Heavy menstrual bleeding.

What counts as heavy bleeding?

Heavy menstrual bleeding (HMB) is defined clinically as bleeding that interferes with a woman’s physical, emotional, social, or material quality of life. Note what that definition does NOT say: it doesn’t require a specific blood loss measurement. NICE explicitly bases the diagnosis on impact, not millilitres.

Practical signs your bleeding is heavy enough to warrant assessment:

• Soaking a sanitary product (pad or tampon) every hour or two for several hours
• Passing clots larger than a 10p coin
• Needing to use both a pad and a tampon together
• Bleeding through clothes or bedding
• Periods lasting longer than 7 days
• Flooding (sudden gushes of blood)
• Restricting your activities (work, exercise, social) around your period
• Symptoms of anaemia (tiredness, breathlessness, pallor)

How heavy bleeding affects life

HMB is not just an inconvenience. Sustained heavy bleeding can cause:

• Iron deficiency anaemia — tiredness, breathlessness, brain fog, restless legs
• Work absences and reduced productivity
• Reduced exercise and physical activity
• Social withdrawal — planning life around periods
• Sexual avoidance
• Significant financial cost (sanitary products, replacement bedding/clothes)
• Effects on mood, self-esteem, and relationships

None of this is "just bad periods." It is a treatable medical condition.

Common causes

Most heavy bleeding has an identifiable cause, although in some cases no specific structural cause is found ("dysfunctional uterine bleeding"). Common causes include:

Structural

• Fibroids — benign muscle growths in the uterus. Very common, often asymptomatic, sometimes cause heavy bleeding.
• Polyps — small growths from the lining of the uterus or cervix
• Adenomyosis — endometrial tissue growing into the uterine muscle wall
• Endometriosis — endometrial-like tissue outside the uterus
• Endometrial hyperplasia — thickening of the lining, sometimes pre-cancerous
• Endometrial or cervical cancer — uncommon but always considered, particularly in women over 45 with new heavy bleeding or post-menopausal bleeding

Hormonal

• Perimenopause — very common cause of heavy/irregular bleeding in 40s
• Polycystic ovary syndrome (PCOS)
• Thyroid disorders

Other

• Bleeding disorders (e.g. von Willebrand disease, often under-diagnosed)
• Anticoagulant medication
• Copper coil (non-hormonal IUD)
• Infections (pelvic inflammatory disease)

When bleeding needs urgent attention

How we assess at MHW

1. The conversation

A thorough conversation about your bleeding pattern, cycle history, pain, sexual health, family history (some bleeding disorders run in families), medications, smear test history, contraception, and what you’d like to achieve. This takes 30–45 minutes — longer than a typical NHS appointment.

2. Examination

For most women with significant HMB, an examination is appropriate. This typically involves:

• Abdominal examination (looking for masses, tenderness)
• Speculum examination (looking at the cervix — with your consent and a chaperone offered)
• Bimanual examination (assessing uterus size, fibroids, ovarian tenderness)

You can decline any part of the examination at any time. A trained chaperone is always offered — see our Chaperone Policy.

3. Pelvic ultrasound

Often arranged same-day or same-week at MHW. Transvaginal ultrasound (a small probe inserted into the vagina) gives the clearest images of the uterus and ovaries and is the recommended first imaging for HMB. We always discuss what’s involved and consent before proceeding.

4. Blood tests

• Full blood count (checking for anaemia)
• Ferritin (iron stores)
• Thyroid function
• Clotting tests if bleeding disorder suspected
• Hormone testing where indicated (FSH/LH/oestradiol if perimenopause is part of the picture)

5. Further investigations if needed

Depending on findings, we may recommend:

• Hysteroscopy (camera inspection of the uterine cavity)
• Endometrial biopsy (sample of the uterine lining)
• MRI scan (occasionally, for complex fibroids or adenomyosis)
• Specialist gynaecology referral

Treatment options

NICE NG88 recommends a stepped approach — starting with less invasive options and escalating only as needed. The right starting point depends on cause, severity, your preferences, contraceptive needs, and whether you want to preserve fertility.

Non-hormonal medication

Tablets taken only during periods can reduce bleeding by 30–50%. Don’t affect cycle or fertility. Suit many women as first-line for short-term management.

Hormonal options

Several hormonal approaches reduce bleeding, alongside providing contraception. Choices include long-acting reversible contraception with hormonal elements, oral hormonal cycle medication, and others. Specific options are discussed in consultation, taking into account your medical history, contraceptive needs, and preferences.

Treatment of underlying cause

Where a specific cause is identified (fibroids, polyps, hyperplasia, thyroid issues, perimenopause), targeted treatment is often more effective than generic HMB treatment.

Surgical options

Where medication isn’t effective or appropriate, surgical options exist — ranging from hysteroscopic polyp/fibroid removal to endometrial ablation (lining destroyed) and, ultimately, hysterectomy. These are gynaecology procedures we refer for; we provide the assessment and discuss when this route makes sense.

Iron deficiency

Iron deficiency is so common in HMB that we check ferritin in essentially every woman with HMB. Iron deficiency without anaemia (low ferritin, normal haemoglobin) is itself worth treating — it causes fatigue, breathlessness, restless legs, and brain fog that improve with replacement.

Iron replacement options:

• Oral iron tablets (cheapest, work for most but side effects common)
• Iron-rich diet (slowest, works as maintenance not for treatment of established deficiency)
• Intravenous iron infusion (fastest, used where oral doesn’t work or isn’t tolerated)

See also our dedicated page on iron deficiency anaemia.

When to consider surgical options

Surgical options come into the conversation when:

• Medical treatments have been tried and haven’t worked
• Medical treatments aren’t suitable for your situation
• You don’t want hormonal treatment
• Anaemia is severe and ongoing
• You’ve completed your family
• Quality of life is significantly affected

The choice between procedures depends on cause, severity, fertility wishes, and personal preference. We refer to gynaecology colleagues for procedures we don’t do in-house and stay involved in your care.

When to see us

Consider booking if:

• Your periods regularly disrupt work, exercise, or daily life
• You’re soaking products every 1–2 hours or passing large clots
• Your periods are getting heavier
• You have bleeding between periods or after sex
• You have unexplained tiredness with heavy periods (likely iron deficiency)
• You’ve been told to "live with it" and aren’t willing to
• You’re post-menopausal and have any bleeding (urgent — needs assessment within 2 weeks)

Frequently asked questions

What if it’s just menopause approaching?

Perimenopause is a very common cause of heavy/irregular bleeding in your 40s. We’ll assess this as part of the consultation and treatment for perimenopause-related bleeding may be appropriate (see our perimenopause page).

Will I need internal examination?

Often it’s recommended, but you’re always asked first and can decline. A chaperone is always offered.

Will I need a smear test?

If you’re overdue for cervical screening we can arrange this. NHS cervical screening is free and we strongly encourage staying up to date.

How much does the ultrasound cost?

Current ultrasound prices are on our Fees page. The cost is quoted before scan.

Can I get a hysterectomy through MHW?

Hysterectomy is a major operation requiring inpatient care; it’s done at hospital. We do the initial assessment and refer to gynaecology colleagues with whom we work closely.

What if I want to preserve fertility?

We can usually find a treatment plan that doesn’t affect fertility. Tell us this at consultation and we’ll plan accordingly.

Does the coil cause heavy bleeding?

Copper coils sometimes do. Hormonal coils typically reduce bleeding (often dramatically), and one of them is itself a NICE-recommended treatment for HMB.

What if I’ve had heavy bleeding for years and been told nothing’s wrong?

Then a fresh assessment with ultrasound and proper bloods is overdue. Many women in this situation turn out to have treatable conditions (fibroids, adenomyosis, iron deficiency, undiagnosed bleeding disorder) that have been missed.