupted sleep - the human cost is real.

  • Intermenstrual or postcoital

    Bleeding between periods or after sex points towards a polyp, cervical cause or endometrial pathology.

  • Pelvic pain and pressure

    Cyclical or constant pelvic pain and pressure suggest fibroids, adenomyosis or endometriosis (see /conditions/endometriosis/).

  • Red flag - postmenopausal bleeding

    Any bleeding after the menopause, or persistent bleeding on treatment, needs urgent gynaecology review.

Treatment

How heavy periods are treated in the UK.

The Mirena IUS first for most, non-hormonal and hormonal alternatives next, and radiological or surgical options when medical therapy is not enough.

  • Levonorgestrel IUS (Mirena)

    NICE first-line where there is no structural disease or fibroids are under 3 cm. Thins the endometrium and reduces flow by up to 90%. See /treatments/mirena-coil-insertion/.

  • Tranexamic acid

    Non-hormonal antifibrinolytic taken during menstruation - reduces blood loss by around a third with a strong safety profile.

  • NSAIDs

    Mefenamic acid or ibuprofen taken during bleeding - useful when dysmenorrhoea coexists and hormones are not wanted.

  • Combined oral contraceptive

    Cycle control and reduced flow for women who also want contraception, provided no cardiovascular contraindications.

  • Oral progesterone

    Norethisterone or long-acting depot progestogen where oestrogen is contraindicated or the cycle is anovulatory.

  • GnRH analogue

    Short-term specialist option to shrink fibroids and settle bleeding before surgery, usually with add-back therapy.

  • Uterine artery embolisation

    Radiological alternative to surgery for symptomatic fibroids - preserves the uterus. See /treatments/uterine-artery-embolisation-uae/.

  • Endometrial ablation

    Day-case procedure for women who have completed their family and want to avoid hysterectomy. See /treatments/endometrial-ablation/.

  • Myomectomy

    Surgical removal of fibroids preserving the uterus - laparoscopic, hysteroscopic or robotic depending on location.

  • Hysterectomy

    Definitive treatment when conservative options have failed or are declined. See /treatments/hysterectomy-open/.

  • Iron replacement

    Oral iron for most, intravenous iron for severe anaemia or intolerance. See /treatments/iv-iron-therapy/.

  • Specialist MDT input

    Complex cases benefit from combined gynaecology, haematology and interventional radiology review.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or gynaecologist knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE. Heavy menstrual bleeding: assessment and management (NG88).

  • FIGO. PALM-COEIN classification of causes of abnormal uterine bleeding.

  • Royal College of Obstetricians and Gynaecologists (RCOG). Green-top guidelines on heavy menstrual bleeding and fibroids.

  • British Society for Haematology. Guidelines on the investigation of women with heavy menstrual bleeding for a bleeding disorder.

  • Wellbeing of Women. Patient information on heavy periods, fibroids and endometriosis.

Red flags

When heavy bleeding needs urgent attention.

Most heavy periods can be managed in primary and secondary care. These are the situations that need faster, specialist input.

  • Postmenopausal bleeding

    Any bleeding after 12 months of amenorrhoea needs a two-week-wait gynaecology referral to exclude endometrial cancer. See /conditions/endometrial-cancer/.

  • Persistent intermenstrual bleeding

    Bleeding between periods, especially over 45 or with risk factors, needs endometrial sampling and hysteroscopy.

  • Rapidly enlarging uterus

    A rapidly enlarging pelvic mass or new pain warrants urgent imaging to exclude sarcoma or malignant change.

  • Severe symptomatic anaemia

    Haemoglobin under 80 g/L with breathlessness, chest pain or syncope needs same-day assessment and transfusion consideration.

  • Bleeding on anticoagulation

    Heavy bleeding on warfarin or a DOAC needs joint gynaecology and haematology review, not simply dose reduction.

  • Suspected bleeding disorder

    A personal or family bleeding history, especially since menarche, needs formal haemostasis screening including von Willebrand testing.

  • Pregnancy-related bleeding

    Heavy bleeding in a woman who could be pregnant needs urgent pregnancy testing and early pregnancy assessment.

  • Suspicious cervical appearance

    An abnormal-looking cervix on speculum needs colposcopy regardless of the smear result.

  • Treatment failure

    Persistent heavy bleeding despite three to six months of first-line therapy deserves specialist gynaecology review and imaging.

Living with it

A treatable problem, with a clear ladder.

Four things that make the biggest difference day to day: track your bleeding, treat the anaemia, work up the ladder and ask for a proper conversation.

A quiet reminder

Heavy is not the same as normal.

If your periods are stopping you doing what you want, that alone is a reason to seek help.

  1. 01 Track

    Keep a simple bleeding diary

    Dates, flow, product use and impact on daily life help you and your clinician judge severity and response to treatment.

  2. 02 Iron

    Treat the anaemia early

    Iron replacement often lifts mood, energy and concentration well before the bleeding itself settles.

  3. 03 Ladder

    Work up the ladder

    Start with the least invasive option that fits your priorities - fertility, contraception, hormone tolerance - and escalate if it does not work.

  4. 04 Support

    Ask for a proper conversation

    Heavy periods are common but not trivial. If you are not being taken seriously, ask for a gynaecology referral in writing.

Frequently asked

Everything we get asked about heavy periods.

Quick answers on scans, biopsies, the Mirena coil, non-hormonal options, cancer risk and hysterectomy.

  • What counts as heavy menstrual bleeding?

    Clinically, blood loss over 80 mL per cycle - but in practice, any bleeding heavy enough to interfere with your physical, social or emotional quality of life. Flooding, large clots, needing double protection or bleeding for more than seven days all count.

  • Do I need a scan and a biopsy?

    Most women benefit from a transvaginal ultrasound to look for polyps, fibroids and adenomyosis. Endometrial biopsy and hysteroscopy are added when you are over 45, have persistent intermenstrual bleeding, or have not responded to first-line treatment.

  • Is the Mirena coil really first-line?

    Yes - NICE NG88 recommends the levonorgestrel intrauterine system as first-line medical therapy where there is no structural cause or fibroids are under 3 cm. It reduces menstrual blood loss by up to 90% and also provides contraception.

  • What if I do not want hormones?

    Tranexamic acid and NSAIDs are effective non-hormonal options taken only during bleeding. For structural causes, uterine artery embolisation, myomectomy or endometrial ablation avoid systemic hormones altogether.

  • Can heavy periods be a sign of cancer?

    Rarely, but endometrial cancer must be excluded in women over 45, with persistent intermenstrual bleeding, or with any postmenopausal bleeding. Ultrasound and endometrial sampling are the standard checks.

  • Is hysterectomy still needed?

    Less often than in the past. Modern first-line medical therapy, uterine artery embolisation, ablation and myomectomy resolve most cases. Hysterectomy remains a good definitive option when conservative treatment has failed or is declined.

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