What is heavy menstrual bleeding?
Heavy menstrual bleeding (HMB) (medically known as menorrhagia) refers to periods with unusually heavy bleeding or longer duration of bleeding.1 ‘Heavy’ means that your periods last longer than 7 days or that you lose more blood than usually lost during normal monthly periods.2
You may bleed so much that you might soak one or more tampons or pads every hour, continuously for several hours.1,2 It is clinically defined as blood loss of more than 80 mL per cycle. 3
Heavy menstrual bleeding can be irritating and troublesome. It can also interfere with your day-to-day activities.3 Blood loss due to heavy periods can cause iron deficiency anaemia, a condition caused by low iron levels in your body. Severe anaemia can cause several health problems. Heavy menstrual bleeding is not normal and may be a sign of a more serious health problem.4
References:
1. Mayo Clinic. Menorrhagia (heavy menstrual bleeding). [Internet] 2022 Jun 25 [cited 2022 Dec 05]. Available from: https://www.mayoclinic.org/diseases-conditions/menorrhagia/symptoms-causes/syc-20352829
2. Centers for Disease Control and Prevention. Heavy menstrual bleeding. [Internet] 2022 Aug 17 [cited 2022 Dec 05]. Available from: https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
3. Herman MC, Mol BW, Bongers MY. Diagnosis of heavy menstrual bleeding. Womens Health. 2016;12(1):15-20.
4.American College of Obstetricians and Gynecologists. Heavy menstrual bleeding. [Internet] 2022 Jun [cited 2022 Dec 06]. Available from: https://www.acog.org/womens-health/faqs/heavy-menstrual-bleeding
Signs and Symptoms of Heavy Menstrual Bleeding
if you suffer from heavy menstrual bleeding
Longer periods
Periods lasting for
more than 7 days1,3
Heavy bleeding
If you soak one or more sanitary pads or tampons every hour, and this happens for several hours continuously1,3
Disturbed sleep because
of bleeding
Waking up at night to change sanitary pad3
Avoid daily activities
Prevents you from doing daily activities like exercise or you have to take time off work because of periods2
Passing large clots
Passing clots larger than about 2.5 cm 2
Anaemia
Symptoms of anaemia (lack of healthy red blood cells), including tiredness, fatigue or shortness of breath3
Double Sanitary pads
Double sanitary pads are required to control the bleeding 1
talk to your doctor for proper diagnosis and treatment.
References:
1. Centers for Disease Control and Prevention. Heavy menstrual bleeding. [Internet] 2022 Aug 17 [cited 2022 Dec 05]. Available from: https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
2. National Health Service. Heavy periods. [Internet] 2021 Nov 03 [cited 2022 Dec 08]. Available from: https://www.nhs.uk/conditions/heavy-periods
3. Mayo Clinic. Menorrhagia (heavy menstrual bleeding). [Internet] 2022 Jun 25 [cited 2022 Dec 05]. Available from: https://www.mayoclinic.org/diseases-conditions/menorrhagia/symptoms-causes/syc-20352829
heavy menstrual bleeding screening tool
Fill in the chart below to know your scores. If your score is more than 100,
visit your doctor as you might be suffering from HMB.
1. Jain S, Agrawal NR, Tilak V, et al. Platelet function disorder in women with heavy menstrual bleeding in Eastern Uttar Pradesh. J Med Soc. 2021;35(1):24-9.
Heavy menstrual bleeding screening tool1
Quiz
Heavy menstrual bleeding can be caused by various reasons. However, it is important to identify the underlying cause to select the most effective treatment.1
References:
1. Herman MC, Mol BW, Bongers MY. Diagnosis of heavy menstrual bleeding. Womens Health. 2016;12(1):15-20.
2. Mayo Clinic. Menorrhagia (heavy menstrual bleeding). [Internet] 2022 Jun 25 [cited 2022 Dec 05]. Available from: https://www.mayoclinic.org/diseases-conditions/menorrhagia/symptoms-causes/syc-2035282
3. Mayo Clinic. Placenta: How it works, what’s normal. [Internet] 2022 Dec 03 [cited 2023 Jan 30]. Available from: https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/placenta/art-20044425#:~:text=The%20placenta%20is%20an%20organ,umbilical%20cord%20arises%20from%20it
4. WebMD. Menorrhagia (Heavy period). [Internet] 2022 Aug 24 [cited 2022 Dec 05]. Available from: https://www.webmd.com/women/heavy-period-causes-treatments
5. Centers for Disease Control and Prevention. Heavy menstrual bleeding. [Internet] 2022 Aug 17 [cited 2022 Dec 05]. Available from: https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
Some Medicines
Some medicines can make your bleeding last longer or make it heavier. These include drugs that reduce inflammation and drugs that prevent blood clots. Examples of drugs that prevent blood clots include warfarin and enoxaparin.2
Pregnancy-Related Problems
During pregnancy, an organ called the placenta develops in the uterus.3 Sometimes, this organ can be in an unusual place, such as low-lying or covering the opening of the uterus. This can cause heavy bleeding during pregnancy.2 Also, miscarriage can be a cause of heavy bleeding.4
Intrauterine Device
Using a non-hormonal intrauterine device (a device inserted into the uterus) to prevent pregnancy can cause heavy bleeding, which is a common side effect.2
Cancer
Uterine cancer (cancer of the uterus) or cervical cancer (cancer of the cervix) may cause heavy menstrual bleeding. 5
Bleeding Disorders
If you have a bleeding disorder, it can be hard to stop bleeding incase of a cut. It can also lead to heavy bleeding during periods and can make your periods last longer than usual.4
Medical Conditions
Excessive bleeding during periods may be related to several medical conditions, such as liver or kidney disorders.2
Uterine Growth
Sometimes, polyps (small growths) and fibroids (non-cancerous growths) in the uterus can cause heavy bleeding during periods or make the periods last longer than usual.4
Hormonal Imbalance
Periods happen when the hormones oestrogen and progesterone balance each other, causing the lining of the uterus to shed. If there is a problem with the balance of these hormones, the lining can build up too much and shed through heavy bleeding during periods. This can be caused by conditions like polycystic ovary syndrome (PCOS), obesity, thyroid disorders, etc.2
References:
1. Herman MC, Mol BW, Bongers MY. Diagnosis of heavy menstrual bleeding. Womens Health. 2016;12(1):15-20.
2. Mayo Clinic. Menorrhagia (heavy menstrual bleeding). [Internet] 2022 Jun 25 [cited 2022 Dec 05]. Available from: https://www.mayoclinic.org/diseases-conditions/menorrhagia/symptoms-causes/syc-20352829
3. Mayo Clinic. Placenta: How it works, what’s normal. [Internet] 2022 Dec 03 [cited 2023 Jan 30]. Available from: https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/placenta/art-20044425#:~:text=The%20placenta%20is%20an%20organ,umbilical%20cord%20arises%20from%20it
4. WebMD. Menorrhagia (Heavy period). [Internet] 2022 Aug 24 [cited 2022 Dec 05]. Available from: https://www.webmd.com/women/heavy-period-causes-treatments
5. Centers for Disease Control and Prevention. Heavy menstrual bleeding. [Internet] 2022 Aug 17 [cited 2022 Dec 05]. Available from: https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
How is Heavy Menstrual Bleeding Diagnosed?
Medical History
Your doctor will take your detailed history and will ask about the duration, intensity and regularity of bleeding during periods.1
Physical Examination
Your doctor may conduct a physical examination, including an examination of the pelvis.2
Blood Tests
Your doctor may ask you to undergo blood tests to evaluate anaemia (lack of healthy red blood cells), blood clotting disorders and thyroid disorders.3
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a test that uses a strong magnetic field to create detailed images of the inside of the body. These images can be used to find the cause of heavy menstrual bleeding, such as fibroids, polyps, endometriosis, and adenomyosis.4
Hysteroscopy
Hysteroscopy is a procedure that allows doctors to look inside the uterus using a thin, lighted tube inserted through the opening of the cervix.2
Endometrial Biopsy
Endometrial biopsy is a test where a small piece of tissue is removed from inside the uterus. It is used to check for any abnormal cells.2,5
Sonohysterography
Sonohysterography is a test in which fluid is injected into the uterus and ultrasound is used to create images of the uterus. This helps to look for problems inside the uterus.2,3
Ultrasonography
A transvaginal ultrasound is a test that uses sound waves to create images of the uterus. It can help to look for fibroids (non-cancerous growths) and check for thickness of the lining of the uterus.1,6
References:
1. Herman MC, Mol BW, Bongers MY. Diagnosis of heavy menstrual bleeding. Womens Health. 2016;12(1):15-20.
2. American College of Obstetricians and Gynecologists. Heavy menstrual bleeding. [Internet] 2022 Jun [cited 2022 Dec 06]. Available from: https://www.acog.org/womens-health/faqs/heavy-menstrual-bleeding
3. Mayo Clinic. Menorrhagia (heavy menstrual bleeding). [Internet] 2022 Jun 25 [cited 2022 Dec 05]. Available from: https://www.mayoclinic.org/diseases-conditions/menorrhagia/diagnosis-treatment/drc-20352834
4. The Society of Obstetricians and Gynaecologists of Canada. Abnormal pain and menstrual bleeding. [Internet] [cited 2022 Dec 15]. Available from: https://www.yourperiod.ca/abnormal-pain-and-menstrual-bleeding/exams-and-tests-used-to-investigate-menstrual-disorders/
5. Johns Hopkins Medicine. Endometrial biopsy. [Internet] [cited 2023 Jan 30]. Available from: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/endometrial-biopsy
6. Mayo Clinic. Transvaginal ultrasound. [Internet] [cited 2023 Jan 30]. Available from: https://www.mayoclinic.org/tests-procedures/ultrasound/multimedia/transvaginal-ultrasound/img-20006141
Medical Treatment
HORMONE THERAPY
Drugs that contain hormones called oestrogen and/or progesterone can help reduce the amount of bleeding.1
ANTIFIBRINOLYTIC MEDICINES
Tranexamic acid is a medication that helps to reduce the amount of bleeding. It works by stopping a blood clot from breaking down, and it is usually taken only when bleeding occurs.1,2
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a type of medicine that can help reduce pain and inflammation. Some examples of NSAIDs are ibuprofen and naproxen sodium. They can help reduce bleeding during periods.2,3
Oral contraceptives
Oral contraceptives (birth control pills) not only prevent pregnancy but also can help reduce heavy or long periods.2
Hormonal intrauterine devices
Intrauterine devices (IUDs) (devices that are placed inside the uterus) release a hormone called levonorgestrel, which helps reduce the amount of bleeding during periods.2
Iron supplements
If you have signs of anaemia (lack of healthy red blood cells), you may be advised to take iron supplements.1
References:
1. Centers for Disease Control and Prevention. Heavy menstrual bleeding. [Internet] 2022 Aug 17 [cited 2022 Dec 05]. Available from: https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
2. Mayo Clinic. Menorrhagia (heavy menstrual bleeding). [Internet] 2022 Jun 25 [cited 2022 Dec 06]. Available from: https://www.mayoclinic.org/diseases-conditions/menorrhagia/diagnosis-treatment/drc-20352834
3. National Health Service. NSAIDs. [Internet] 2022 Oct 07 [cited 2023 Jan 30]. Available from: https://www.nhs.uk/conditions/nsaids
4. American College of Obstetricians and Gynecologists. Heavy menstrual bleeding. [Internet] 2022 Jun [cited 2022 Dec 06]. Available from: https://www.acog.org/womens-health/faqs/heavy-menstrual-bleeding
5. Mayo Clinic. Endometrial ablation. [Internet] 2020 Nov 20 [cited 2022 Dec 15]. Available from: https://www.mayoclinic.org/tests-procedures/endometrial-ablation/about/pac-20393932
SURGICAL TREATMENT
Myomectomy
A myomectomy is a surgery to remove fibroids (non-cancerous growths). The surgeon may perform the procedure through a large incision, small incisions, or through the vagina, depending on the size, number, and location of the fibroids. 2
Dilation and Curettage (D&C)
Dilation and curettage (D&C) is a procedure where a doctor removes tissue from the inside of the uterus. The doctor opens the cervix and scrapes the tissue. This procedure helps reduce bleeding during periods. If heavy bleeding recurs, another D&C may be needed.2
Hysterectomy
A hysterectomy is a surgery to remove the uterus. After this surgery, a woman will no longer be able to get pregnant and will stop having periods.1
Uterine Artery Embolisation
Uterine artery embolisation is a procedure to treat heavy menstrual bleeding caused by fibroids (non-cancerous growths). The procedure blocks the blood supply to the fibroids to shrink them. A small tube is inserted into an artery in the thigh and guided to the uterine arteries. The blood flow to the fibroids is reduced by injecting a substance into the blood vessels.2
Endometrial Ablation
Endometrial ablation is a procedure to reduce bleeding during periods. The doctor destroys the inner lining of the uterus without making any cuts. The doctor inserts thin tools through the vagina. Different methods such as extreme cold, heated fluids, microwave energy, or high-energy radio frequencies can be used, depending on the size and condition of the uterus.2,5
References:
1. National Health Portal of India. Abnormal uterine bleeding. [Internet]. 2017 Jul 28 [cited 2022 Dec 23].
2. Bradley LD, Gueye NA. The medical management of abnormal uterine bleeding in reproductive-aged women. Am J Obstet Gynecol. 2016;214(1):31-44.
3. WebMD. Abnormal uterine bleeding. [Internet]. 2022 Sep 07 [cited 2022 Dec 23]. Available from: https://www.webmd.com/women/abnormal-uterine-bleeding
4. Mayo Clinic. Uterine fibroids. [Internet]. 2022 Sep 21 [cited 2022 Dec 23]. Available from: https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/diagnosis-treatment/drc-20354294
5. The Federation of Obstetric and Gynaecological Societies of India. Abnormal uterine bleeding. [Internet]. 2020 [cited 2022 Dec 26]. Available from: https://fogsi.org/wp-content/uploads/fogsi-focus/fogsi-focus-abnormal-uterine-bleeding-2021.pdf
6. Mayo Clinic. Myomectomy. [Internet]. 2022 Jun 28 [cited 2022 Dec 29]. Available from: https://www.mayoclinic.org/tests-procedures/myomectomy/about/pac-20384710
7. Mayo Clinic. Endometrial ablation. [Internet]. 2022 Dec 20 [cited 2022 Dec 26]. Available from: https://www.mayoclinic.org/tests-procedures/endometrial-ablation/about/pac-20393932
8. Web MD. Do I need surgery for uterine fibroids. [Internet]. 2020 Nov 10 [cited 2022 Dec 28]. Available from: https://www.webmd.com/women/uterine-fibroids/surgery-for-uterine-fibroids
9. Siskin GP, Englander M, Stainken BF, et al. Embolic agents used for uterine fibroid embolization. AJR Am J Roentgenol. 2000;175(3):767-73.
10. Mayo Clinic. Abdominal hysterectomy. [Internet]. 2021 Apr 27 [cited 2022 Dec 26]. Available from: https://www.mayoclinic.org/tests-procedures/abdominal-hysterectomy/about/pac-20384559#
:~:text=An%20abdominal%20hysterectomy%20is%20a,the%20uterus%20and%20the%20cervix
11. Johns Hopkins Medicine. Dilatation and curettage. [Internet]. 2021 Oct 19 [cited 2022 Dec 29]. Available from: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/dilation-and-curettage-d-and-c