Heavy Menstrual Bleeding

Heavy menstrual bleeding is menstrual blood loss severe enough to interfere with a person's physical, social, emotional or material quality of life. That definition is deliberately about IMPACT rather than millilitres, because nobody measures their blood loss and the volume was never the point. Around one in three people who menstruate report periods they consider heavy, and it is one of the most under-reported and most normalised symptoms in medicine. It is also, in the great majority of cases, treatable — often without surgery, and often without hormones.

Three reasons, and each is routinely missed. First, heavy periods are the commonest cause of iron deficiency in menstruating people, and iron deficiency causes exhaustion, breathlessness and cognitive fog long before anaemia appears — so the tiredness gets treated as a lifestyle problem while the cause bleeds on every month. Second, up to a fifth of people with heavy menstrual bleeding have an UNDIAGNOSED INHERITED BLEEDING DISORDER, most often von Willebrand disease — and almost nobody asks. Third, HMB is a symptom, and it has causes: fibroids, adenomyosis, polyps, ovulatory dysfunction, and — rarely but importantly — endometrial cancer. 'Some people just have heavy periods' is where the diagnosis goes to die.

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   FoundationHormonal HealthHow to read hormones properly — and why both over-treatment and under-treatment cause harm.
2. 2

   BiomarkerFerritinIron stores — with an inflammation caveat
3. 3

   Signal RecordAnticoagulantsDOACs and warfarin — among the most effective drugs in medicine, and the most misunderstood
4. 4

   Body SystemHormonesEndocrine signaling that regulates the whole body.
5. 5

   ConditionIron Deficiency & AnaemiaThe commonest nutritional deficiency in the world — and a finding that always has a cause

1. Recognize risk factors
2. Get diagnosed
3. Track key biomarkers
4. Lifestyle first
5. Evidence-based treatment
6. Long-term monitoring

An orientation to how this topic is typically approached — not medical advice.

• Iron-rich food helps, and it does not fix a monthly loss that exceeds what you can absorb — treat the bleeding, not just the iron
• Track the cycle and the impact: flooding, clot size, protection changes. It is the evidence that gets you taken seriously
• Do not accept exhaustion as your baseline; get ferritin checked

Heavy menstrual bleeding is defined by impact on quality of life rather than measured volume, and affects a large minority of menstruating people. It is the commonest cause of iron deficiency in this group, and ferritin falls before haemoglobin — so iron deficiency is frequently present, symptomatic, and missed in the presence of a 'normal' full blood count. An underlying inherited bleeding disorder, most often von Willebrand disease, is present in a substantial minority (estimates in referred populations run up to around 20%) and is under-investigated; a history of heavy bleeding from menarche is the key discriminator. The levonorgestrel intrauterine system is first-line and reduces menstrual blood loss substantially in randomized evidence. Tranexamic acid is effective and non-hormonal. NSAIDs reduce both bleeding and pain. Structural causes (fibroids, polyps, adenomyosis) and endocrine causes (thyroid disease, ovulatory dysfunction) require their own management. Hysterectomy is effective but is a last-line intervention. Intermenstrual, post-coital and post-menopausal bleeding are distinct symptoms requiring investigation for malignancy.

• NICE NG88 — Heavy menstrual bleeding: assessment and management
• FIGO PALM-COEIN classification of abnormal uterine bleeding
• Guidance on the investigation of inherited bleeding disorders in women with heavy menstrual bleeding
• Cochrane reviews of the levonorgestrel intrauterine system and tranexamic acid for heavy menstrual bleeding