Heavy periods: evidence to help you weigh up treatment options

In this blog for people affected by heavy periods, Dr Stuart Spencer, Specialty Trainee in Obstetrics and Gynaecology at John Radcliffe Hospital, and Dr Martin Hirsch, Consultant Gynaecologist at John Radcliffe Hospital, look at the Cochrane evidence on various treatment options, weigh up the pros and cons, and highlight some questions you may wish to consider and discuss with a healthcare professional.

People with heavy periods have heavy menstrual bleeding that interferes with their quality of life. It is common, affecting around 20-50% of people who menstruate Treatment for heavy periods can include oral medications, a hormone-releasing coil in the womb, or surgery There is Cochrane evidence (published May 2022) that the coil may be the most effective first treatment for reducing bleeding, followed by non-hormonal and hormonal medications. If these treatments don’t work or aren’t suitable, hysterectomy or endometrial ablation (burning the lining of the womb) may be effective alternatives Potential benefits and harms should be considered when making treatment choices, along with your own preferences and priorities. All the treatments may have side effects, and some treatments are more invasive than others. These are all things to discuss with your doctor to help you work out what might be the best option for you

What are heavy periods and who do they affect?

Heavy periods are common, affecting up to half of all people who menstruate at some point in their life. The definition of heavy periods used to be passing more than 80 ml of blood during a period, but the definition now includes menstrual blood loss that affects quality of life – feeling physically, emotionally, socially or materially worse off due to heavy periods.

Heavy periods become more common with increasing age. Although 2% (1 in 50) of people who menstruate under 40 years old may need to see their GP each year with heavy periods or other period problems, this rises to 5% (1 in 20) for those aged 45-49 years.

People with heavy periods can have other issues due to their heavy bleeding. This may include painful periods, fatigue, headaches and fainting, or more serious effects such as low levels of healthy red blood cells (anaemia) which may affect up to 1 in 4 people with heavy periods.

Some of the different terms that can be used to describe abnormal bleeding, period problems or other causes of heavy periods include:

  • Heavy menstrual bleeding
  • Abnormal uterine bleeding / dysfunctional uterine bleeding – this can include bleeding between periods, prolonged periods, or heavy menstrual bleeding
  • Menorrhagia – another term for heavy periods
  • Dysmenorrhoea – painful periods
  • Adenomyosis – where the internal lining of the womb is found in the middle (muscular) layer of the womb
  • Fibroids – benign (non-cancerous) masses that grow in the womb

What are some of the causes of abnormal bleeding?

While many cases of heavy periods don’t have any obvious cause (also called idiopathic), it is important to try and work out if there is some underlying reason for the bleeding. This is particularly the case where there are other symptoms associated with heavy periods. Such as bleeding between periods, pelvic pain, or a feeling of pressure in the pelvis.

Some other reasons for heavy or abnormal bleeding may include:

  • Fibroids – non-cancerous growths within the womb
  • Polyps – a growth of tissue out from the inside lining of the womb
  • Adenomyosis – where cells from the lining of the womb make their way into the muscular layer of the womb
  • Overgrowth of the lining of the womb (hyperplasia) or cancer
  • Hormonal changes
  • Abnormal blood clotting
  • Medications

When you talk to your GP about your periods, they will ask more questions about your bleeding including:

  • how and when the bleeding happens
  • other symptoms associated with the bleeding
  • the impact of the bleeding on your everyday life
  • any other factors that may affect your treatment

If you have heavy periods that do not appear to be due to another cause, it’s recommended that you have a blood test to check your level of red blood cells (a full blood count) and work out whether you have anaemia. You may be offered a physical examination (for example, of your tummy or pelvis). This will depend on what treatment options are being considered.

Abnormal bleeding that is due to other causes, such as those listed above, may require further investigation such as blood tests, an ultrasound scan, a camera test to look at the lining of the womb (hysteroscopy), or referral to a specialist service such as a gynaecologist.

What treatments are available for heavy periods?

There are a number of options available to help manage heavy periods. These may include hormonal or non-hormonal medication, a contraceptive coil within the womb, and surgery. Not having any treatment is also an option.

Deciding which treatment is right for you should involve having a conversation with your doctor or healthcare professional. You might like to discuss questions such as:

  • What have you tried already?
  • Which options are available to you?
  • What are the possible benefits and drawbacks of each option?
  • Do you want to have the option in future of trying to get pregnant? (As this may affect which treatment options are suitable for you)

Potential benefits and risks of the different treatments for heavy periods: what does the evidence say?

In a recent Cochrane overview of reviews: ‘Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis’ (published May 2022) authors studied the evidence for different types of heavy period treatments.

Medication (first-line) treatments

The evidence suggests that, in order, the most effective treatments for reducing menstrual blood loss may be:

  • the hormone-releasing coil
  • followed by tranexamic acid (a non-hormonal treatment)
  • followed by hormonal medications (such as the contraceptive pill)
  • followed by NSAID medications

In general, because lots of different medications have been studied in a lot of different ways, it is difficult to say which medication gives the greatest satisfaction with treatment.

Depending on the treatment there may be different risks to you. Each medication has a different set of possible side effects.

Let’s look at each treatment option, in turn.

Hormone-releasing coil

For people with heavy periods, the first treatment that may be recommended is the hormone-releasing coil (levonorgestrel-releasing intrauterine system).

The coil works by releasing a small amount of hormone constantly into the womb, to thin the lining of the womb while also giving very effective birth control. Only the Levosert® and Mirena® coils are licensed for the treatment of heavy periods in the United Kingdom.

The Cochrane evidence suggests that:

  • the coil may be the most effective treatment for reducing blood loss
  • the coil may also reduce the chance of needing more treatment in the future
  • the risk of side effects may be little or no different compared with people not having any treatment

Other things to consider:

  • It may take up to 6 months to see the most effect of treatment with the coil
  • There is a small chance that you won’t be happy with the bleeding pattern and will want to have the coil removed
  • There is a very small risk of a hole in the womb – this is not common and is unlikely to be life-threatening. If it does happen, it may require an ultrasound, x-ray, or keyhole surgery to remove the coil

Tranexamic acid

If the coil is not right for you, the Cochrane evidence suggests that tranexamic acid is probably the next most effective medication for reducing menstrual blood loss. This is a non-hormonal medication and works by helping blood to clot. It can be taken for up to four days around the time of your period.

Tranexamic acid is usually safe when used in this manner. It may cause an upset tummy, and may not be the best choice for women at high risk of forming blood clots.

Hormonal medications

After tranexamic acid, the evidence suggests that the next most effective treatments for reducing bleeding may be hormonal medications, such as the contraceptive pill. Hormonal medications are medications that include one or more hormones to reduce bleeding. They may also be used for contraception, depending on the medication. They may be taken without a break, or at certain times during your cycle.

Most hormonal medications have a small increased risk of blood clots in the legs (deep vein thrombosis) or lungs (pulmonary embolism) alongside other less serious side effects.

Non-steroidal anti-inflammatory (NSAID) drugs

Another medication that may be commonly used to treat heavy bleeding is non-steroidal anti-inflammatory (NSAID) drugs. Common NSAIDs used to reduce bleeding include ibuprofen, and mefenamic acid. They can also help manage painful periods.

The Cochrane evidence suggests that NSAID medications may be less effective than tranexamic acid and hormonal medications.

Surgical (second-line) treatments

You might consider surgical treatments if:

  • you have completed your family / you have no future plans to fall pregnant
  • medication treatments are not right for you
  • medications have not helped reduce your bleeding enough to make you feel better.

Hysterectomy

When medication isn’t suitable or hasn’t worked, the Cochrane evidence suggests that hysterectomy (surgical removal of the womb) may be the most effective surgical treatment for heavy periods.

A hysterectomy is now commonly performed without making a large cut on your tummy. The most common techniques are either the vaginal or keyhole approach. This aims to improve satisfaction with the operation and allow you to get back to your activities more quickly. A hysterectomy is a big operation though, and this may mean extra risks to you.

Endometrial ablation

Another surgical option is endometrial ablation. This involves using a device to heat the lining of the womb, and this reduces the amount that the womb lining can grow during your cycle and then shed during your period. There are various different devices that can be used to perform endometrial ablation.

The evidence suggests that endometrial ablation may be less effective at treating heavy periods than hysterectomy, but more effective than the hormone-releasing coil.

Because there are many different ways of performing endometrial ablation, the evidence for any particular device or method is of low certainty, meaning we can’t really be sure about its potential effects.

Potential risks of surgery:

  • Discuss the risks of each type of surgery in detail with a gynaecologist who performs the procedure.
  • Each surgery has a different set of risks. When comparing hysterectomy and endometrial ablation, a person needs to balance the surgical risk against the effectiveness of the procedure.
  • A hysterectomy may be more effective at reducing heavy periods while endometrial ablation generally has less risks, but is more likely to need further treatment that may include a hysterectomy at a later date.

Who can you talk to about heavy periods? What questions can you ask?

Deciding which treatment is right for you can be difficult, but there are people and support available to help you make your decision.

If your heavy periods are affecting your life, then the first person to speak to will usually be your GP.

Having a conversation with your GP about how your periods affect your life and what you have tried to manage your periods will help you have a conversation about what treatments are available and which treatment is the right one for you.

There are three questions you can ask to get the information you need to choose a treatment:

  • What are my options?
  • What are the pros and cons of each option for me?
  • How do I get support to help me make a decision that is right for me?

Here you can view, and print, a decision aid: Heavy periods – what are my options? It can help you discuss options for treating heavy periods with your healthcare professional and help reach a shared decision that works for you.

 

References (pdf)

Stuart’s biography appears below. Read Martin’s biography and his other blogs.

Stuart and Martin have nothing to disclose.

Join in the conversation on Twitter with @DrStuartSpencer @MartinHirsch100 @CochraneUK and @CochraneCGF or leave a comment on the blog.

Please note, we cannot give medical advice and do not publish comments that link to individual pages requesting donations or to commercial sites, or appear to endorse commercial products. We welcome diverse views and encourage discussion but we ask that comments are respectful and reserve the right to not publish any we consider offensive. Cochrane UK does not fact check – or endorse – readers’ comments, including any treatments mentioned.



Heavy periods: evidence to help you weigh up treatment options by Stuart Spencer

is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International

4 Comments on this post

  1. Dr. Spencer, Just wanted to leave a note to say that I appreciate the inclusive language you used in this blog! I identify as female but thought this was well done to include everyone. The imagery and language we use when talking about health is so important — well done!

    Muriah Umoquit / Reply
  2. ‘The Cochrane evidence suggests that tranexamic acid is probably the next most effective medication for reducing menstrual blood loss’.
    Why have you not mentioned specifically hypothyroidism as a cause for many women of heavy menstrual loss?
    In advocating all this ways to stop heavy menstrual bleeding, you have not looked at the whole woman, but at ‘gadgets’.

    Linda Page / Reply
  3. I am so disappointed to see the lack of the word woman/women in this article. As a result, this piece is misogynistic and dehumanising. Articles like this are causing me to turn away from seeing Cochrane as a reliable source of information and evidence. I cannot recommend pages like this to the women in my care who are upset by this approach. You seem more interested in pleasing a tiny minority than in meeting the needs of the women you purport to serve. You should know that, while you may well be pleasing some biological females who don’t want to own their femininity, you are hurting, traumatising and alienating a far larger number of women with your stance.

    Alice / Reply
    • “Hello Alice,
      We are sorry to read that you feel our choice of language is dehumanising – that is not our intention, but rather to show respect, and indeed potentially empower, everyone who comes to these blogs. We support our bloggers’ use of inclusive language in this blog, and others. We recognise that people who do not identify as female can also be affected by heavy periods. Referring to heavy periods as only a ‘women’s problem’ can make things even more difficult for those who do not identify as female, in terms of seeking information and accessing health and support services.
      Cochrane is an inclusive organisation and using more inclusive language is something for us as an organisation to consider as a means of demonstrating that and, importantly, championing equity in health care. We work with our bloggers to provide timely, evidence-based information and other resources, to help everyone affected make informed decisions.
      Best wishes
      Sarah Chapman and Selena Ryan-Vig [Editors]”

      Selena Ryan-Vig / (in reply to Alice) Reply

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