Heavy bleeding


Heavy bleeding can disrupt your daily life and be quite distressing. What causes it, how heavy bleeding is diagnosed and what treatments are available are all discussed.

What is heavy bleeding?

1/3 cup, or 80ml

Heavy menstrual bleeding (also known as menorrhagia) is excessive and/or prolonged menstrual bleeding. The amount varies from woman to woman and can change at different stages in your life; for example, in teenage years or approaching menopause. It is defined as blood loss greater than 80ml (equal to one-third of a cup) per cycle, or periods lasting more than seven to eight days. Heavy menstrual bleeding affects about one in five women[1] and is a common problem in the 30-50-year-old age group.

How do you know if your bleeding is too heavy?

It is very difficult to determine whether your bleeding is too heavy. The best guide is to decide whether your period is having an impact on your quality of life – if it is causing you to be housebound, interrupting your daily activities, or causing you stress and anxiety. The following signs might indicate you are experiencing heavy bleeding:

  • bleeding or 'flooding' not contained within a pad/tampon (especially when wearing the largest size)
  • changing a pad/tampon every hour or less
  • changing a pad overnight
  • clots greater than a 50-cent piece in size
  • bleeding for more than seven to eight days.

How can heavy bleeding affect you?

You might:

  • feel fatigued, exhausted, dizzy and look pale
  • have low iron levels because of the blood loss
  • have cramping and pain in the lower abdomen
  • need to change sanitary products very frequently
  • fear bleeding through to your clothes, which can affect your daily activities.

What causes heavy bleeding?

About 50% of women with heavy menstrual bleeding have no abnormalities in their uterus. It might be related to hormonal or chemical levels in the endometrium (the internal lining of the uterus) or conditions not yet identified in the endometrium.

In the other 50% of cases, the cause might be related to:

Pregnancy or complications of pregnancy Please contact your doctor if you have bleeding during pregnancy
Polycystic ovary syndrome (PCOS) Some women can have heavy menstrual bleeding if the lining of the uterus is thickened; this can lead to pre-cancerous or cancerous changes
Endometriosis Occurs when tissue similar to that found in the lining of the uterus grows outside of it
Endometrial polyps Usually non-cancerous (benign) growths in the endometrium that look like a large 'teardrop' of tissue
Endometrial hyperplasia An overgrowth of the endometrium, which can progress to cancer
Endometrial cancer Cancer of the uterus
Adenomyosis Endometrium growing in small pockets inside the muscle layer of the uterus
Fibroids Non-cancerous growths or lumps within the uterus wall
Intrauterine device (IUD): A contraceptive device

There is a range of other possible causes that are not as common, such as:

  • hormonal disorders, such as an underactive thyroid gland (hypothyroidism)
  • bleeding disorders in which excessive bleeding can occur, such as Von Willebrand disease (more common in teenagers)
  • chronic kidney or liver disease.

It is important to note that women who have gone through the menopause should not have any vaginal bleeding/spotting. If this occurs, see your doctor.

How is heavy bleeding diagnosed?

After a thorough history and clinical examination – including a cervical screening test and swabs – your doctor might order blood tests and/or a pelvic ultrasound to eliminate some of the possible causes listed previously.[2] The gold standard is to perform a hysteroscopy and curette in all women over 35 years of age to rule out endometrial hyperplasia or cancer.[3] This is where the lining of the womb is viewed with a telescope – the hysteroscope – and is then lightly scraped away and a biopsy (a sample of cells) taken for examination.

How is heavy bleeding treated?

Your doctor might prescribe the following treatments to reduce bleeding and pain:

Anti-inflammatory drugs

Can reduce inflammation, pain and blood loss

Tranexamic acid Can reduce blood loss by about 50%. It is non-hormonal and is taken only on the heavy days of the period.
Insertion of a Mirena® intrauterine device (IUD)

Releases a progestin hormone that thins the endometrium and can reduce bleeding by up to 95% after 12 months[5]

The oral contraceptive pill Can reduce bloodflow by up to 50%
Progestins (synthetic forms of progesterone) Can reduce blood loss by about 30%

Sometimes with heavy menstrual bleeding, iron stores (ferritin) and iron levels can get low. Your doctor might get you to take a blood test and recommend iron therapy if the levels are found to be low. This usually involves taking an iron supplement daily or, if the levels are very low, an iron infusion. Usually an infusion is recommended when ferritin levels are low.

If medications fail to reduce the bleeding, or if there are other symptoms that develop, such as pain, discuss the options available with your doctor and develop a management plan that is the most appropriate for you. Your doctor will usually refer you to a gynaecologist if surgery is recommended. Careful discussion about the risks and benefits of the appropriate procedure/procedures should take place before you make your decision.

What are the surgical options available?

There are several surgical options available for treating heavy bleeding, depending on the cause of the bleeding and whether you wish to be able to have children. There are treatments that will allow you to keep your uterus, one of which might be appropriate for you.

Uterine-preserving procedures

Hysteroscopy

If polyps or fibroids are the cause of the heavy bleeding, an operation called a hysteroscopy may be performed.

Usually a day procedure, a hysteroscopy is done either in an outpatient setting or in an operating theatre of a hospital, and occasionally in a gynaecologist's office.

A hysteroscopy is performed by inserting a telescope (hysteroscope) through the cervix into the uterus, and removing either a polyp (endometrial polypectomy) or a fibroid that bulges into the uterine cavity (submucous fibroid) by resection. A tiny cutting loop using an electrical current is attached to the hysteroscope and cuts out the polyp or fibroid

Endometrial ablation

Endometrial ablation is another hysteroscopic or intrauterine procedure. In this procedure, the lining of the uterus is either burnt or destroyed by various different techniques, including diathermy, radiofrequency energy, microwave, thermal balloon and freezing. This treatment is an option when a problem with the endometrium is causing heavy bleeding; however, the procedure is not recommended if a woman still wishes to have children.

For more information, please see the patient information videos on Hysteroscopy and Endometrial ablation on the AGES website (Australasian Gynaecological Endoscopy & Surgery Society).

Hysterectomy

Hysterectomy is an option when all other treatments are ineffective, or when the woman chooses this treatment. It is an irreversible operation in which the uterus is removed permanently, stopping periods and the ability to get pregnant. A hysterectomy can be performed either through the vagina (vaginal hysterectomy), via keyhole surgery (laparoscopic hysterectomy), or through an incision in the abdominal wall (abdominal hysterectomy).

A total hysterectomy means to remove the whole of the uterus, including the cervix or neck of the womb, but not the ovaries and tubes. Most gynaecologists now recommend that the tubes be removed at the same time because research suggests some ovarian cancers arise from the tubes. Occasionally, a sub-total hysterectomy is performed, in which the cervix is retained.

See our webpage on Hysterectomy for more information.

References

  1. Hallberg L, Högdahl AM, Nilsson L, Rybo G. Menstrual blood loss – a population study. Variation at different ages and attempts to define normality. Acta Obste Gynaecol Scand. 1966;45(3):320–51.

  2. Heavy menstrual bleeding; assessment & management. NICE guideline [NG88] www.nice.org.uk/guidance/ng88. March 2018

  3. Quinn S, Higham J. Outcome measures for heavy menstrual bleeding, Womens Health 2016;(1) 21-26.

  4. Dijkhuizen FP, Mol BW, Brolmann HA, Heintz AP. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer. 2000;89:1765.

  5. Stewart A, Cummins C, Gold L, Jordan R, Phillips W. The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review. BJOG. 2001;108(1):74.

  6. Davies J, Kadir RA. Heavy menstrual bleeding: an update on management. Thromb. Res 2017, 151(1):70-77.

  7. Lethaby A et al. Combined hormonal contraceptives for heavy menstrual bleeding. Cochrane Database Syst. Rev. 11.2.CD000154 doi: 10.1002/14651858 CD 000154 pub3.

Last updated 19 February 2019 — Last reviewed 10 July 2018

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at July 2018.

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