Reviewed September 2020
Knowing your choices for menorrhagia treatment
Periods differ from woman to woman, and your own period will differ throughout your life, even sometimes from one cycle to the next. In medicine, we speak in averages. The average woman loses around 35mls of blood during her period, roughly a few teaspoonfuls. The average sanitary pad holds 5mls of blood, or about one teaspoonful, so that’s about one soaked pad a day.
Of course, this varies for everyone. For some, it is less, for some it’s a heavy flow for the first day or two and then it tapers off, and for some women it can be much, much more. Heavy menstrual bleeding is estimated to affect around a quarter of those who menstruate.1
While previous medical definitions of menorrhagia (heavy menstrual bleeding) suggested it could be quantified as blood loss of more than 80mls during one menstrual period (two to three times more than average), these days we rely more on what you think of your period, and how we can help you to maintain your quality of life during your cycles.
This means that if you go to your doctor about heavy periods they will ask you questions such as how many pads you use in a day, if you’ve ever needed to wear more than one pad at once, if you’ve ever had any accidents where your flow has been so heavy as to leak through your pads and on to clothes (flooding), and whether you pass large clots. For some women, all these things may be the case, and they can find it anything from a slight hindrance to severely debilitating.
Establishing the cause of menorrhagia
The first step in deciding treatments for menorrhagia is to determine what is causing it in the first place, and it could be down to a wide variety of causes. For example, menorrhagia could be the result of a hormonal imbalance resulting in some cycles where you don’t ovulate, causing your periods to be heavy and irregular.
It could be because of a non-hormonal intrauterine device (IUD) such as the copper coil, and so you would be able to pinpoint the change in your flow to after the insertion of your IUD. Uterine fibroids (benign growths of the uterine muscle) can also cause menorrhagia. This can leave you with heavy periods, a larger than usual uterus that causes issues with urination, and the feeling of heaviness or something coming down (prolapse).
Your heavy periods could be due to endometriosis or adenomyosis, where the endometrial lining grows outside the uterus, or within the uterine muscle respectively, and bleeds from there every month too. These conditions can also cause your periods to be extremely painful.
Your doctor will evaluate all of the factors that can cause menorrhagia and also take into account your prior gynaecological history, any family or medical history to do with clotting disorders, medications you are on that may cause bleeding such as blood thinners, and your age, weight, and family size, to form a diagnosis
Sometimes menorrhagia is caused by an endometrial polyp, a small growth within the womb that can also cause spotting in between your periods. Alternatively, it might be due to entering the climacteric, when your body is preparing to enter menopause.
Your doctor will evaluate all of these factors and also take into account your prior gynaecological history, any family or medical history to do with clotting disorders, medications you are on that may cause bleeding such as blood thinners, and your age, weight, and family size, to form a diagnosis.
Once you have given your doctor a history and they have examined you, they will suggest investigations to determine if your blood levels are low (anaemia) as a result of heavy periods, and whether or not your need treatment for that.
Your doctor will also decide what the most appropriate next investigation is in order to diagnose a cause for your bleeding. This may involve taking a sample from the lining of your womb, which can be done in a clinic and feels like a smear test. Or, you might be sent for an ultrasound, a hysteroscopy (a camera in the womb, which can be done in clinic or under general anaesthetic), or another form of imaging.
What are your menorrhagia treatment options?
Your choices for treatment depend on the cause of your heavy bleeding, and also on whether or not you are trying to conceive, whether you wish to have a family in the future, or if you are not planning on having any more children. They also depend on your age, comorbidities, and if there is anything suspicious in your history or whether you need investigations that need a tissue sample to diagnose. Your doctor will offer you a range of options from those detailed below to best suit your personal symptoms and needs.
The first step is ensuring you are at a healthy weight and the keeping of a menstrual diary. This helps you and your doctor to delineate what the cause may be and how it is affecting your life. Although the evidence for cause-and-effect is limited, having a high BMI can increase the risk of ovulatory dysfunction and, therefore, heavy menstrual bleeding.2 Being overweight can contribute to hormonal imbalances resulting in changes to your menstrual cycle, because fat cells release oestrogen. Thyroid disorders can also lead to heavy menstrual cycles.
From there, your doctor may prescribe you a drug to decrease your blood loss, called tranexamic acid. This tablet works by encouraging your blood to clot, and it is so effective that it is used in major trauma situations to keep people alive.
The next step is hormonal medication. Going on the pill helps with heavy periods because it regulates hormone levels, preventing a build up of endometrial lining and reducing the heaviness of your flow when it does occur.
Alternatively you may be offered to take the pill back-to-back for three months, and only have a withdrawal bleed four times a year, to minimise the effect of heavy menstrual bleeding on your life.
The Mirena intrauterine device has revolutionised treatment for heavy menstrual bleeding, as it provides a local distribution of a low-dose progesterone hormone that has drastically improved symptoms and reduced the rate of surgery. It’s a tiny t-shaped device a few centimetres long that can be fitted by your GP, and lasts for five years.
Should you decide you don’t wish to continue using the Mirena coil, it can be easily removed by your GP too.
If your heavy bleeding is a result of fibroids, you may be offered a hormonal injection that puts your body into a temporary menopause for three to six months. This has the benefit of both stopping your periods and also shrinking the size of your fibroids if they are quite large, which can make surgery to remove them easier if that is what is needed.
The Mirena intrauterine device has revolutionised treatment for heavy menstrual bleeding, as it provides a local distribution of a low dose progesterone hormone that has drastically improved symptoms and reduced the rate of surgery. It’s a tiny t-shaped device a few centimetres long that can be fitted by your GP, and lasts for five years
However, a side effect of this is an increased likelihood of developing osteoporosis or brittle bones3 – and so you will be given ‘add back therapy’ which consists of supplements to keep your bones strong.
Surgical treatment options for heavy periods
From there we move on to surgical options, which again will be decided upon after a discussion between you and your doctor, and depend upon your fertility goals, your quality of life, other medical issues, and any concerns.
A hysteroscopy and/or polypectomy (camera inserted into womb and removal of a growth) may be offered if a growth was suspected as the cause on ultrasound, or if you are above the age of 40 or perimenopausal, and a scan shows a thickened or irregular endometrial lining.
Endometrial ablation is another very effective technique in the management of heavy menstrual bleeding that can help you to avoid major surgery. It involves putting you to sleep and inserting a device that measures the size of the uterine cavity, which calculates the dosage of the technique used that is needed to destroy or remove your endometrial lining. Techniques used include radiofrequency, freezing, and heating. This option is only suitable for women who are not looking to have any more children.
In a slightly similar approach, you may be offered a transcervical resection of your endometrium (which means they go in through the vagina and use heat to cut away the endometrial lining under direction vision). If you have quite a large uterine cavity and it isn’t felt that ablation will be successful, or it has been tried but it failed, this may be an option. Again, this is only to be used if you are not going to have any more children.
Depending on the size and location of the fibroid, this can be done either through the cervix (a transcervical resection of fibroid) or abdominally (a myomectomy). Both these options are suitable if it is fibroids causing your heavy bleeding and you are looking to conceive in the future. You may be placed on hormonal treatment prior to surgery in order to reduce the size of your fibroids and ensure their successful removal. Not everyone is suitable for this treatment, however, for example if the fibroids are too large or there are too many.
Finally, hysterectomy or removal of the uterus and fallopian tubes is an option. This can be done with or without the removal of the ovaries, depending on your age, family history, and preferences after discussing the risks and benefits of removing your ovaries with your doctor.
There are a vast array of treatments ranging from non invasive and non hormonal, to hormonal, and progressively more invasive. Treatment depends upon the cause of your bleeding, your preferences, your quality of life, your age and your fertility desires.4
Last updated September 2020
Next update due 2022
Author’s disclaimer: This content is designed to provide general information and is not a substitute for medical advice. Medical opinion, practice and routine may vary from country to country and may change from time to time. The author is not liable for the results of misuse or inappropriate application of the information. If you are an individual who chooses to access this information, you should not rely on the information as professional medical advice or use it to replace any relationship with your doctor or other qualified healthcare or social care professional. For medical concerns, including decisions about medications and other treatments, individuals should always consult their doctor or, in serious cases, seek immediate assistance from emergency personnel. Individuals with any type of medical condition are specifically cautioned to seek professional medical advice before beginning any sort of health treatment. Individuals with specific queries or concerns should seek appropriately qualified medical advice. Clinicians must use their own judgement when interpreting this information and deciding how best to apply it to the treatment of patients.
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- Bruinvels, G., et al., The prevalence and impact of heavy menstrual bleeding among athletes and mass start runners of the 2015 London Marathon, British Journal of Sports Medicine, 2016, vol 50, issue 9, p 566
- Maybin, J.A., and Critchley, H.OD., Medical management of heavy menstrual bleeding, Women’s Health (Lond), January 2016, vol 12, no 1, pp 27-34
- InformedHealth.org, ‘Uterine Fibroids: when is treatment with hormones considered?‘ in Institute for Quality and Efficiency in Health Care, Cologne, Germany, InformedHealth.org, March 2020, [online] (accessed 12 September 2020)
- NICE, Heavy Menstrual Bleeding: assessment and management, Nice Guideline NG88, National Institute for Health and Care Excellence, March 2020 [online] (accessed 12 September 2020)
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