Heavy Menstrual Bleeding

Abnormal uterine bleeding (AUB) refers to bleeding that differs from typical menstrual patterns in its frequency, timing, duration, or amount.

Examples include:

• Heavy menstrual bleeding: Soaking through menstrual products frequently, needing double protection, passing large blood clots, or experiencing bleeding that interferes with daily activities.

• Prolonged bleeding: Periods lasting longer than 8 days.

• Irregular periods: Menstrual cycles that are consistently unpredictable, occur too frequently, or are unusually far apart.

• Bleeding between periods: Spotting or bleeding outside your expected menstrual cycle.

• Bleeding after intercourse: Spotting or bleeding following sexual activity.

• Postmenopausal bleeding: Any vaginal bleeding after 12 consecutive months without a period, when not explained by hormonal medications.
  
  

Remember: You do not have to experience severe bleeding or anemia for your symptoms to deserve attention. If your periods are interfering with your daily life or have changed significantly from your usual pattern, please discuss your concerns with your healthcare provider.

• Heavy Menstrual Bleeding (ACOG)

• Abnormal Uterine Bleeding (ACOG)

• Abnormal Uterine Bleeding: A Guide for Patients (ASRM)

• Heavy Menstrual Bleeding: What's Too Much? (Lora Shahine, MD, video)

Heavy or abnormal uterine bleeding can occur for many reasons. Some conditions affect the structure of the uterus, while others involve hormonal changes, irregular ovulation, or underlying medical conditions. Understanding the cause of your bleeding can help determine which treatment options may be most effective.

Structural Causes

These conditions involve physical changes within the uterus or cervix.

• Uterine Fibroids: Common, noncancerous growths of the uterine muscle. Depending on their size and location, fibroids may cause heavy or prolonged periods, pelvic pressure, or pain.

• Adenomyosis: A condition in which tissue similar to the uterine lining grows within the muscular wall of the uterus. It can cause heavy, painful periods and pelvic discomfort.

• Endometrial polyps: Usually benign growths arising from the uterine lining. They may cause irregular bleeding, spotting between periods, or heavy menstrual bleeding.

  • 1. • Uterine Polyps (Cleveland Clinic)

       • Understanding Uterine Polyps (Natalie Crawford, MD, video)

• Endometrial hyperplasia: Abnormal thickening or overgrowth of the uterine lining, sometimes associated with prolonged estrogen exposure without adequate progesterone. Certain forms can increase the risk of endometrial cancer.

  • 1. • Endometrial Hyperplasia (ACOG)

       • Endometrial Hyperplasia (Yale)

• Cervical conditions: Cervical polyps, inflammation, or other abnormalities may cause spotting or bleeding, particularly after intercourse.

  • 1. • Cervical Polyps (Merck)
         
         

Hormonal & Ovulatory Causes

Hormonal changes can affect how regularly the uterine lining develops and sheds.

• Perimenopause: Fluctuating hormone levels and less predictable ovulation can cause irregular, heavier, or prolonged periods.

• Polycystic ovary syndrome (PCOS): Irregular or absent ovulation may lead to infrequent periods followed by episodes of heavy or prolonged bleeding.

• Other ovulatory changes: Stress, significant weight changes, certain medical conditions, and other factors can interfere with normal ovulation and menstrual cycles.
  
  

Other Possible Causes

• Bleeding disorders: Conditions affecting blood clotting can contribute to unusually heavy periods, sometimes beginning during adolescence.

• Medications: Blood thinners, certain hormonal medications, and some contraceptive methods may change bleeding patterns.

• Thyroid disorders: Both overactive and underactive thyroid conditions can affect menstrual regularity.

• Pregnancy-related conditions: Miscarriage, ectopic pregnancy, and other pregnancy complications can cause unexpected bleeding.

• Endometrial cancer: Although less common, abnormal bleeding can occasionally be a sign of cancer of the uterine lining, particularly after menopause.

Not all causes of abnormal bleeding are visible on an ultrasound. Your medical history, symptoms, examination, and any recommended testing help determine the most likely cause.

If you are experiencing heavy, irregular, or unexpected bleeding, your healthcare provider may recommend an evaluation to help identify the underlying cause. The tests recommended will depend on your age, symptoms, medical history, and individual risk factors. Not every patient needs every test. Your evaluation will be tailored to your specific concerns.

Medical History & Physical Examination

Your provider will ask about your menstrual cycles, including how often you bleed, how long your periods last, and how heavy your flow is. We may also discuss associated symptoms, medications, medical conditions, and your pregnancy plans.

A pelvic examination may be recommended to look for abnormalities involving the cervix, uterus, or vagina.

Depending on your symptoms and examination findings, your provider may also recommend testing for vaginal infections or sexually transmitted infections (STIs). Certain infections, particularly those involving the cervix, can cause spotting, bleeding between periods, or bleeding after intercourse.

• Vaginal Infections & Discharge 

• STIs (Sexually Transmitted Infections)
  
  

Laboratory Testing

Depending on your symptoms, blood tests may include:

• Complete blood count (CBC): Checks for anemia related to blood loss.

• Iron studies: May be recommended to evaluate for iron deficiency, even if you are not anemic.

• Pregnancy test: Helps rule out pregnancy-related causes of bleeding when appropriate.

• Thyroid or other hormone testing: May be recommended when your history suggests an underlying hormonal condition.

• Additional testing: Occasionally needed to evaluate for bleeding disorders or other medical conditions.
  
  

Pelvic Ultrasound

A pelvic ultrasound uses sound waves to evaluate the uterus, uterine lining, and ovaries. It can help identify fibroids, ovarian abnormalities, and other possible causes of bleeding. Ultrasound may be performed over the abdomen, vaginally, or using both approaches.

• Ultrasound Exams (ACOG)
  
  

Saline Infusion Sonohysterogram (SIS)

A sonohysterogram is a specialized ultrasound performed after a small amount of sterile saline is introduced into the uterine cavity through a thin catheter. The saline helps outline the uterine lining, making it easier to identify abnormalities such as endometrial polyps or fibroids that extend into the uterine cavity. This test may be recommended when a routine ultrasound does not provide enough information.

• Sonohysterography (ACOG)

• Saline Infusion Sonohysterogram (ASRM)
  
  

Endometrial Biopsy

An endometrial biopsy involves collecting a small sample of tissue from the uterine lining to examine under a microscope. It may be recommended to evaluate for endometrial hyperplasia, precancerous changes, or endometrial cancer, particularly in patients age 45 and older with abnormal bleeding or younger patients with certain risk factors.

• Endometrial Biopsy: What to Expect
  
  

Hysteroscopy

In some cases, your provider may recommend hysteroscopy, a procedure that uses a thin camera to look directly inside the uterus. Hysteroscopy can help identify abnormalities that may not be clearly visible on ultrasound and may allow removal of polyps or other abnormal tissue.

• Hysteroscopic Surgery
  
  

Remember: The goal of testing is to understand why your bleeding is occurring so we can recommend treatment options that best fit your symptoms, preferences, and reproductive goals.

Heavy or abnormal menstrual bleeding can affect more than just your period. While occasional changes in bleeding may not be concerning, persistent or excessive bleeding can affect your physical health, emotional well-being, and quality of life.

Iron Deficiency & Anemia

Heavy or prolonged bleeding can cause your body to lose more iron than it can replace. Over time, this may lead to iron deficiency, with or without anemia.

Symptoms may include:

• Fatigue or low energy

• Weakness or dizziness

• Headaches

• Shortness of breath with activity

• Difficulty concentrating

• Heart palpitations

Severe anemia can place additional strain on your heart and may occasionally require urgent treatment.

Impact on Daily Life

Heavy or unpredictable bleeding can interfere with work, exercise, travel, sleep, and social activities. Some patients find themselves planning their schedules around their periods, worrying about bleeding through clothing, or avoiding activities because of discomfort or embarrassment.

Your quality of life matters. Even if your blood counts are normal, bleeding that interferes with your daily activities is a valid reason to discuss treatment.

Identifying Underlying Medical Conditions

Abnormal bleeding can sometimes be a symptom of an underlying condition, such as fibroids, polyps, hormonal disorders, or changes involving the uterine lining. Evaluation is important because certain conditions, including endometrial hyperplasia or cancer, may require specific treatment or monitoring.

Improving Your Overall Well-Being

Treatment can help reduce bleeding, improve energy levels, prevent or correct iron deficiency, and make menstrual cycles more manageable. There are many treatment options available, ranging from medications to minimally invasive procedures and surgery. The best  approach depends on the cause of your bleeding, your symptoms, and your personal preferences.

Remember: You do not need to wait until your bleeding becomes severe or causes anemia to seek help. If your periods are affecting your quality of life, we can discuss options to help.

There are many treatment options available for heavy or abnormal uterine bleeding, ranging from medications to minimally invasive procedures and surgery. The best treatment depends on the underlying cause of your bleeding, the severity of your symptoms, your medical history, and whether you are planning future pregnancies. Not every patient needs surgery, and many patients experience significant improvement with medications alone.

Nonhormonal Medications

These medications can help reduce menstrual bleeding without changing your hormone levels.

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Medications such as ibuprofen (Advil, Motrin) or naproxen (Aleve) can help reduce menstrual bleeding and relieve menstrual cramps. They are typically taken during your period and may not be appropriate for patients with certain medical conditions.

• Tranexamic acid (Lysteda): A prescription medication that helps reduce menstrual blood loss by supporting the body's natural clotting process. It is taken only during heavy bleeding days and does not contain hormones. It is not appropriate for everyone, particularly patients with a history of blood clots or certain other risk factors.

Hormonal Contraception

Hormonal birth control can be very effective for managing heavy, painful, or irregular periods, even when contraception is not needed.

Options may include:

• Combined hormonal contraception: Birth control pills, patches, or vaginal rings can help regulate menstrual cycles, reduce bleeding, and improve menstrual cramps.

• Progestin-only contraception: Certain progestin-only pills, injections, or implants may help manage bleeding, although some methods can also cause unpredictable spotting.

• Hormonal IUD (Mirena): A levonorgestrel-releasing IUD that delivers progestin directly to the uterine lining. It is one of the most effective nonsurgical treatments for heavy menstrual bleeding and may significantly reduce or even eliminate periods.

→ Birth Control & Contraceptive Options

Other Hormonal Medications

Some hormonal medications are used specifically to control abnormal bleeding or treat underlying conditions. Some of these medications temporarily create a low-estrogen state and may cause hot flashes, changes in bone density, or other side effects. Certain treatments have limitations on how long they can safely be used.

• Oral progestins: Medications such as norethindrone acetate (Aygestin) or medroxyprogesterone acetate (Provera) can help stabilize the uterine lining and reduce irregular or prolonged bleeding. They may be prescribed for short-term treatment or longer-term management.

• Myfembree: A combination medication that suppresses certain reproductive hormones and is approved for heavy menstrual bleeding associated with uterine fibroids. It may also be used for moderate to severe endometriosis-associated pain.

• Oriahnn: Another hormonal medication approved to reduce heavy menstrual bleeding associated with uterine fibroids.

• Leuprolide (Lupron): An injectable medication that temporarily suppresses ovarian hormone production. It may be used to shrink fibroids, improve bleeding, or prepare for surgery.
  
  

Minimally Invasive Procedures

When medications are ineffective or a specific abnormality is identified, a procedure may be recommended.

• Hysteroscopy: A procedure that uses a thin camera to look directly inside the uterus. It can also be used to remove endometrial polyps or certain fibroids that extend into the uterine cavity.

• Endometrial ablation: A procedure that destroys the uterine lining to reduce or stop menstrual bleeding. It may be an option for patients who have completed childbearing and do not have certain underlying uterine conditions. Please note: Endometrial ablation is not a form of contraception. Pregnancy after ablation can be dangerous, so reliable contraception is still necessary until menopause.
  
  

Fibroid-Specific Procedures

When uterine fibroids are contributing to heavy bleeding, several additional treatments may be available.

• Uterine artery embolization (UAE): A minimally invasive procedure performed by an interventional radiologist that blocks blood flow to fibroids, causing them to shrink.

• Sonata: A procedure that uses ultrasound guidance and radiofrequency energy to treat certain fibroids from inside the uterus.

• Acessa: A laparoscopic procedure that uses radiofrequency energy to treat fibroids through small abdominal incisions.

• Myomectomy: Surgery to remove fibroids while preserving the uterus. Depending on the size, number, and location of fibroids, this may be performed hysteroscopically, laparoscopically, robotically, or through an abdominal incision.

Not every procedure is appropriate for every type of fibroid. If you are planning future pregnancies, your reproductive goals are especially important when selecting a treatment.

→ Uterine Fibroids
→ Fibroid Procedures

Hysterectomy

A hysterectomy is surgery to remove the uterus. It is the definitive treatment for uterine bleeding, because menstrual bleeding permanently stops after the uterus is removed. Hysterectomy may be considered when other treatments have been unsuccessful, are not appropriate, or when a patient prefers a permanent solution. The procedure may be performed vaginally, laparoscopically, robotically, or through an abdominal incision, depending on individual circumstances.

Removing the uterus does not necessarily mean removing the ovaries. In many cases, the ovaries can be preserved, allowing continued natural hormone production until menopause. Pregnancy is no longer possible after hysterectomy.

→ Hysterectomy

Treating Iron Deficiency & Other Underlying Conditions

Patients with heavy bleeding may also need treatment for iron deficiency or anemia. This may include oral iron supplements or, in more severe cases, intravenous iron.

Other underlying conditions, such as thyroid disorders, infections, or endometrial hyperplasia, may require additional or condition-specific treatment.

Choosing the Right Treatment

There is no single treatment that is best for everyone. Some patients prefer to avoid hormones, while others prioritize lighter periods, contraception, preserving fertility, or finding a permanent solution.

Our goal is to help you find a treatment that improves your symptoms and fits your individual needs and preferences.

• What are the treatment options for heavy periods? (Informed Health) 

• Decision Aid: Treatment Options for Heavy Periods (Informed Health)

• Treatment Options for Heavy Menses & Fibroids (Michigan Medicine, video)

• Tips To Manage Your Period (Natalie Crawford, MD, video)