Heavy periods during the perimenopause: what you need to know

If you suffer with heavy bleeding or flooding, help is at hand

• Heavy bleeding is common during the perimenopause
• Various treatments can help, including HRT
• Learn how to manage heavy bleeding and ask for help

One in three women describe their periods as heavy [1], a condition that’s medically known as menorrhagia. If this affects you, it might be something you’ve had to deal with for most of your life or it might be a new, unwelcome symptom of perimenopause. Either way, heavy periods can cause disruption, distress and difficulties in every area of your life, including work, exercise, your social life and your sex life.

What is classed as a heavy period?

It is difficult to measure the blood lost during your period, but they are considered heavy if you need to change your pad or tampon every one to two hours, or empty your menstrual cup more often than is recommended. If you regularly need to double up on sanitary products, such as using a pad and a tampon together, if your periods last more than seven days, or you bleed through clothes or bedding, this can also suggest heavy periods.

Other signs include passing blood clots larger than the size of a 10p coin, avoiding daily activities like exercise, or taking time off work due to your periods and feeling tired or short of breath.

Heavy periods don’t necessarily mean painful periods, but they can bring you pain and discomfort.

What causes heavy periods?

In more than half of cases the exact cause of heavy periods is not known [2]. Common causes can include:

• Fibroids, which are benign enlargements of muscle in the wall of your womb, or endometrial polyps, benign outgrowths of the lining of your womb
• Endometriosis, when cells similar to the lining of your womb grow elsewhere in the body, and adenomyosis, when these cells grow in the muscular walls of the womb, can both cause heavy periods.
• Pelvic inflammatory disease, an infection which can affect your womb, fallopian tubes and ovaries
• A sexually transmitted disease or by bacteria that normally live in your vagina
• Polycystic ovarian syndrome (PCOS)
• If you have a copper coil, this can also lead to heavy periods
• Some auto-immune conditions and some thyroid disorders can put you at higher risk of heavy periods

During perimenopause, it’s not unusual for women to experience heavy bleeding [3], and changes to your periods are often an early sign of the perimenopause. During this time, oestrogen and progesterone, the hormones that regulate your menstrual cycle, fluctuate and decline, which means your cycle can become unpredictable and irregular. This can lead to longer cycles, or shorter ones with more frequent periods, and can make your periods heavier or lighter.

RELATED: Changes in bleeds: your FAQ

Sometimes, and this often becomes more common during perimenopause, your ovaries may not release an egg (anovulation). Normally the release of an egg triggers the production of progesterone, which controls the development of your womb lining. This doesn’t happen in anovulation, and can lead to heavier, longer and irregular periods.

What should I do about my heavy periods?

The first and most important thing is to not put up with heavy periods. Make an appointment with your healthcare professional so they can look into the cause of your bleeding. They will ask you about your bleeding, whether you bleed between periods and whether your periods are painful or come with a feeling of pressure. They are likely to examine you, and you could be referred for further tests to rule out other conditions such as cancer of your womb lining, called endometrial carcinoma, and some other conditions which can cause heavy periods.

You may have an ultrasound to look at your womb, biopsies to study a sample of the lining of your womb, a hysteroscope (where a thin telescope is passed through your cervix to check look at your womb) and internal swabs to check for infections. Your doctor may carry out a blood test to see if you are anaemic. Anaemia can be caused by blood loss from heavy periods, leaving you feel tired, lacking in energy, feeling breathless and your skin looking pale.

RELATED: Iron factsheet

What are the treatment options?

For those experiencing heavy menstrual bleeding, there are several medical treatment options available. One effective long-term option is a hormone coil such as a Mirena coil. This is a small device placed inside your womb by a doctor or nurse which releases a type of progestogen. It is licenced for both heavy bleeding and also works as a contraceptive. While the progesterone within the Mirena coil is not classed as body identical, it is a low dose of progestogen and it usually leads to them stopping or can lead to your periods becoming lighter and shorter.

RELATED: The Mirena Coil or Intrauterine System (IUS)

There are various hormonal options that can help regulate menstrual cycles and lessen bleeding.  These include the oral combined contraceptive pill and the progesterone only pill.  These work primarily by suppressing ovulation, which means they prevent the ovaries from releasing eggs. This action minimises the hormonal fluctuations that typically cause the lining of the womb to thicken, leading to lighter and more regular menstrual bleeding. However, these are synthetic hormones so are not structurally the same as our own natural hormones.

Some women find that taking natural progesterone (one type is Utrogestan) in the second half of their menstrual cycle improves periods and reduces periods. This can also often help with symptoms of PMS and PMDD.

If you are taking HRT, changing your regimen can help manage and reduce heavy bleeding during perimenopause. One common approach is to adjust the balance of oestrogen and progesterone in your HRT.  Your clinician may increase your dose of progesterone or suggest changing it from being taken orally to vaginally. This can reduce heavy bleeding. Sometimes switching the type of HRT can make a difference. For example, if you are on a sequential HRT regime (where oestrogen is taken every day and progesterone is taken for part of the month), changing to a continuous regime (where both hormones are taken every day) might help. This extended exposure to progesterone can help to control the womb lining and reduce bleeding.

Non-hormonal treatments include medications such as tranexamic acid, which can reduce bleeding, and prescription-only anti-inflammatory painkillers, such as mefenamic acid or naproxen, which can also be effective in reducing blood loss and alleviating pain.

RELATED: sequential and continuous HRT: what’s the difference?

If medical treatments are not effective, there are surgical options to consider. Endometrial ablation is a procedure that destroys the lining of the womb to reduce or stop bleeding. For a more definitive solution, a hysterectomy is surgical removal of the womb. However, these options can affect your fertility. There are also treatments for conditions that are causing bleeding. For example, a myomectomy, which involves removing fibroids, and uterine artery embolisation, a procedure that blocks the blood supply to fibroids, causing them to shrink.

What else can I do?

• Keeping a period diary may help you and your healthcare professional to understand the pattern of your bleeding and decide which test or treatment may be helpful. The periods section in the journal area of our free balance app is designed with this in mind.

• You can also use the balance app to log any symptoms you are experiencing.
• Using double protection, such as tampon and towels, or also using period pants can help with heavy unpredictable flow and give some extra peace of mind.
• Switching to higher frequency absorption such as night-time products during the day, can also help you withstand heavy days.

Your healthcare professional will help you find the best approach to minimise the impact of heavy periods on your life, and if the first treatment does not improve bleeding then you should consider alternative treatments.

Resources

NICE (2018): heavy menstrual bleeding: assessment and management

References

1. Women’s Health Concern: Heavy Periods
2. Women’s Health Concern: Heavy Periods
3. Paramsothy P., Harlow S.D., Greendale G.A., Gold E.B., Crawford S.L., Elliott M.R., Lisabeth L.D., Randolph J.F. Jr. (2014),  ‘Bleeding patterns during the menopausal transition in the multi-ethnic Study of Women’s Health Across the Nation (SWAN): a prospective cohort study’, BJOG. 121(12):1564-73. doi: 10.1111/1471-0528.12768

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Seeking support and care from a healthcare professional

If you need menopause treatment advice, seek help from your healthcare professional or book an appointment with Newson Health.

Newson Health offers evidence-based treatment and care for women going through the perimenopause and menopause. With clinics nationwide we offer in-person and virtual consultations. We are also able to see patients who reside outside the UK following a first appointment either face-to-face in one of our clinics or virtually while in the UK.* All follow-up consultations can then be held virtually in the country you resided in.

Our team of menopause specialist doctors, nurses and pharmacists will take time to listen to you, discuss your symptoms and offer a comprehensive treatment plan, tailored to your needs and preferences.

Use the button below to find out more and book your appointment.

*This doesn’t currently apply to residents of the US and Canada. All medication will need to be sent to a UK postal address; this includes PO Box addresses.