Cover image used with licensed permission. © Center for Endometriosis Care/Ken Sinervo MD, MSc, FRCSC. All rights reserved. No reproduction permitted without written permission. Revised since original publication and current as of 2023. No external funding was utilized in the creation of this material. The Center for Endometriosis Care neither endorses nor has affiliation with any resources cited herein. The following material is for informational purposes only and does not constitute medical advice.

Heavy periods: we hate them. 1 in 5 people with periods suffer from heavy bleeding, but their symptoms may often be dismissed and ignored, for upwards of 8-10 years (endometriosis sufferers can relate!). There’s even a hashtag (#WeHateHeavyPeriods) and robust awareness campaign underway, fronted by Actress, Comedian, Director and Women’s Health Activist Aisha Tyler (WeHateHeavyPeriods.com). We had the pleasure of sitting down with Aisha, Dr Cindy Basinski and Jenelle Shaw at a recent health and empowerment event, where Ms. Tyler reminded us of ‘how important it is to be engaged in our own medical care.’

By talking about heavy periods, we can remove the stigma and taboos that continue to enshroud the disorder. But how do we know what’s normal, and when it’s time to seek help?

Abnormal uterine bleeding (AUB) refers to any change in the regularity, frequency, heaviness or length of menstruation (Brennan et al. 2018), with heavy menstrual bleeding (HMB) among the most common clinical presentations of AUB (Elmaoğullari et al. 2018). This common gynecologic problem occurs in approximately 10-35% of menstruators (Kaunitz 2017), including adolescents (Elmaoğullari et al. 2018). But how much is too much, and for how long? Average blood loss during menses has been defined as approximately 30-40 milliliters (2-3 tablespoons) over a period of 4-5 days; a loss of more than 80 milliliters (twice the normal amount) in one cycle - which may last upwards of 7 or more days - is considered heavy and prolonged menstrual bleeding (Smith 2017).

However, thought leaders have pointed out various shortcomings to this volume definition, as actual blood loss is largely subjective and difficult to quantify objectively. Instead, physicians will often rely on the patient narrative: how heavy periods affect their physical, social and emotional status. The need to change menstrual hygiene products after only one or two hours, feeling fatigued or weak during menses and passing sizable clots are among common physical indicators (NCBI 2017). Severe cramping, clotting, nausea and exhaustion are not unusual. Anemia is also common, though it is not required for a diagnosis of AUB.

According to Hologic, those with AUB miss an average of 18 days a year from work and/or school. In addition, 81% find that their heavy period is disruptive to their sex life; 73% say their relationships with others are negatively impacted; and more than 60% have had to miss social or athletic events as a result of heavy bleeding. But it’s not just “a woman’s problem:” the estimated annual direct costs associated with heavy menstrual bleeding is a staggering 1 billion dollars, with indirect costs soaring past 12 billion dollars due to the impact on lost work and quality of life (Sriprasert et al. 2017). It's time to end the silence!

There are various potential causes for AUB, ranging from primary endometrial dysfunction, von Willebrand disease, fibroids, hypothyroidism, hyperprolactinemia, polycystic ovary syndrome and polyps, to adhesions, clotting disorders, adenomyosis or endometriosis  (Brennan et al. 2017, Elmaoğullari et al. 2018, NCBI 2017). Rarely, malignancy may be at the root of the heavy bleeding; sometimes, no clear cause can be defined. Blood tests, pelvic examination, Pap, biopsy, ultrasound or hysteroscopy may be ordered to help clarify the diagnosis, depending on the patient’s specific situation. Treatments may involve medical and/or surgical interventions, and will depend largely on the individual’s fertility plans and the underlying cause of their heavy bleeding. The American College of Obstetricians & Gynecologists states that “treatment for acute AUB should be chosen on the basis of clinical stability, overall acuity, suspected etiology, desire for future fertility and underlying medical problems” (ACOG 2015). To that end, a levonorgestrel-releasing intrauterine device, combined oral contraceptives, progestins or non-steroidal anti-inflammatory drugs (NSAIDs) may be among options offered as medical therapies. In patients with adenomyosis, endometriosis, fibroids or other gynepathology, Laparoscopic surgery may be indicated. Each situation will be handled on a case-dependent basis between the patient and their healthcare partner.

Hysterectomy offers a definitive surgical approach to abnormal uterine bleeding; however, many individuals may seek alternatives to removal of their uterus. One such option is the Novasure® endometrial ablation. This quick, in-office procedure has been demonstrated to be “one of the most effective second-generation techniques in the treatment of chronic heavy menstrual bleeding” (Al-Inizi S 2017). The procedure removes the layer of the uterus, called endometrium, which causes heavy bleeding. It is critical to note that although the uterus remains intact, future fertility is contraindicated. The procedure is not for everyone, and is not without risks, so be sure to check with your personal physician to determine if endometrial ablation is right for you (note: endometrial ablation is not the same procedure as Laparoscopic ablation of endometriosis lesions).

If you suffer from heavy bleeding and your period is affecting your quality of life, physical health, or social and emotional well-being, talk to your doctor. You are not alone, and there are options – and you don’t have to suffer in silence. As Ms. Tyler says, "'it’s time for real talk about below the belt health.”

For more information and to join the conversation, visit:
https://www.multivu.com/players/English/8313451-hologic-we-hate-heavy-periods

https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html

Disclaimer: Any reference to a person, organization, activity, product, brand, technology or service named or otherwise linked herein does not constitute or imply the affiliation with, endorsement by or recommendation of the Center for Endometriosis Care. Any and all material(s) presented herein are offered for informational purposes only. Novasure® is a registered trademark of Hologic, Inc., Marlborough, MA, USA. No financial relationship exists between the CEC and Hologic.

References:

Al-Inizi S. NovaSure radiofrequency endometrial ablation for the management of acute abnormal uterine bleeding. Int J Gynaecol Obstet. 2017 Nov;139(2):247-248.

American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in non -pregnant reproductive-aged women. The. Committee opinion. Number 557, 2013 (Reaffirmed 2015).

Apgar BS, Kaufman AH, George-Nwogu U, Kittendorf  A. Am Fam Physician. 2007 Jun 15;75(12):1813-1819. Web: https://www.aafp.org/afp/2007/0615/p1813.html. Accessed April 27, 2018.

Brennan A, Hickey M. Abnormal uterine bleeding: managing endometrial dysfunction and leiomyomas. Med J Aust. 2018 Feb 5;208(2):90-95.

Elmaoğulları S, Aycan Z. Abnormal Uterine Bleeding In Adolescents. J Clin Res Pediatr Endocrinol. 2018 Feb 28.

Kaunitz AM. Management of abnormal uterine bleeding (June 7, 2017). Web: https://www.uptodate.com/contents/management-of-abnormal-uterine-bleeding. Accessed April 27, 2018.

National Center for Biotechnology Information (NCBI), U.S. National Library of Medicine. Heavy periods: Overview. May 4, 2017. Web: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072478.

Smith, L. What causes heavy menstrual bleeding? (February 1, 2017). Web: https://www.medicalnewstoday.com/articles/295202.php. Accessed April 27, 2018.

Sriprasert I, Pakrashi T, Kimble T, Archer DF. Heavy menstrual bleeding diagnosis and medical management. Contraception and Reproductive Medicine. 2017;2:20.