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Patient education: Heavy periods (Beyond the Basics)

Patient education: Heavy periods (Beyond the Basics)
Literature review current through: May 2024.
This topic last updated: May 23, 2024.

INTRODUCTION — Most menstrual cycles (periods) occur every 24 to 38 days (as measured from the first day of one bleeding episode to the first day of the next); the average is every 28 days. In a normal menstrual cycle, a person loses an average of 2 to 3 tablespoons (35 to 40 milliliters) of blood over four to eight days. However, some people lose a lot more blood or bleed for a longer duration (prolonged periods). Doctors define "heavy" periods as bleeding so much that it affects your physical health, emotional health, or quality of life.

Heavy periods (which doctors sometimes call "menorrhagia") can lead to low iron stores and iron deficiency anemia (low red blood cell count caused by ongoing excessive blood loss), which can cause fatigue, weakness, and other symptoms.

Several treatments for heavy bleeding are available.

CAUSES OF HEAVY PERIODS — The most common causes of excessive menstrual bleeding are:

Not ovulating every month (called "anovulation")

Having abnormal tissue in the uterus, such as polyps, fibroids, or adenomyosis

Having a condition that increases bleeding throughout the body (for example, a bleeding disorder)

Certain medications, like "blood thinners" or the copper intrauterine device (IUD)

These causes are discussed in the following sections.

Anovulation — Anovulation occurs when your ovaries do not produce and release an egg (ovulate) once per month. This causes your bleeding to be irregular or absent. Anovulation is common in adolescents soon after menstruation starts and in people who are near menopause (perimenopause). Most people with polycystic ovary syndrome (PCOS) do not ovulate regularly. (See "Patient education: Absent or irregular periods (Beyond the Basics)".)

Abnormal tissue in the uterus — Noncancerous growths in the uterus can cause heavy menstrual bleeding. The most common noncancerous growths are:

Polyps, which are small, grape-like growths of the lining (cavity) of the uterus

Fibroids (see "Patient education: Uterine fibroids (Beyond the Basics)")

Adenomyosis, in which uterine lining tissue grows into the muscular wall of the uterus

Overgrowth of the lining of the uterus (called endometrial hyperplasia), which can be a precursor to uterine cancer

Bleeding tendency — Certain bleeding conditions or medications can cause heavy menstrual bleeding. Examples include:

von Willebrand disease (see "Patient education: von Willebrand disease (Beyond the Basics)")

Having a low platelet count

Taking an anticoagulant (blood thinner), such as warfarin (brand name: Jantoven) or apixaban (brand name: Eliquis), or a related medication (see "Patient education: Warfarin (Beyond the Basics)")

SYMPTOMS OF HEAVY PERIODS — People with heavy or prolonged menstrual bleeding typically have one or more of the following:

Soak through a pad or tampon every one to three hours on the heaviest days of the period

Have bleeding for more than seven days

Need to use both pads and tampons at the same time due to heavy bleeding

Need to change pads or tampons during the night

Pass blood clots larger than 1 inch (approximately 2.5 centimeters)

Iron deficiency anemia (see "Patient education: Anemia caused by low iron in adults (Beyond the Basics)")

When to seek help — If you soak through two pads or tampons in one hour for two hours in a row, call your health care provider or go to the emergency department. Bleeding this heavily can be serious or even life threatening.

TESTING AND DIAGNOSIS — If you have heavy menstrual bleeding, your health care provider will want to perform a physical exam, including a pelvic exam. They might recommend other tests, based on what they find during the exam. These can include:

Blood tests to look for anemia, iron deficiency, thyroid disease, or a bleeding disorder.

A pelvic ultrasound – This is an imaging test that uses sound waves to create a picture of the uterus and ovaries; it is usually done by inserting an ultrasound probe in your vagina, but can also be done by placing a probe on your abdomen. An ultrasound can detect endometrial polyps and fibroids. A specialized pelvic ultrasound called a "sonohysterogram" or "saline infusion sonogram" involves placing a small flexible tube through the vagina and cervix into the uterus; this is used to infuse a small amount of sterile water, which distends the cavity of the uterus and makes it easier to visualize a polyp or some types of fibroids.

A biopsy of the tissue inside of the uterus – This is called an endometrial biopsy. It is usually done in a doctor's office.

A hysteroscopy – This test uses a small scope to look inside the uterus. This may be performed in a doctor's office or in an operating room as day surgery.

MEDICAL TREATMENT FOR HEAVY PERIODS — If you have heavy menstrual bleeding, the best treatment for you will depend on:

The cause of your bleeding

Your preferences

Whether you want to prevent pregnancy

Whether you might want to be able to get pregnant in the future

Your health care provider will probably recommend treatment with one or more medicines first. If these treatments do not reduce bleeding enough, surgical treatment might be an option. (See 'Surgical treatment for heavy periods' below.)

Hormonal birth control — If you have heavy menstrual bleeding and do not want to get pregnant right now, hormonal birth control might be a good option. Options include the pill, skin patch, vaginal ring, shot, and hormonal intrauterine device (IUD). These treatments reduce uterine bleeding. Hormonal birth control can also reduce cramps and pain when you have bleeding. It might take three months for bleeding to improve after you start taking hormonal birth control.

Some forms of hormonal birth control, including the pill, skin patch, and vaginal ring, are designed to be used for three weeks in a row, followed by one week off. During the fourth week, you will have bleeding.

More information about hormonal birth control is available separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

Some doctors and nurses advise people with heavy menstrual bleeding to take hormonal birth control continuously, without a break week. If you take this approach, you will not have monthly bleeding. This strategy is called "continuous dosing."

Most birth control pills contain estrogen and progestin hormones. Several brands of estrogen-progestin birth control pills are packaged with three months of pills to make it easier to take the pill continuously (table 1). You can also take other types of hormonal birth control continuously. This is explained in detail separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)", section on 'Continuous dosing'.)

Progestin pills — Norethindrone acetate (brand name: Aygestin) or medroxyprogesterone acetate (brand name: Provera) pills are also an option. Progestin pills are sometimes recommended for people who do not ovulate regularly. They may be prescribed for use 5 to 14 days each month or continuously (every day).

This treatment helps to make the lining of the uterus thinner, reducing or even eliminating bleeding.

Hormonal intrauterine device — There are IUDs that slowly release a hormone, progestin, into the uterus. They do not contain estrogen. Two progestin-containing IUDs (brand names: Mirena, Liletta) can be used to both prevent pregnancy for up to eight years and reduce bleeding (figure 1). A health care provider places the IUD inside the uterus in the office. This might be a good choice if you do not want to become pregnant for at least the next six months.

The most common side effect of the hormonal IUD is irregular bleeding; this is usually light bleeding or spotting, and usually improves after the first several months after IUD placement. In people who use a hormonal IUD specifically to treat heavy bleeding, expulsion rates (when the uterus pushes the IUD into an improper position or completely out of the uterus) are higher than in people who use it just for preventing pregnancy. (See "Patient education: Long-acting methods of birth control (Beyond the Basics)", section on 'Intrauterine device'.)

Shot — Depot medroxyprogesterone acetate (brand name: Depo-Provera) is a long-acting form of a progesterone-like hormone, called a progestin. It is a shot given once every three months. This treatment prevents pregnancy and can reduce heavy menstrual bleeding. You might choose the shot if you do not want to become pregnant for at least one year.

The most common side effect of medroxyprogesterone acetate is bleeding and spotting, particularly during the first few months. Many people completely stop having bleeding after using this treatment for one year. More detailed information about medroxyprogesterone acetate is available separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)", section on 'Injectable birth control'.)

Antifibrinolytic medicines — Antifibrinolytic medicines, such as tranexamic acid (brand name: Lysteda), can help to slow menstrual bleeding quickly. These medicines work by helping the blood clotting system.

The advantages of antifibrinolytic medicines over other medical treatments are that:

The medicine slows bleeding quickly (within two to three hours)

You need to take the medicine only a few days each month

The medicines do not affect your chances of becoming pregnant

Side effects can include headache and muscle cramps or pain. If you take hormonal birth control, you should not take antifibrinolytic medicines unless your health care provider approves; there is controversy regarding a possible increased risk of blood clots, stroke, and heart attack when taken together.

Nonsteroidal anti-inflammatory drugs (NSAIDs) — Nonsteroidal anti-inflammatory drugs, such as ibuprofen (brand name: Motrin and Advil), naproxen (brand name: Aleve), and mefenamic acid (brand name: Ponstel), can help reduce menstrual bleeding and menstrual cramps. You can buy some NSAIDs (including ibuprofen) without a prescription.

NSAIDs are not expensive, have few side effects, and reduce pain and bleeding, and you need to take them only during your menstrual period. You can take NSAIDs in combination with any of the medical treatments discussed here. However, NSAIDs do not reduce bleeding as well other medical treatments.

Gonadotropin-releasing hormone (GnRH) agonists — GnRH agonists are a type of medicine that can be used to temporarily reduce menstrual bleeding. This treatment might be recommended for people who are waiting to have surgical treatment.

These medicines work by "turning off" the ovaries, causing a temporary menopause. The medicines can be taken for up to six months. Side effects may include hot flashes and vaginal dryness (common symptoms of natural menopause). GnRH agonists are not usually recommended for longer than six months in a row due to the risk of osteoporosis (weakened bones) when used for long periods of time.

In some cases, GnRH agonists are prescribed along with hormonal tablets (combined [estrogen-progestin] birth control pill or progestin tablets). This combination limits the side effects experienced with GnRH agonists alone, such as hot flashes and weakening of the bones, while also reducing heavy bleeding. When used together, these medications can be taken for up to two years.

SURGICAL TREATMENT FOR HEAVY PERIODS — If you have growths in your uterus, such as polyps or fibroids, getting treatment to remove them can reduce or eliminate heavy bleeding.

Fibroids can be treated by removing them (called myomectomy) or blocking their blood supply (called uterine artery embolization). These procedures are discussed in detail in a separate article. (See "Patient education: Uterine fibroids (Beyond the Basics)".)

Other surgical treatments for heavy menstrual bleeding include the following.

Endometrial ablation — Endometrial ablation is a treatment that destroys or removes most of the lining of the uterus. This can reduce heavy menstrual bleeding or stop menstrual bleeding altogether. It is not a good option if you might want to get pregnant in the future and may not be appropriate if your abnormal bleeding is caused by anovulation. The cause of the bleeding should be identified before endometrial ablation is performed.

The treatment can be done in the office or as a day surgery. After the treatment, you may have some cramping, vaginal discharge, and nausea. You may also have a pinkish vaginal discharge for two to three days afterward; this gradually becomes clear and watery and can last for 2 to 10 days. Most people can go back to work or school the following day. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

Hysterectomy — Hysterectomy is a major surgery that removes the uterus. This is a permanent treatment that cures heavy menstrual bleeding. However, the surgery can have complications and may require six or more weeks for full recovery. Pregnancy is not possible after hysterectomy. More detailed information about hysterectomy is available separately. (See "Patient education: Abdominal hysterectomy (Beyond the Basics)" and "Patient education: Vaginal hysterectomy (Beyond the Basics)".)

WHICH TREATMENT IS RIGHT FOR ME? — There are many treatments for heavy menstrual bleeding, and it can be hard to decide which one is right.

Step one — In most cases, you should start with medication:

If you would like to become pregnant in the next several months, a nonsteroidal anti-inflammatory or antifibrinolytic medicine might be a good option. However, nonsteroidal anti-inflammatory drugs (NSAIDs) are not as effective in treating heavy menstrual bleeding as hormonal treatments. (See 'Nonsteroidal anti-inflammatory drugs (NSAIDs)' above and 'Antifibrinolytic medicines' above.)

If you might want to get pregnant in the future, but not soon, a hormonal birth control method, hormonal intrauterine device (IUD), progestin pills, or progestin shot might be a good option. (See 'Hormonal birth control' above.)

If you have no desire to become pregnant in the future, you can use any of the medical treatments described above. Hormonal birth control (including the IUD) and antifibrinolytic medicines are probably the most effective medical treatments.

Step two — If you have tried one or more medicines and you still have heavy menstrual bleeding, talk to your health care provider. A surgical treatment might be a good option in this case. (See 'Surgical treatment for heavy periods' above.)

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Heavy periods (The Basics)
Patient education: Menstruation (The Basics)
Patient education: Immune thrombocytopenia (ITP) (The Basics)
Patient education: Endometrial ablation (The Basics)
Patient education: Uterine adenomyosis (The Basics)
Patient education: Intrauterine devices (IUDs) (The Basics)
Patient education: IUD insertion (The Basics)
Patient education: IUD removal (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Absent or irregular periods (Beyond the Basics)
Patient education: Uterine fibroids (Beyond the Basics)
Patient education: von Willebrand disease (Beyond the Basics)
Patient education: Warfarin (Beyond the Basics)
Patient education: Anemia caused by low iron in adults (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Long-acting methods of birth control (Beyond the Basics)
Patient education: Care after gynecologic surgery (Beyond the Basics)
Patient education: Abdominal hysterectomy (Beyond the Basics)
Patient education: Vaginal hysterectomy (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Overview of endometrial ablation
Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management
Uterine fibroids (leiomyomas): Epidemiology, clinical features, diagnosis, and natural history
Hormonal contraception for menstrual suppression
Abnormal uterine bleeding in nonpregnant reproductive-age patients: Terminology, evaluation, and approach to diagnosis
Causes of female genital tract bleeding
Uterine fibroids (leiomyomas): Treatment overview
Approach to the patient with postmenopausal uterine bleeding

The following organization also provides reliable health information.

National Library of Medicine

(www.medlineplus.gov)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Howard Zacur, MD, who contributed to earlier versions of this topic review.

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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