Heavy Periods

Often no structural cause

In a substantial proportion of women no abnormality is found. That does not make the bleeding less real or less treatable — it simply means treatment is aimed at the bleeding itself, which works well.

Structural causes

• Fibroids — benign growths in the womb, very common, and a frequent cause
• Adenomyosis — womb lining growing into the muscle wall. Causes heavy and painful periods with a bulky tender uterus, and is under-diagnosed
• Endometrial polyps
• Endometriosis

Hormonal and medical causes

• Anovulatory cycles — common in the first years after periods start and again in perimenopause
• Underactive thyroid, which is easy to test and easy to treat
• PCOS
• Bleeding disorders — particularly von Willebrand disease. This is important: a meaningful proportion of teenagers with heavy periods from the very start have an undiagnosed inherited bleeding disorder. Heavy periods since your first one, easy bruising, nosebleeds, or heavy bleeding after dental work or childbirth all point to it, and it is very often missed for decades
• Medication — anticoagulants such as warfarin, apixaban and rivaroxaban; and the copper coil, which commonly makes periods heavier

What must be excluded

Endometrial hyperplasia or cancer — which is why bleeding between periods, after sex, or after the menopause is always investigated, and why persistent heavy bleeding over 45 warrants assessment of the womb lining.

The history establishes the diagnosis; testing establishes the cause and the consequences.

Blood tests — the essential one

• Full blood count and, critically, ferritin. Haemoglobin alone is not enough — iron stores empty long before haemoglobin falls, so a woman can be severely iron deficient and exhausted with a completely normal full blood count. Ferritin is the test that finds it, and it is skipped constantly
• Thyroid function
• Clotting studies and von Willebrand testing where periods have been heavy since they began, or where there is a bleeding history

Imaging

Pelvic ultrasound where fibroids or adenomyosis are suspected, where the uterus feels enlarged, or where treatment has not worked. Not needed for everyone — treatment can begin without it in a woman with a normal examination and no red flags.

What we cannot do remotely

We cannot examine you or take a smear. Pelvic examination is needed where there is pain, suspicion of a structural cause, or unexplained bleeding, and we arrange it. Cervical screening is a physical procedure and free on the NHS — if you are due, we will say so.

Bleeding that changes the assessment entirely

Bleeding between periods, bleeding after sex, or any bleeding after the menopause is investigated in its own right and is not treated as part of heavy periods. Over 45 with heavy bleeding not responding to treatment, assessment of the womb lining is warranted.

Getting the iron right

• Alternate-day dosing absorbs better than daily. Counter-intuitive, well-evidenced, and gentler on the stomach
• Take with orange juice or a vitamin C tablet
• Avoid tea, coffee, milk and calcium supplements within two hours — all substantially block absorption, and tea with iron tablets is a common and avoidable mistake
• Expect dark stools; that is normal. Constipation is common and manageable
• Keep going for three months after your ferritin is normal — stopping as soon as the number recovers means the stores never refill and you will be back within months

Getting tranexamic acid right

It works best started as soon as heavy bleeding begins and taken regularly through the heavy days — not saved for the worst day.

Practical measures

• Track your cycle — an app or a note. Recording days of bleeding, flooding and how often you change protection turns a vague account into evidence, and makes it far easier to show whether treatment is working
• Menstrual cups hold considerably more than tampons and let you measure loss, which some women find useful
• Dietary iron helps but cannot correct an established deficiency on its own — you cannot eat your way out of it once stores are empty
• Period products are free in schools and colleges, and available through some community schemes

The thing worth saying

Periods that stop you working, ruin clothes or leave you exhausted are not something to put up with. Effective treatment exists, much of it simple and non-hormonal, and there is no prize for endurance.

How do I know if my periods are actually heavy?

If they are interfering with your life, they are heavy — that is the clinical definition, and your judgement is what counts. Practical markers: changing protection hourly, clots bigger than a 10p coin, flooding through clothes, needing to change at night, or bleeding beyond seven days. Most women have no reference point, which is why so many assume theirs are normal.

Why should I ask for ferritin and not just a blood count?

Because iron stores empty long before haemoglobin drops. You can be profoundly iron deficient — exhausted, breathless, losing hair — with a completely normal full blood count. Ferritin is the test that shows it, and it is routinely omitted. If you have heavy periods and fatigue, ask for it by name.

What is tranexamic acid?

A non-hormonal tablet taken only during your period that reduces blood loss by roughly half. It does not affect your hormones, your cycle or your fertility. It is cheap, effective and considerably under-prescribed — for a lot of women it is the whole answer, and many have never heard of it.

Do I have to have a coil?

No. The hormonal coil is the most effective option and is recommended first-line, but it is a recommendation rather than a requirement. Tranexamic acid, mefenamic acid, the combined pill and other options all exist, and a non-hormonal route is perfectly reasonable if that is what you want.

Could this be fibroids?

Possibly — they are very common and a frequent cause. So is adenomyosis, where the lining grows into the muscle of the womb, causing periods that are both heavy and painful. An ultrasound answers the question, and it does not change the first steps of treatment.

My periods have been heavy since I was 13. Is that relevant?

Very. Heavy bleeding from the very first period raises the question of an inherited bleeding disorder such as von Willebrand disease, which is more common than people realise and frequently goes undiagnosed for decades. Easy bruising, frequent nosebleeds or heavy bleeding after dental work make it more likely. It is worth testing for.

Will this affect my fertility?

Heavy bleeding itself usually does not, though the underlying cause sometimes can — fibroids and endometriosis in particular. Iron deficiency affects how you feel rather than your fertility. Most treatments are fully reversible, and tranexamic acid does not affect fertility at all.

Is it just perimenopause?

Periods commonly become heavier and less predictable in the years before the menopause, and that is a real explanation. But it is not a reason to leave it untreated — and it does not exclude fibroids or a problem with the womb lining. Over 45 with heavy bleeding that does not respond to treatment, the lining should be assessed.