Heavy periods

Comprehensive Guide to Heavy Periods: Causes, Diagnosis, and Treatment Options



What Are Heavy Periods? Heavy menstrual bleeding (menorrhagia) refers to abnormally heavy or prolonged periods. Clinically, this is defined as blood loss exceeding 80 mL per cycle or lasting more than 7 days. However, for most patients, diagnosis is based on symptoms such as soaking through one or more pads/tampons every hour, passing large clots, or interference with daily life.



Causes of Heavy Periods

  1. Hormonal Imbalance
  • Low progesterone or unopposed estrogen can cause endometrial thickening.
  • Common during puberty, perimenopause, and in PCOS.
  1. Uterine Conditions
  • Fibroids (leiomyomas)
  • Endometriosis
  • Adenomyosis
  • Polyps
  • Uterine cancer (rare but important to rule out in older women)
  1. Coagulation Disorders
  • Von Willebrand disease
  • Platelet function disorders
  • Factor deficiencies
  • Can be genetic and present from menarche
  1. Other Medical Conditions
  • Thyroid dysfunction (especially hypothyroidism)
  • Liver disease (affects clotting factors)
  • Pelvic inflammatory disease
  • IUD-related bleeding
  1. Nutrient Deficiencies
  • Iron deficiency (can be cause and effect)
  • Vitamin K or C deficiency (rare)
  1. Medications
  • Anticoagulants
  • Hormonal contraceptives (wrong dose or withdrawal)
  • Herbal supplements (e.g., ginseng, ginkgo)
  1. Genetics
  • Family history of bleeding disorders or endometriosis



How Heavy Periods Affect the Body

  • Anemia: Low iron, fatigue, pallor, shortness of breath
  • Low ferritin: May cause hair thinning, brittle nails, cognitive dysfunction
  • Inflammation: Prostaglandins released during shedding may lead to uterine cramping and migraines
  • Psychological Impact: Depression, anxiety, missed work/school



Key Tests for Evaluation

  1. CBC with ferritin and iron panel
  2. TSH
  3. Coagulation panel (PT, aPTT, von Willebrand factor)
  4. Pelvic ultrasound
  5. Hormonal panel: LH, FSH, estradiol, progesterone (mid-luteal), testosterone, SHBG
  6. Endometrial biopsy (if >35 years or unresponsive to treatment)



Treatment Options

  1. Non-Hormonal Medications
  • Tranexamic Acid: 650 mg 2 tabs BID-TID x 5 days; antifibrinolytic that stabilizes clots
  • Side effects: nausea, muscle cramps, rare risk of thrombosis
  • Contraindicated in: history of thromboembolism
  • NSAIDs (e.g., ibuprofen, mefenamic acid): reduce prostaglandins and flow
  1. Hormonal Therapy
  • Progesterone: oral micronized progesterone 100-200 mg/day for 10–14 days per cycle
  • Oral contraceptives: regulate hormones and thin endometrial lining
  • LNG-IUD (Mirena): localized progesterone, reduces bleeding in 3–6 months
  • GnRH analogs (for fibroids or endometriosis): temporary suppression of estrogen
  1. Iron Replacement
  • Oral iron: ferrous sulfate 325 mg daily with vitamin C
  • IV iron: Ferric carboxymaltose 750 mg IV x 1–2 doses for severe deficiency
  1. Supplements
  • Vitamin C: improves iron absorption
  • Magnesium: may reduce cramps
  • Vitamin K2: may support clotting
  1. Diet and Lifestyle
  • Iron-rich foods: liver, spinach, lentils, red meat
  • Anti-inflammatory diet: omega-3s, turmeric, berries, leafy greens
  • Avoid excess alcohol/caffeine which can deplete nutrients



Hormonal Shifts and Migraines

  • Estrogen fluctuations may trigger menstrual migraines.
  • Progesterone may stabilize the hormonal environment, reducing headaches.
  • Magnesium and B6 are often beneficial for menstrual migraine support.



When to Seek Help

  • Bleeding more than 7 days
  • Changing pad/tampon every 1–2 hours
  • Clots larger than a quarter
  • Associated symptoms: shortness of breath, fainting, heart palpitations



Fun Facts

  • The average woman loses only 2–3 tablespoons of blood per period.
  • Heavy menstrual bleeding is one of the leading causes of iron deficiency anemia in reproductive-age women.
  • Estrogen dominance without adequate progesterone is the most common hormonal pattern linked to menorrhagia.



While the body is generally excellent at maintaining hormonal balance, menstrual hormones—especially estrogen and progesterone—are particularly vulnerable to disruption for a few key reasons:

🔄 Why Estrogen Dominance Happens

  1. Aging & Anovulatory Cycles (Especially in Perimenopause):
    In your 30s and 40s, ovulation often becomes irregular. No ovulation = no progesterone production that cycle.
    ➤ Estrogen still rises → progesterone does not →         unopposed estrogen stimulates the uterine lining → heavy bleeding.
  2. Stress & HPA Axis Dysfunction:
    Chronic stress raises cortisol, which "steals" from progesterone production (via pregnenolone).
    ➤ Low progesterone → estrogen dominance symptoms like heavy periods, PMS, breast tenderness.
  3. Environmental Estrogens (Xenoestrogens):
    Plastics (BPA), pesticides, personal care products can act like estrogen in the body.
    ➤ This adds to total estrogen load without increasing progesterone.
  4. Obesity or High Body Fat %:
    Fat cells convert androgens into         estrone (a type of estrogen). More fat = more estrogen production.
  5. Liver or Gut Dysfunction:
    Estrogen must be broken down and excreted. If liver detox pathways (esp. methylation, glucuronidation) or gut microbiome (e.g. beta-glucuronidase activity) are impaired:
    ➤ Estrogen is reabsorbed →         recirculation leads to excess estrogen.

⚖️ Why Doesn’t the Body “Fix” It?

  • The body relies on ovulation to produce progesterone. If ovulation fails (due to age, stress, PCOS, thyroid issues, etc.), the balance can’t be restored naturally.
  • The modern environment (diet, xenoestrogens, chronic stress, poor sleep) creates a hormonal mismatch from what the body evolved to handle.
  • Unlike blood pressure or glucose, there’s no acute feedback loop correcting estrogen-progesterone balance month-to-month.

🧠 Fun Clinical Insight

Estrogen is a growth-stimulating hormone (thickens endometrium), while progesterone is growth-regulating and calming (differentiates tissue and prevents overgrowth).
When estrogen “goes unchecked,” it not only causes menorrhagia but also increases the risk of fibroids, endometriosis, and even estrogen-sensitive cancers if prolonged.







Conclusion Heavy periods can significantly impact physical, hormonal, and emotional health. A comprehensive workup and individualized treatment plan—ranging from diet to medication and hormone therapy—can help manage symptoms, correct underlying imbalances, and restore quality of life.

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