Fact sheet: Heavy periods (hypermenorrhea)

It can be hard to assess what is “normal” with your monthly period. Most women actually do not shed very much blood when they menstruate. They change their tampon or pad usually only once every few hours. So if your periods are so heavy that you have to go to the toilet very often and you have to think a lot about whether you might soak through your clothes, that is much more than normal. And if the blood loss is interfering with your everyday life and dragging you down, then you are one of the women for whom heavy menstrual bleeding is a real problem. About 1 in 20 women (5%) are affected by what is called hypermenorrhea.

Many women are not bothered by heavy bleeding, or they have found good strategies to help them manage. Others also look for medical options or consider surgery. We explain these options, as well as coping strategies, in this fact sheet. However, many women with heavy periods also have other problems – their periods go on for too long, or are very irregular, for example. We do not address those other problems here.

What is hypermenorrhea and how common is it?

The mucous lining of the uterus (womb), called endometrium, changes during the course of the menstrual cycle: It builds up after every monthly period and its blood supply increases so that a fertilized egg cell can settle in the uterus and grow there. If the egg cell is not fertilized, the mucous membrane is shed with the next menstruation. Although this is often called “menstrual bleeding”, the body not only loses blood during the period, but also parts of the endometrium. You can read more about the menstrual cycle here.

Even though menstrual blood may look like a lot when it is on a pad or a tampon, normally only about 20 to 60 ml of blood are shed during the monthly period: that is only 4 to 12 teaspoons. At that rate of bleeding, it takes about 4 hours for a regular tampon or pad to become full. That is just an average: it is also normal for some days to be heavier than others.

In gynecology, a woman has hypermenorrhea when she regularly loses more than 80 ml blood during a period. It is very individual though, which amount of blood is felt to be too high: for some women, less than 80 ml can make life difficult, while for others even much larger amounts cause no real bother. Regardless of the exact amount of blood lost, in heavy menstrual bleeding help may be needed when women feel so bad that their everyday activities are affected. If you notice that your periods are often a lot heavier than they used to be or if they bother you a lot more, you may have hypermenorrhea. About 5% of women between the ages of 30 and 49 go to the doctor looking for help for heavy menstrual bleeding. That is about 1 in every 20 women.

The rule of thumb is: If it is common for you to soak through a pad or tampon in an hour (or sometimes even faster) and you get weak and tired easily, then that might be very heavy menstrual bleeding. If you have a lot of big blood clots in your menstrual flow, then that also means you are shedding a lot of blood.

What causes heavy periods?

Some women have heavy periods right from the start, but many women’s periods only become heavier later on in life. The hormonal changes in the time leading up to the menopause can also be a factor. One common reason for heavy menstrual bleeding is the growth of too much tissue in the uterus. These growths are usually benign.

There are two main types of benign growths that can cause heavy periods:

• Polyps: little soft growths in the endometrium and
• Myomas: growths in the muscle layer of the uterus.

These kind of growths in the endometrium or muscle layer of the womb are fairly common and often do not cause any symptoms. Very rarely, malignant (cancerous) growths like uterine or cervical cancer can lead to heavy bleeding, too. There are also some other less common causes, such as hormone problems.

Less frequently heavy periods can be caused by other, less common medical conditions like bleeding disorders or problems in the heart, kidneys, thyroid gland or liver. But it is not always possible to pinpoint what is causing heavy menstrual bleeding.

What are the physical effects of heavy periods?

When a woman loses a lot of menstrual blood during her period, this can lead to iron deficiency. Iron is very important for building red blood cells. If the body does not have enough iron, it cannot produce enough red blood cells, which leads to anemia.

We need red blood cells to carry inhaled oxygen to our organs so that they can work properly. If there is a lack of red blood cells in our blood, our bodies get less oxygen, making us feel weak and tired. Other signs of anemia include a pale complexion, and cold hands and feet. More severe anemia can also cause other symptoms, like breathing difficulties and a racing heart, particularly following physical activity. A doctor can find out if you have anemia by doing a blood test.

Even if heavy menstrual bleeding does not cause anemia, affected women often feel weak and sluggish when they have their period. Their symptoms are similar to anemia, although generally not quite as strong.

How do other women feel about heavy periods?

It is not only the physical symptoms due to high blood loss that are sometimes difficult to cope with: heavy periods can be embarrassing, annoying and sometimes they can be scary. Some women feel like blood is just “flowing out” of them, and the feeling can be very unpleasant.

If women feel very tired, it can be difficult for them to cope with everyday demands at home or at work. Even social activities and hobbies that are usually enjoyable can then become a burden. Some women who have heavy periods experience mood swings and/or anxieties. It can cause problems sleeping, too.

Sometimes friends, relatives, colleagues and even doctors do not take hypermenorrhea seriously. That does not help. If you are always told that menstrual bleeding is natural and not a medical condition, you may find it hard to take some time out to relax, seek medical advice or look for a suitable treatment. Even if menstruation is a part of life for women, if heavy periods are affecting your quality of life, there are things you can do to get some relief and help you cope with it.

How do other women cope with heavy periods in everyday life?

Although some women have some days where the bleeding is so bad, they need to stay at home, mostly women manage by making sure they keep an eye out for toilets and go before it becomes urgent to change their tampon or pad. Using a combination of tampons and pads on very heavy days is also common. Wearing dark trousers or skirts on heavy days also helps reduce the stress of worrying about leaks.

It can be easy to sometimes forget to take pads or tampons with you. It can then be a good idea to keep some at work or in your handbag. Women who soak through at night or are worried about this, often put an extra layer on the bed, like a waterproof sheet or simply a towel.

How is hypermenorrhea usually diagnosed?

Usually the amount of blood that is being lost is not measured exactly, because it is the problems associated with the period that are more important. If you go to the doctor to discuss hypermenorrhea, though, you will be asked to describe how heavy your periods are. One indication is how many sanitary pads or tampons you use per day during your period, so you might want to keep track of it for a month or two.

Because heavy periods are most commonly caused by benign growths in the womb, doctors will usually examine the womb. They palpate (feel) the womb and do an ultrasound to look at it. Sometimes a hysteroscopy is recommended as well. This is a procedure in which a tiny camera is inserted into the womb. A blood test will show whether the heavy periods have led to anemia. If necessary, the doctor might do more tests, too.

Your personal situation and any symptoms you notice can give your doctor useful clues about possible causes too. That is why it is important for your doctor to know about any illnesses you have, illnesses that run in your family, medications you are taking, weight problems and whether you are under psychological stress.

What are the non-prescription options?

Some women find that relaxation techniques or yoga help them feel more relaxed and relieve stress. Some women also find that doing a lot of exercise provides relief and helps reduce the symptoms associated with heavy periods.

Some women say that their hypermenorrhea symptoms got better after they lost weight (if they were overweight before) or gained weight (if they were underweight before). Another common piece of advice is to change your diet: certain fatty acids, vitamins or fibers are meant to help women cope better with heavy periods. But we do not know of a change in diet that has been proven to reduce heavy menstrual bleeding. If you have anemia, eating foods that are rich in iron might help. Foods like meat, pulses (such as lentils or beans), green leafy vegetables and whole-grain bread are rich in iron.

Non-steroidal anti-inflammatory drugs (NSAIDs) are often used by women with period problems, including heavy menstrual bleeding. This is a group of drugs that reduce inflammation and relieve pain, including ibuprofen and diclofenac. There are indications that NSAIDs can be able to reduce the amount of blood lost during menstruation, but not as much as hormonal medications. Because they can relieve cramps and pain as well, they are often used by women who also have period pain. The women taking NSAIDs for heavy menstrual bleeding in trials did not report many more adverse effects than women taking placebos (dummy tablets). You can read more about the advantages and disadvantages of using NSAIDs for menstrual pain here.

If heavy menstrual bleeding makes you feel very tired or you have even developed anemia because of it, this is normally due to a lack of iron. Iron deficiency anemia is usually treated with iron tablets. These can have adverse effects such as gut ache and constipation. They can also make stool turn black.

Unfortunately, there is little strong research on whether homeopathic or herbal medicines can relieve the symptoms. Some women say that chaste tree (Vitex agnus-castus) and ergot (Secale cornutum) help in heavier periods. If new research is published on these treatments, we will report on the results here.

What are the other medication options and how do the results compare with surgery?

As long as you are not anemic, it is generally possible to deal with the “heavier” days without having any treatment. If you decide to use medicines or have surgery you should know the advantages and the disadvantages and weigh them up. For menstrual problems, the choices are also affected by whether a woman wants to have a child or not. The most effective treatments all limit the possibility of getting pregnant, either temporarily, with the pill for example, or permanently in the case of surgical removal of the uterus (hysterectomy). You can read more about how hormonal contraceptives work here.

There are a number of medications that aim to reduce the amount of blood lost during menstruation and relieve the associated symptoms. If you use one kind of medication and it does not work for you, it is usually possible to try out other kinds of medications or combinations.

How do the options compare with one another? Taking effectiveness as well as women’s satisfaction with treatment and their quality of life into account, then the most effective methods are hormone-releasing intrauterine devices and hysterectomy. The less invasive forms of surgery that remove or destroy the endometrium come quite close in possible benefits to hysterectomy, but with a much lower risk of adverse effects. However, about 1 in 5 women who have these other forms of surgery will have another operation within 2 years.

Hormone-releasing intrauterine devices

Hormone-releasing intrauterine devices (IUDs or “coils”) prevent women from getting pregnant while they are using them. If a woman has the IUD removed, she can become pregnant again. The statutory health insurances in Germany generally cover the costs of IUDs prescribed for the treatment of hypermenorrhea rather than for contraception.

One example of such a coil is the levonorgestrel intrauterine system (LNG-IUS). This device is inserted into the womb, where it can be left for about five years. Here it continuously releases the hormone levonorgestrel (LNG). Trials show that progestin-releasing coils like the LNG-IUS can reduce blood loss during menstruation. A lot of women with hypermenorrhea are happy to use a coil like this and do so for longer periods of time – these women are about as satisfied with their treatment results as women who have hysterectomies. In fact, in one trial in Great Britain where women who were waiting for hysterectomy used LNG-IUS, many even cancelled their planned operation.

Studies of hormone-releasing coils show that some young women who use them will have more days of bleeding, but that bleeding is much lighter. The most common adverse effects for these hormone-releasing coils come from the hormones: water retention and breast tenderness, but these are not as common as when women take the hormones as tablets. Hormone-releasing coils can also cause benign cysts on the ovaries. In about 1 in 20 women, the coil may be rejected, so they need to see the doctor again.

Contraceptive pill

The oral contraceptive pill (“pill”) is a hormone-based medication that prevents pregnancy when taken regularly. It either contains both estrogen and progestin or just progestin. Women with hypermenorrhea more commonly use a pure progestin preparation (a so-called “mini pill”).

The progestin pill can reduce menstrual bleeding in some women, but not as much as the hormone-releasing IUD. The adverse effects of the contraceptive pill are also more common and severe than with the IUD, including water retention and breast tenderness. The pill sometimes also causes blood clots. Therefore, regulatory authorities recommend women with a higher risk of blood clotting (women who smoke, for example) not take the pill. You can find more information about the possible adverse effects of the pill here.

Another option is to take the oral contraceptive pill continuously over a long period of time. Usually, taking the pill involves a few days of taking no pills or taking dummy tablets, which allows a period to happen. If the pill is taken without pause, there is no period, or only some breakthrough bleeding. Low-dose monophasic pills are used by some women for heavy menstrual bleeding. In these medications, each pill contains the same amount of progestin and estrogen, or just progestin.

In Germany no pill has been authorized for continuous use, because there is not enough research yet. Using the pill this way is so-called “off-label use”, which means that you have less legal protection if you take the pill without a pause. Your doctor should explain this to you when she or he prescribes such a pill without a pause. You can read more about what off-label use means here.

Other prescription medications

Another medication that can help against heavy menstrual bleeding is tranexamic acid: this medication affects blood clotting and reduces the tendency to bleed. This is not as effective as the hormone-releasing IUD, but it has more adverse effects than hormone medications. It can cause nausea and leg cramps.

What surgical options are there, and how do they compare to one another?

Surgery might be needed if heavy periods are being caused by myomas or polyps. Doctors can remove myomas through the vagina or abdominal cavity. This operation is called a myectomy. The uterus stays intact, however, and it is usually still possible for women to get pregnant afterwards.

Many women think that surgery must mean hysterectomy (removal of the uterus), but there are other operations. Hysterectomy is a big step that can have physical and emotional impact. The woman no longer has menstruation, and cannot get pregnant. It is a major operation that can sometimes have serious adverse effects such as secondary bleeding. It is usually necessary to stay in the hospital if a hysterectomy is done. In rare cases, the ovaries are also removed with the uterus, for example if pathological changes become evident during surgery. In that case, the woman will experience menopause soon after the surgery. You can read more about menopause here.

Another surgical approach to heavy periods is to only remove the endometrium, which produces the monthly period. These operations are called endometrial ablation or endometrial resection. Endometrial resection removes the endometrium. Endometrial ablation destroys this tissue instead, using surgical equipment such as lasers or microwaves. These operations can stop periods, but the endometrium might also grow back. When this happens, further options include re-doing the surgery or considering a hysterectomy: about 1 in 5 women will have another operation within 2 years. An endometrial resection or ablation is a smaller operation than a hysterectomy. This surgery might be done as an outpatient treatment.

The other advantages of endometrial operations are that there are less adverse effects and women can get back to their usual daily activities more quickly than is possible after hysterectomy. However, hysterectomy is a little more effective against symptoms. Unless there are complications, only one operation is necessary. Most women who have had surgery are satisfied with the results they get with all the methods. If you are considering surgery, you can read more about the research comparing the types of surgery here.

How can I find a solution suitable for me?

Individual women experience their periods differently, and the amount of menstrual blood they lose can vary naturally from month to month. Whereas some women who have heavy periods may not think it is a big problem, others already feel extremely uncomfortable with less heavy periods. It may help to see your doctor to be reassured that your hypermenorrhea is not being caused by a serious medical condition. You can take your time to decide whether or not you would like treatment and, if so, which treatment is most suitable for you. But if heavy menstrual bleeding does not affect you otherwise and you are coping well with it, there is no need for you to feel like you are not healthy.

Researchers looking at what women prefer and choose when they are fully informed about all their options find that they mostly prefer to avoid surgery. You can read more about weighing up the pros and cons of different treatment options here. We also have information on period pain here, and will be publishing information on other menstrual problems in future. If you would like to stay up-to-date on the latest topics on our website, you can subscribe to our newsletter.

Author: German Institute for Quality and Efficiency in Health Care (IQWiG)

© IQWiG (Institute for Quality and Efficiency in Health Care)