Heavy periods: causes, treatment and when to see a GP

The NHS says you may have heavy periods if you:

• need to change your pad or tampon every 1 to 2 hours, or empty your menstrual cup more often than recommended

• need to use 2 types of period product together, such as a pad and a tampon

• have periods lasting more than 7 days

• pass blood clots larger than about 2.5cm (the size of a 10p coin)

• bleed through to your clothes or bedding

• avoid daily activities such as exercise, or take time off work because of your periods

• feel tired or short of breath a lot

The NHS periods page says that during a period you lose about 20 to 90ml (about 1 to 5 tablespoons) of blood, although some women bleed more heavily. A period usually lasts about 5 days and can last between 2 and 7 days, with bleeding heaviest in the first 2 days.

NICE says that the range and natural variability in menstrual cycles and blood loss should be taken into account, and that the aim of any intervention is to improve quality of life rather than to focus on the measured volume of blood loss. In practice, if your periods are heavy enough to affect your life, it is worth raising with a GP.

The NHS says it can be normal to have heavy periods, and that they can sometimes be heavy at particular times, such as when you first start your periods, after pregnancy, or approaching menopause.

It lists the following possible causes:

• Conditions affecting the womb or ovaries, such as polyendocrine metabolic ovarian syndrome (PMOS), fibroids, endometriosis, adenomyosis and pelvic inflammatory disease.

• Conditions that make you bleed more easily, such as von Willebrand disease.

• Some medicines and treatments, including some anticoagulant medicines and chemotherapy medicines.

• Rarely, womb cancer.

The NHS says heavy periods do not always need treatment, but there are treatments that can help if they are affecting your daily life. Treatments from a GP include some types of contraception, such as an intrauterine system (IUS) or the combined contraceptive pill, medicine to reduce bleeding such as tranexamic acid, and prescription-only anti-inflammatory painkillers such as mefenamic acid or naproxen.

NICE guideline NG88 adds detail on how options are chosen. It suggests considering a levonorgestrel-releasing intrauterine system (LNG-IUS) as the first treatment where no cause is found, where fibroids are smaller than 3cm and not distorting the womb cavity, or where adenomyosis is suspected or diagnosed. If an LNG-IUS is declined or unsuitable, it lists tranexamic acid, NSAIDs, combined hormonal contraception and cyclical oral progestogens.

NICE says women who are offered an LNG-IUS should be told to expect changes in bleeding pattern, particularly in the first few cycles and sometimes for longer than 6 months, and that it is advisable to wait at least 6 cycles to see the benefit.

The NHS says that if treatments do not work or a GP thinks a condition may be causing heavy periods, you will usually be referred for tests or to see a specialist, and you may have blood tests to check for underlying conditions such as iron deficiency anaemia.

NICE recommends a full blood count for all women with heavy menstrual bleeding. It says testing for a coagulation disorder such as von Willebrand disease should be considered if you have had heavy bleeding since your periods started and have a personal or family history suggesting one. It advises against routine female hormone testing, and against thyroid testing unless there are other signs of thyroid disease.

Where the history suggests fibroids, polyps or changes in the lining of the womb, NICE recommends outpatient hysteroscopy, which looks inside the womb with a miniature telescope passed through the cervix. A pelvic ultrasound is offered if the womb can be felt on examination or a pelvic mass is suspected, and a transvaginal ultrasound if adenomyosis is suspected.

The NHS says heavy periods and pregnancy are very common causes of iron deficiency anaemia. Symptoms include tiredness and lack of energy, shortness of breath, noticeable heartbeats, paler than usual skin and headaches. A GP can check with a full blood count. The NHS says the cause, such as heavy periods, will be treated, and iron tablets are taken for about 6 months.

For diet, the NHS suggests eating more dark-green leafy vegetables, fortified cereals and bread, meat, dried fruit and pulses, and eating and drinking less tea, coffee, milk and dairy foods, and foods high in phytic acid such as wholegrain cereals, which can make it harder to absorb iron. It says drinking orange juice after an iron tablet may help absorption.

Diet alone is not described as a treatment for heavy bleeding itself. If you are feeling exhausted or breathless, ask for a blood test rather than self-treating with supplements.

Heavy bleeding in pregnancy is different from a heavy period and needs prompt advice. The NHS defines heavy bleeding in pregnancy as red blood that soaks through a period pad, possibly with clots or lumps. It says to call 999 if you are pregnant and bleeding and you have severe tummy pain, shoulder pain, feel sick, faint or dizzy, or the bleeding is heavy and soaks a pad soon after you put it on.

For light bleeding or spotting with no pain or mild pain, the NHS says to call your maternity unit or an early pregnancy unit if you are under 20 weeks, or NHS 111 if you cannot reach one. It lists possible causes including implantation bleeding, miscarriage, ectopic pregnancy and problems with the placenta.

The NHS says to see a GP if heavy periods are affecting your life, you have had them for some time, you have severe pain during your periods, you bleed between periods or after sex, or you have heavy periods and other symptoms such as pain when peeing, pooing or having sex.

Rarely, heavy periods can be a sign of womb cancer, so a change from your usual pattern, bleeding between periods or after sex should always be reported.

If you feel faint, have a racing heart, or are soaking through products every hour or so with dizziness, seek urgent help through NHS 111 or, if severe, 999.

Most heavy periods are managed by a GP with medicines or an IUS. If these do not help, a GP refers you to gynaecology for scans, hysteroscopy or surgery. Some people choose a private gynaecology consultation for faster scans or procedures. In either route, NICE guidance sets out the same range of options, and outcomes and test results should be recorded with your GP.