Heavy Periods (Heavy Menstrual Bleeding)
A period is heavy when it interferes with your life — soaking through a pad or cloth every hour or two, lasting more than seven days, passing clots larger than a ten-rupee coin, flooding at night, or leaving you too tired to work. There is no volume you have to measure; the impact is the definition. The usual causes are fibroids, adenomyosis, polyps in the womb lining, cycles where no egg is released, an underactive thyroid, a copper coil, blood-thinning medicines, and — much less often — an inherited bleeding disorder or a cancer of the womb lining. Because iron deficiency is already common among women in Pakistan, heavy bleeding very often produces anaemia, and the exhaustion it causes is a separate problem that needs treating alongside the bleeding. The first tests are a blood count with a ferritin level, a thyroid test and a pelvic ultrasound, with a sample of the womb lining if you are over 45 or the bleeding is irregular. Most people are treated successfully without surgery, using tablets taken only on bleeding days, hormonal treatment, or the hormone-releasing coil. Bleeding after the menopause, or any bleeding in a possible pregnancy, is different and always needs to be seen.
Health writers · Aslam Clinic
What counts as heavy
Older definitions used a figure — more than 80 millilitres of blood loss per period. Nobody can measure that at home, and it turned out to match poorly with how much trouble the bleeding was actually causing. Current guidance defines heavy menstrual bleeding by its effect on you: bleeding that interferes with your physical, emotional, social or working life. If you are planning your week around your period, that is the definition met.
In practical terms, doctors ask about the things that can be counted. How many pads or cloths in a day, and how soaked each one is when it is changed. Whether you have to get up at night to change. Whether you pass clots, and how big. Whether you have ever bled through onto a chair or a bed. Whether you use two forms of protection at once. Any of these on its own is worth mentioning; several together make the case on their own without a single test.
What causes it
Gynaecologists sort the causes into problems with the structure of the womb and problems with how it is being controlled. The distinction matters because it decides whether the answer is an operation or a tablet.
- Fibroids. growths of muscle in the wall of the womb. Extremely common, often causing nothing at all, but a fibroid pressing into the cavity can double or treble the bleeding.
- Adenomyosis. The lining tissue grows into the muscle wall. Classically causes heavy periods with deep, dragging pain and a bulky womb on scan.
- Polyps. Small soft tags of lining tissue. Almost always , and a common cause of bleeding between periods as well as heavy ones.
- Cycles without ovulation. If no egg is released, the lining builds up under oestrogen with no progesterone to hold it, then sheds unpredictably and heavily. Usual in the first years after periods start and in the years approaching menopause, and typical of polycystic ovary syndrome.
- An underactive thyroid. is easy to miss and easy to treat, and heavy periods are one of the ways it presents. This is why a is checked even when nothing else points to the thyroid.
- A copper coil. A copper intrauterine device reliably increases bleeding, usually most in the first few months. The hormonal coil does the opposite.
- Medicines. Warfarin, aspirin taken daily, and the newer blood thinners all increase menstrual loss. So can some herbal preparations sold for other purposes.
- Bleeding disorders. Around one woman in ten with genuinely heavy periods has an inherited clotting problem, most often von Willebrand disease. The clue is a lifetime pattern — heavy from the very first period, with easy bruising, frequent nosebleeds, or heavy bleeding after a tooth extraction or childbirth.
- Cancer of the womb lining. Uncommon, and rare before 45, but it is the reason bleeding after menopause or a change in a settled pattern is always investigated rather than watched.
Why heavy periods leave you so tired
Every period costs iron. When the loss each month is more than the diet replaces, iron stores fall first, then the follows, and the result is iron-deficiency . National survey data puts anaemia in something like half of Pakistani women of reproductive age, so most women who bleed heavily here start from a low base rather than a full one.
That matters for two reasons. First, the tiredness, breathlessness on stairs, , hair fall and the constant feeling of cold are the anaemia, not the bleeding — and they will not lift just because the bleeding is controlled, because the stores take months to refill. Second, the ferritin level is often the most useful single number in the whole assessment: a normal with a floor-level ferritin says the stores are already empty and the anaemia is coming.
Iron tablets are sold over the counter here, and it is still better to take them because a blood test showed you need them. Iron that is not needed is not harmless, and there are other causes of tiredness worth finding rather than covering.
How it is diagnosed
The history does most of the work. Expect to be asked when the bleeding changed, how the days of the cycle run, whether there is bleeding between periods or after sex, whether there is pain, what contraception you use, and whether pregnancy is possible. Bring a rough count of pads if you can — even a week noted on a phone is more useful than a guess.
- A pregnancy test, whenever pregnancy is possible. Bleeding in early pregnancy is a different problem with a different urgency.
- and ferritin to find anaemia and measure the iron stores behind it.
- to check the .
- A pelvic , ideally transvaginal, which shows fibroids, adenomyosis, polyps and the thickness of the lining. This is the single most informative test.
- A sample of the womb lining () if you are over 45, if the bleeding is irregular or between periods, if treatment has not worked, or if the scan shows a thickened lining. It is taken in clinic with a fine tube and takes a couple of minutes.
- A clotting screen where the pattern suggests an inherited bleeding disorder.
- A camera examination of the cavity (hysteroscopy) where a polyp or a fibroid inside the cavity needs to be confirmed or removed.
| What to look at | Usual | Heavy | Needs urgent review |
|---|---|---|---|
| Pad or cloth changes | Every 3-4 hours | Every 1-2 hours on the worst days | Soaked through every hour for 2 hours running |
| Length of bleeding | 3-7 days | More than 7 days | Bleeding that does not stop at all |
| Clots | Small, occasional | Larger than a ten-rupee coin, most days | Large clots with faintness or breathlessness |
| Nights | One pad lasts the night | Getting up to change, or flooding the bed | Unable to stand without feeling faint |
| Between periods | No bleeding | Occasional spotting | Bleeding after sex, or any bleeding after menopause |
| How you feel | Normal energy | Tired, breathless on stairs, | Chest pain, fainting, grey clammy skin |
Treatment
Treatment is chosen around three questions: what is causing the bleeding, whether you want contraception, and whether you want a pregnancy soon. Almost everyone starts with medicine. Surgery is what is offered when medicine has genuinely been tried and has not worked, or when a fibroid or polyp is clearly the culprit.
| Treatment | What it does | Worth knowing |
|---|---|---|
| Antifibrinolytic tablets (tranexamic acid) | Slow the breakdown of clots in the womb lining, cutting blood loss by roughly a third to a half | Non-hormonal. Taken only on the heavy days, not through the month. Does not affect fertility or the cycle |
| Reduce both bleeding and period pain | Useful when cramps are as much of a problem as the flow. Not for people with stomach ulcers, kidney disease or asthma made worse by them | |
| The hormone-releasing coil (levonorgestrel IUS) | Thins the womb lining from inside. The most effective medical treatment there is; many women stop bleeding altogether after six to twelve months | Lasts five to eight years and is contraceptive. Irregular spotting in the first three to six months is expected and is the commonest reason people give up too early |
| Combined hormonal contraception | Regulates the cycle and lightens the flow | Also contraceptive. Not suitable if you smoke and are over 35, or with with aura, or with a history of clots |
| Progestogen tablets | Given for part of each cycle to control an overgrown lining | Useful for cycles without ovulation and as a short-term measure while waiting for a scan |
| Removing a fibroid or polyp | Takes out the specific structure causing the bleeding, keeping the womb | The right answer when one growth is clearly responsible and you may want a pregnancy |
| Endometrial ablation | Destroys the womb lining, usually in a day-case procedure | For women who have completed their family. Pregnancy afterwards is unsafe, so reliable contraception is still needed |
| Hysterectomy | Removes the womb, ending periods permanently | Definitive, and a last resort rather than a first offer. Ask what has not yet been tried before agreeing to it |
What you can do yourself
- Keep a simple record. Dates, number of pads, clots, and how the day went. Three months of this changes an appointment from guesswork into a decision.
- Take the iron properly. With vitamin C — a glass of fresh lemon water or an orange — and not within two hours of tea, which blocks absorption substantially. Expect three to six months of treatment to refill the stores, and keep going after the normalises.
- Eat for iron. Liver and red meat give the form of iron the body absorbs best. Beans, lentils, dark leafy saag, dates and jaggery contribute, and absorb far better in the same meal as something acidic.
- Treat the pain properly. Taking an anti-inflammatory at the first hint of cramp works better than waiting until it is bad, and reduces the flow at the same time.
- Do not stop a hormonal treatment in the first three months because of irregular spotting. That is the phase it is expected in, and it settles for most people.
- Rest is not the treatment. Heavy bleeding with tiredness is not something to wait out, and it does not mean you are weak. It is a treatable medical problem with a specific set of tests behind it.
When to see a doctor
Book an appointment if your periods have become heavier than they used to be, if they last more than seven days, if you are passing large clots, if you are bleeding between periods or after sex, or if you are tired and breathless in a way you did not used to be. Take the record of your last two or three cycles with you, and mention any blood-thinning or herbal medicines you take.
See someone sooner — within a week or two rather than whenever is convenient — if you are over 45 and the pattern has changed, if you are trying to conceive, or if a previous treatment has stopped working. Go the same day for fever with the bleeding, and the same hour for the emergency signs listed above.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
