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Illustrations by Katrin Friedmann

Bleeding

Heavy periods: How to tell if your heavy periods are “normal”

by Dr. Vedrana Högqvist Tabor, Former Head of Science at Clue; and Prof. Dr. Malcolm G. Munro MD, FRCS(c), FACOG1
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Menstruation varies from person to person, making it harder to distinguish normal from excessive blood loss. So how do you tell what is “normal?”

Let’s get medical: In clinical research studies, the symptom of heavy menstrual bleeding (HMB) is defined as blood loss larger than 80 mL per cycle.

However, blood loss can be very hard to measure, unless you use a menstrual cup. And even if you lose less than 80 mL, it can still affect your quality of life, particularly if the timing of your periods is irregular and, therefore, difficult to anticipate. Consequently, the more accepted and practical definition of HMB is “excessive menstrual blood loss which interferes with a woman’s physical, social, emotional and/or material quality of life.”(National Institute for Health and Care Excellence or NICE)

Causes of Heavy Menstrual Bleeding

There are a variety of conditions that can cause HMB. The most common conditions include:

  • Polyps, or growths in the uterine lining, usually cause spotting or bleeding between periods and sometimes HMB.
  • Adenomyosis, the abnormal growth of uterine lining (endometrium) into the muscular wall of uterus, but can sometimes cause heavy and/or painful periods.
  • Uterine fibroids, benign growths (smooth muscle tumors) on the uterus, also known as leiomyomas, can sometimes cause HMB. If they grow in the uterine lining (endometrium) they will most likely cause HMB.
  • Cancers and precancers are very uncommon, but important, causes of abnormal bleeding, particularly for individuals under the age of 40. While they can cause HMB, cancers and precancers more likely cause irregular bleeding or bleeding between periods.
  • Coagulopathy, an inherited disorder preventing the blood from clotting normally, will cause HMB usually from menarche (the first period).
  • Ovulatory disorder, the absence or irregularity of ovulation, is a hormonal problem that may cause irregular bleeding that may or may not include HMB as a symptom.
  • Endometrial disorder, an abnormality in the lining of the uterus, prevents the tissues from stopping the bleeding normally.

Most medications and birth control pills don’t cause HMB, but there are two exceptions: Copper-containing intrauterine devices may increase the amount of blood lost during menstruation and anticoagulants (“blood thinners”), which prevent blood clots, usually cause HMB.

Do you have Heavy Menstrual Bleeding?

Understanding whether or not you suffer from HMB requires the accurate recording of your menstrual history. The intensity of bleeding varies from person to person, so determining what is clinically heavy is tricky. Furthermore, while a single period can be heavy, a real problem isn’t likely to exist unless the HMB is present at least most of the time. The medical definition of this is when HMB is present for the majority of periods within the previous six months. Entering your bleeding intensity diligently and correctly in the Clue app will make it easier to assess if bleeding qualifies as heavy.

Your healthcare provider may ask you how many (and what size) pads/tampons you have been using in one day. Also, blood clots are very important to note — their size, number and color. They contain blood, and it is important to measure and count them to get an approximation of how much blood has been lost.

  1. Distinguish between regular and maxi tampons or pads, as maxi can usually absorb twice more than regular (each maxi tampon or pad should be counted as two regulars).
  2. Check how soaked your tampon or pad is. Is it fully soaked with blood, or just half? (For half soaked, divide the number of half soaked pads by two.)
  3. Count blood clots; they contain blood too.
  4. For a menstrual cup, check the volume capacity and measure how full the cup is (e.g. if it is a 10 mL cup and it is ¾ full, the amount of the blood your menstrual cup contains is 7.5mL).
  5. If the number of soaked tampons or pads is sixteen or more for the entire duration of your period (or eight fully soaked maxi tampons or pads), then your flow is heavy.
  6. If you note 80mL or more blood with your menstrual cup for one entire cycle, your flow is heavy.

Here are some more guidelines to determine if what you are experiencing is heavy:

  1. Your menstrual period lasts longer than seven days.
  2. Your flow soaks through tampons or pads every hour for a few hours in a row.
  3. You need to change pads or tampons during the night.
  4. You have multiple grape-sized (or larger) blood clots.
  5. Your heavy menstrual flow keeps you from doing things you would normally do.
  6. You are tired, have a lack of energy or are short of breath.
  7. You feel heavy pain in your abdomen and lower back.
heavy-menstrual-bleeding

Make an appointment with your gynecologist if your menstrual bleeding seems heavier than usual, or if it lasts more than seven days or impacts your life.

If you experience bleeding between periods, during or after sex, during pregnancy or after you have entered menopause, it is important to visit your gynecologist.

Possible consequences of Heavy Menstrual Bleeding

Whenever you have a period, you lose blood. For those with normal bleeding, and a diet containing normal amounts of iron, blood loss and iron intake should be in balance. However, for those with heavy menstrual bleeding, and especially when the diet is deficient in iron, blood loss can exceed iron intake and may result in an iron deficiency and possible low red blood count, or anemia. Iron deficiency, with or without anemia, can cause fatigue and interfere with the ability to concentrate, exercise, and, enjoy life in general.

What should I do about it?

To treat HMB, you and your healthcare provider need to determine its cause or causes. This can be done by a few simple tests including a blood test, a transvaginal ultrasound and/or taking a sample tissue from the uterine lining (endometrial biopsy).

Polyps: Surgical removal of the polyp is the most effective therapy.

Adenomyosis: Treatment with hormonal contraception, especially an intrauterine device that releases a hormone called progestin.

Fibroids: Some medical or hormonal therapies are effective, although procedures involving surgery are often necessary.

Cancer or pre-cancer: Most pre-cancers can be treated with medication, but cancers usually require surgery.

Blood clotting disorder: Tranexamic acid or hormonal medications are the usual treatment strategy.

Ovulatory disorders: Ovulatory disorders can generally be treated with hormonal medication such as progestins or other hormonal contraceptive medications.

Endometrial disorders: People with endometrial disorders can respond well to tranexamic acid, use of simple NSAIDs like ibuprofen, naproxen or mefenamic acid, the progestin-releasing intrauterine system or other types of hormonal contraception. When a copper intrauterine device is the cause, some of the treatments for endometrial disorders can be effective.

Iron deficiency: Whenever there is an iron deficiency, and especially if there is anemia, an iron replacement should be part of the treatment.

Surgery can be important especially for removal of polyps or fibroids since it can be performed simply and in a way that preserves fertility. Finally, invasive surgery (such as endometrial ablation and hysterectomy) is the last resort to help with the HMB, but is always carefully considered as these procedures can remove your chances to bear children.

If you suspect you might have HMB, contact your healthcare provider immediately. This condition is easily treated in most of the cases. Early detection and diagnosis will make treatment more successful and less invasive.

If you are still unsure if you have HMB, try to track more details during your next cycle, and analyze it afterwards. If you note any of the signs we have mentioned here, book an appointment with your healthcare provider.

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