Heavy Periods: When Is It Not Normal?

Having a period every month is a part of life. But if your period has started to run your life, you do not have to put up with it in silence. The NHS notes that many women have heavy periods and that this can be normal for some. Still, heavy menstrual bleeding, known medically as menorrhagia, is a condition that can be assessed and treated.

What counts as heavy bleeding? According to the NHS and the US Centers for Disease Control and Prevention (CDC), these may point to heavy menstrual bleeding:

• You need to change your pad or tampon every 1-2 hours, or empty your menstrual cup more often than recommended
• You need to use two products at the same time
• Your period lasts longer than 7 days
• You pass clots larger than about 2.5 cm (1 inch)
• Blood leaks through onto your clothes or bedding
• Because of the bleeding, you avoid daily activities such as exercise or cannot go to work
• You often feel tired or short of breath

What really matters is your quality of life. The UK's National Institute for Health and Care Excellence (NICE) stresses that heavy menstrual bleeding seriously affects a woman's quality of life, and that treatment should focus on improving quality of life rather than on the amount of blood. Cycles and blood loss vary from woman to woman. If you do not feel you are in the normal range, you have every right to talk about it with your doctor.

It is more common at certain times of life. The NHS notes that heavy periods can occur in the first years after periods start, after giving birth and when approaching menopause. The American College of Obstetricians and Gynecologists (ACOG) also says that cycles without ovulation can cause irregular and sometimes heavy bleeding, especially in the first years of periods and during the transition to menopause. Even at these times, if the bleeding affects your life, it needs to be assessed.

Possible causes: The main causes listed by the NHS and ACOG:

• Fibroids and polyps: Noncancerous growths in the uterus
• Adenomyosis: The lining of the uterus growing into the wall of the uterus
• Endometriosis and pelvic inflammatory disease
• Ovulation problems: Polycystic ovary syndrome and an underactive thyroid can disrupt ovulation and cause irregular, sometimes heavy bleeding.
• Bleeding disorders: For example, von Willebrand disease
• Some medicines: Such as blood thinners. According to ACOG, a copper IUD can also make periods heavier, especially in the first year.
• Rarely, uterine cancer

ACOG notes that sometimes more than one cause can be present at once.

Clues that suggest a bleeding disorder: According to ACOG, if your periods have been heavy since they first started, you may have a bleeding disorder. Other signs are heavy bleeding after childbirth or surgery, bleeding gums after dental work, easy bruising and frequent nosebleeds. NICE recommends considering clotting tests for women whose periods have been heavy from the start and who have a personal or family history suggesting a bleeding disorder.

Watch for anemia: The CDC notes that untreated heavy bleeding can lead to anemia and leave you tired and weak. According to the CDC, tiredness, low energy and shortness of breath are signs to watch for. NICE recommends a full blood count for every woman with heavy menstrual bleeding, at the same time as treatment.

What will your doctor look at? According to NICE, your doctor will first listen to your symptoms and how they affect your life, and examine you if needed. Depending on your symptoms, an ultrasound or a hysteroscopy, in which a thin camera is used to look inside the uterus, may be ordered. NICE recommends not routinely doing thyroid tests if there are no other thyroid symptoms, nor female hormone tests. ACOG and the CDC recommend noting down, for a few weeks before your appointment, the dates of your bleeding, how many days it lasts and how heavy it is, for example how many pads or tampons you use. HeyMom's period tracker can be a practical way to do this.

Treatment options: According to NICE, treatment is chosen together with you based on your preferences, any other health conditions and whether you have fibroids or polyps. The general framework:

• For women with no obvious cause, with fibroids smaller than 3 cm (about 1.2 inches) that do not distort the uterine cavity, or with adenomyosis, a hormone-releasing intrauterine system can be considered as the first option.
• If this is not suitable, there are non-hormonal options (tranexamic acid, nonsteroidal pain relievers) or hormonal options (combined hormonal birth control, cyclical progestogen tablets).
• If treatment does not work or symptoms are severe, referral to a specialist and surgical options can be discussed, such as endometrial ablation, which destroys the lining of the uterus, removal of fibroids inside the uterus or removal of the uterus.

If you are planning a pregnancy, be sure to say so, because some treatments affect fertility. Use medicines only as recommended by your doctor.

When to see a doctor, when to go to the ER? According to the NHS, see your doctor if heavy periods are affecting your life, have been going on for a long time, if you have severe pain or if you have bleeding between periods or after sex. According to ACOG, if you are changing your pad or tampon every hour for more than 2 hours and this comes with chest pain, shortness of breath, lightheadedness or dizziness, get emergency medical help right away and call your local emergency number. If you think you might be pregnant and have heavy bleeding, also get help without waiting.

Dear woman, if your period wears you out every month and ruins your plans, this is not something you are "exaggerating." With the right assessment and treatment, many women find relief. Do yourself this kindness and do not hesitate to speak up.