Heavy periods
Heavy Periods and Blood Clots: What’s Normal and What Isn’t
The four-point test: is your bleeding actually heavy?
Most women have no idea whether their periods are heavy, because they have only ever experienced their own. If your mother bled heavily and your sister bleeds heavily, heavy feels like the baseline.
So here is an objective test. If any one of these is true, your bleeding meets the clinical definition of heavy menstrual bleeding.
1. You soak through a pad or tampon in under two hours. Not on the worst hour of the worst day — as a pattern.
2. You pass clots larger than 2.5 centimetres. A ten-rupee coin is almost exactly this size. Keep one in mind as a reference.
3. Your bleeding lasts more than seven days.
4. You need double protection, or you wake at night to change. A pad plus a cloth. A pad plus a tampon. Setting an alarm.
There is a fifth test that is not in any textbook but which I trust more than the others: has your period started deciding things for you? If you plan to travel around it, refuse invitations because of it, carry a spare set of clothes, sit differently in a meeting, or take a day off each month — then regardless of what the measurements say, something is wrong and it is worth investigating.
Why clots form, and what size tells you
So clots are not an abnormality in themselves. They are a marker of volume. Small clots simply mean blood pooled briefly. Large, frequent clots mean you are losing a lot of blood, quickly.
Colour matters far less than most women think. Dark brown or blackish blood is usually just older blood that took longer to leave. It is volume, clot size and duration that matter — not shade.
What causes heavy bleeding
I find it useful because it stops the search too early. If the scan shows a fibroid, it is tempting to conclude the fibroid is the cause and stop looking. Sometimes the fibroid is incidental and something else is doing the damage.
Structural causes
Adenomyosis: The uterine lining grows into the muscle wall. Classically causes periods that get heavier and more painful year on year, and a bulky, tender uterus. Frequently missed on routine scans.
Polyps: Small growths in the uterine lining. Often causes bleeding between periods or after intercourse. Usually removable in a short day-case procedure.
Cancer and precancerous change: I am naming this plainly rather than leaving it out, because leaving it out is what makes people afraid. It is a much less common cause than the others, but it is a real one — and this is precisely why heavy or irregular bleeding needs proper evaluation rather than reassurance. Any bleeding after menopause requires assessment, always, regardless of amount.
Non-structural causes
Hormonal imbalance, including PCOS, and irregular ovulation during perimenopause. In the years leading to menopause, cycles become erratic and bleeding often becomes heavier before it stops altogether.
Thyroid disorders: An underactive thyroid commonly causes heavier, longer periods. A simple TSH blood test picks it up, and treatment is usually a single tablet.
Clotting disorders: Frequently missed, particularly in younger women. If you have bled heavily since your very first period, bruise easily, or bleed excessively after dental work, mention it.
Copper IUD: A well-recognised cause of heavier periods. Worth remembering if your bleeding changed after insertion.
When to see a doctor this week, not next month
- You are soaking a pad every hour for several hours
- You feel dizzy, breathless, or your heart races on climbing stairs
- You have fainted, or nearly fainted
- You are passing clots larger than a lemon
- You are bleeding after intercourse
- You are bleeding after menopause — this always needs assessment
- You are bleeding between periods and it is new
What the doctor will actually do
A proper history. How many pads, how large the clots, how many days, what you have stopped doing. This is why I ask you to note it down beforehand.
An examination, including a pelvic examination.
Blood tests. Haemoglobin, and — importantly — ferritin. Ferritin measures your iron stores, and it falls long before haemoglobin does. A normal haemoglobin with a low ferritin means you are running on empty and about to become anaemic. Many women are told their haemoglobin is fine and sent away still exhausted. Ask for ferritin. Also TSH for thyroid.
A transvaginal ultrasound, which shows the uterus far more clearly than an abdominal scan.
An endometrial biopsy or hysteroscopy, where indicated — particularly if you are over forty, if bleeding is irregular, or if the scan shows a thickened lining. A hysteroscopy uses a fine camera passed through the cervix to look directly inside the uterus. It takes fifteen to twenty minutes, involves no cuts, and you go home the same day.
The treatment ladder
This is the section I most want you to read.
Treatment for heavy bleeding is a ladder. You start at the bottom and climb only as far as you need to. A great many women are advised hysterectomy having stood on the first rung for a few months.
| Rung | Treatment | How it works | Roughly how effective | Preserves fertility | Reversible |
| 1 | Tranexamic acid | Slows the breakdown of clots, reducing flow. Taken only during bleeding days | Substantial reduction for many women [VERIFY figure] | Yes | Yes |
| 2 | NSAIDs (mefenamic acid) | Reduce both bleeding and pain | Moderate reduction | Yes | Yes |
| 3 | Combined pill / progestogens | Regulate the cycle, thin the lining | Good for many | Yes | Yes |
| 4 | Hormonal IUD (Mirena) | Releases hormone directly into the uterus, keeping the lining thin | The most effective non-surgical option | Yes | Yes |
| 5 | Hysteroscopic removal | Removes a polyp or submucosal fibroid causing the bleeding | Very effective where that is the cause | Yes | n/a |
| 6 | Endometrial ablation | Destroys the uterine lining | Effective for the right candidate | No | No |
| 7 | Myomectomy | Removes fibroids, preserving the uterus | Effective where fibroids are the cause | Yes | n/a |
| 8 | Hysterectomy | Removes the uterus | Definitive | No | No |
Tranexamic acid is underused. It is inexpensive, taken only on bleeding days, and works well for a great many women. It is often skipped entirely.
The hormonal IUD deserves more attention than it gets. It is the most effective non-surgical treatment available for heavy bleeding, it is reversible, and fertility returns immediately on removal. There is one thing you must know before having one fitted: irregular spotting is common for the first three to six months. This is expected and it settles. But many women are not warned, panic in month two, have it removed — and abandon it exactly at the point it was starting to work. If you are going to have one, commit to six months or do not start.
Ablation is permanent and rules out pregnancy. Do not have it if there is any chance you might want a child.
Hysterectomy is rung eight. If someone has moved you from rung one to rung eight, ask what happened to the six rungs in between.
What does not work
No herbal, ayurvedic or homeopathic preparation has been shown in good-quality trials to reduce menstrual bleeding or shrink a fibroid. Some women feel generally better on them, and I do not dismiss that. But the risk is not that the bottle fails. The risk is that eight months pass while you are bleeding heavily, and by the time you come to me your haemoglobin is six and correcting it takes far longer than preventing it would have.
If you want to try something alongside medical treatment, that is your decision. But check your haemoglobin every three months. If it is falling, please come in.
Diet will not stop heavy bleeding, though good iron intake helps you cope with it. Rest will not stop it. And “it will settle after your next pregnancy” is not a treatment plan.
Anaemia — the complication nobody mentions
Women bleeding heavily every month for years become iron deficient. Slowly, so they never notice it happening. And because it is gradual, they attribute it to something else entirely.
The symptoms: constant tiredness. Breathlessness climbing stairs. Hair falling. Brittle nails. Poor concentration and forgetfulness. Feeling cold. Low mood. Sometimes an odd craving for ice or mud.
Almost every woman I see with these symptoms has decided it is stress, or age, or having too much to do.
Two things matter here. First, ask for ferritin, not just haemoglobin — iron stores empty long before the haemoglobin number moves. Second, correcting the iron is not the treatment. If you take iron tablets while bleeding heavily every month, you are refilling a bucket with a hole in it. Treat the bleeding and the anaemia follows.