Heavy periods (menorrhagia): causes, tests and treatment

The NHS says heavy periods do not always need to be treated, but there are treatments that can help if they are affecting your daily life. NICE says treatment should aim to improve quality of life, not just reduce blood loss, and should take account of your preferences, other conditions and whether fibroids, polyps or other causes are present.

Menorrhagia is the medical term for heavy periods, also called heavy menstrual bleeding. The NHS says they can affect anyone who has periods and may be normal for you. NICE advises that menstrual cycles and blood loss vary naturally and that clinicians should discuss this variation, and that if you feel your bleeding is outside the normal range, care options should be discussed.

The NHS lists these signs that your periods may be heavy.

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

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

• Your periods last more than 7 days.

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

• You bleed through to your clothes or bedding.

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

• You feel tired or short of breath a lot.

Heavy bleeding on its own is common, but certain features suggest a cause needs to be looked for. 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.

NICE says persistent bleeding between periods, pelvic pain or pressure symptoms may suggest a problem in the womb cavity, adenomyosis or fibroids, and that these features affect which tests are offered. The NHS lists feeling tired or short of breath a lot among the signs of heavy periods, and says blood tests may check for iron deficiency anaemia.

The NHS says it can be normal to have heavy periods, and that they can sometimes be heavy at different times, such as when you first start your periods, after pregnancy or approaching the menopause. Often no cause is found.

Sometimes they are caused by conditions affecting the womb or ovaries, such as polycystic ovary syndrome, fibroids, endometriosis, adenomyosis and pelvic inflammatory disease, by conditions that make you bleed more easily such as Von Willebrand disease, or by some medicines and treatments, including some anticoagulant medicines and chemotherapy medicines. Rarely, the NHS says, heavy periods can be a sign of womb cancer.

NICE recommends that the GP takes a history covering the nature of your bleeding, related symptoms and the impact on your life, and examines you if there are other related symptoms. A full blood count is recommended for all women with heavy menstrual bleeding, in parallel with any treatment, and testing for bleeding disorders such as Von Willebrand disease should be considered if you have had heavy periods since they started and have a personal or family history suggesting one.

NICE says to offer outpatient hysteroscopy (a camera passed through the neck of the womb) if your history suggests submucosal fibroids, polyps or abnormalities of the womb lining. A pelvic ultrasound may be offered if the womb can be felt on examination, a pelvic mass is suspected or examination is difficult, and a transvaginal ultrasound if there is significant period pain or a bulky tender womb that suggests adenomyosis. The NHS says you may have blood tests to check for iron deficiency anaemia.

NICE says hormone tests are not needed, and thyroid tests are only needed if there are other signs of thyroid disease. If cancer is suspected, the separate NICE suspected cancer guideline applies.

The NHS says that if treatments from the GP do not work, or the GP thinks a condition may be causing heavy periods, you will usually be referred for tests or to a specialist. Specialist treatments include removing the lining of the womb (endometrial ablation), removing fibroids if they are thought to be causing the heavy periods, and total or partial removal of the womb (hysterectomy).

NICE says endometrial ablation should be followed by effective contraception, because pregnancy should be avoided afterwards, and that a hysterectomy needs a full discussion first, including the effect on fertility, sexual feelings, bladder function and the possible loss of ovarian function. Uterine artery embolisation or myomectomy may allow you to keep your fertility.

NICE says discussions about treatment should cover suitable treatments if you are trying to conceive, and whether you want to keep your fertility or your womb. Tell your GP if you are trying for a baby or may want children in future, so that the options discussed take that into account.

See a GP if your periods are affecting your life or you have other symptoms listed above. The NHS says you should also see a GP if you bleed between periods or after sex.

On the NHS, most women start with a GP, who may offer a blood count and a first treatment without further tests, and refer to a gynaecology clinic if treatment fails, symptoms suggest a structural cause or fibroids are large.

Private gynaecology services can offer ultrasound, hysteroscopy and treatments, usually with quicker access. Whichever route you choose, ask which cause has been looked for, what the plan is if the first treatment does not work, and how any fertility implications will be handled.