What is Heavy Menstrual Bleeding (HMB)?

It is likely that, from time to time, you will experience heavier than usual bleeding during your menstrual period, but it can be hard to know if this is normal or if your periods are heavy compared with other women. Heavy menstrual bleeding (HMB) can be a serious and debilitating condition.

It is defined by the impact it has on a woman's physical, social and emotional quality of life, for example if your monthly period limits your normal daily activities, or affects your role at work.

A good indication that blood loss is excessive is if you experience any of the following:

  • Are using an unusually high number of tampons or pads, for example if there is enough blood to soak a pad or tampon every hour for several consecutive hours

  • Are you experiencing flooding (heavy bleeding) through to clothes

  • Need to use double protection, i.e. tampons and pads together

  • Are experiencing night time bleeding that requires you to get up to change pads or tampons, use extra protection at night and / or change your bed sheets

One in three women have heavy menstrual bleeding at some point in their lives.

83% of women with HMB state that it affects their daily activities:

91% feel HMB impacts their ability to perform sport and fitness activities

80% feel that their heaviest bleeding days affect their performance at work

68% do not tend to participate in social activities when their period is heavy

However, in up to 60% of women with HMB, no underlying cause is found. This means that many women can be treated by their GP.

What causes HMB?

For up to 60% of women with HMB, there is no obvious cause. However some conditions have been linked to HMB, including:

  • Polycystic ovary syndrome (PCOS)A common condition caused by an imbalance of reproductive hormones that affects how a woman's ovaries work
  • Pelvic inflammatory disease (PID)An infection in the upper genital tract (the womb, fallopian tubes or ovaries) that can cause pelvic or abdominal pain and bleeding after sex or between periods
  • FibroidsNon-cancerous growths that develop in or around the womb
  • EndometriosisWhen small pieces of the womb lining are found outside the womb, such as in the fallopian tubes, ovaries, bladder or vagina
  • HypothyroidismAn underactive thyroid, where the thyroid gland doesn't produce enough hormones, causing tiredness, weight gain and feelings of depression
  • Cervical or endometrial polypsNon-cancerous growths in the lining of the womb or cervix (neck of the womb)
  • Blood clotting disorders
  • Cancer of the womb

It is important to note that, whether or not a direct cause can be found, HMB is a highly treatable condition and there are choices available for you to discuss with your GP.

What to expect from your GP appointment

If you feel your periods are impacting your daily life and you may be suffering from HMB, it is important to seek advice from your GP. During your consultation your GP should ask you key questions, which will enable them to make a clear diagnosis of HMB:

How much do you bleed?

Do you have to change sanitary protection (pads or tampons) at night?

During the day would you manage 2-3 hours without changing your pad or tampon?

Does your bleeding affect you physically, i.e. do you find yourself breathless or faint?

How does it affect your daily life?

If HMB is diagnosed, depending on your medical history, the cause of your heavy bleeding may need to be investigated further.

Up to 60% of women there is not an obvious cause for HMB, in some women there are certain high-risk factors that should be checked, for example if you experience bleeding between periods or after sex, or if you have pelvic pressure or pain.

Further tests can rule out serious illness, and may include:

  • A pelvic examination
  • An endometrial biopsy (a small sample of the lining of the uterus is taken and looked at under a microscope for abnormal cells)
  • Blood tests
  • An ultrasound scan

Treating HMB

HMB is a highly treatable condition, and there are a wide range of treatment options available. Most healthcare professionals will recommend a medical therapy first, however if your HMB worsens or is not effectively managed with these treatments, other more invasive options will need to be considered.

In addition to the following treatment options for HMB, your doctor may also recommend you take regular iron supplements to help treat anaemia (iron deficiency) due to blood loss.

If you are not considering getting pregnant and would prefer a treatment that also has contraceptive benefits, the following can be considered:

Intrauterine system (IUS)

An IUS is fitted once and stays inside the womb. It slowly releases a small amount of a hormone called progestogen, which provides reliable contraception and has been shown to reduce HMB by 96%.

The fitting usually takes a few minutes and can be done at a local GP surgery or contraceptive clinic.

It lasts for up to five years but can be removed at any time. It is the recommended first treatment option for HMB.

Possible side effects of using IUS include

  • irregular bleeding/spotting that may last more than six months
  • breast tenderness
  • acne
  • periods may stop or become significantly lighter
Combined hormonal contraceptives

Aside from providing birth control, oral contraceptives can help reduce episodes of excessive or prolonged menstrual bleeding. Certain (or some) types of the combined pill, often referred to as 'the pill', has been shown to reduce heavy bleeding by up to 80% and can have the added benefit of regulating the menstrual cycle and reducing period pain.

Common side effects of the pill include:

  • mood changes
  • nausea
  • fluid retention
  • breast tenderness
Oral norethisterone

Oral noresthisterone (man-made progesterone) can be used to treat heavy periods, and is taken daily in tablet form. It works by preventing your womb lining from growing quickly and can reduce heavy bleeding.

Oral noresthisterone is not suitable if you are trying to conceive as it is likely to stop ovulation.

Oral progestogens are associated with:

  • weight gain
  • short term acne
  • breast tenderness

If you are considering getting pregnant and would prefer a non-hormonal treatment, the following can be considered:

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs work by reducing the body's production of a hormone-like substance called prostaglandin, which is linked to heavy periods. They can also help relieve period pain. NSAIDs are less effective than the IUS but are associated with fewer side effects and therefore might be suitable for milder HMB or for HMB associated pain.

Gastrointestinal issues are the most common side effects seen with NSAIDs.

Tranexamic acid tablets

Tranexamic acid tablets work by helping the blood in the womb to clot, and have been shown to significantly improve menstrual blood loss. Tranexamic acid tablets are not a form of contraception and won't affect your chances of becoming pregnant.

Gastrointestinal issues are the most common side effects including:

  • diarrhoea
  • indigestion

Surgical treatment options for HMB

If medical management is not working to treat your HMB, surgical intervention may need to be considered. The most common surgical procedures for HMB include:

  • Uterine artery embolisation (UAE) If HMB is caused by fibroids, this procedure will aim to shrink the fibroids in the uterus. UAE involves inserting a small tube into the groin and injecting small plastic beads through the tube into the arteries supplying blood to the fibroid. This blocks the arteries, stopping blood flow to the fibroid and causing it to shrink.
  • Myomectomy This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
  • Endometrial ablation With endometrial ablation the lining of the uterus is permanently destroyed using laser beams or microwave energy.
  • Hysterectomy A hysterectomy is surgery to remove your uterus and cervix. This is a permanent procedure that causes sterility and ends menstrual periods.

Interactive questionnaire

Heavier than usual bleeding is not necessarily a sign that something is wrong, but it is important to establish whether your heavy bleeding warrants further investigation. Take this short questionnaire to see if you fall into the 'heavy bleeding' category and may require further assessment and treatment.

Section A refers to questions to assess whether you may have HMB, and Section B relates to the impact your HMB may have on your quality of life

    A. How heavy are your monthly periods?

  1. Does your period last longer than seven days?

  2. Do you need to change your pad or tampon excessively throughout the day, i.e. every hour for a few hours in a row

  3. Do you need to use double protection, such as a pad and a tampon or two pads, to prevent leaks?

  4. Do you have to get up in the night to change your pad?

  5. B. How does your period affect your quality of life?

  6. Do you become tired, breathless or feel faint due to your heavy bleeding?

  7. Do your periods affect your social life, fitness or sexual intimacy?

  8. Do you sometimes miss work because of the heaviness of your periods?

  9. Do you have to change the way you dress or avoid wearing light clothes during your period?

  10. Do you avoid leaving home for fear of accidents?

SUBMIT ANSWERS

Based on your responses, your periods are very heavy and are probably affecting your general health and quality of life. We recommend that you seek advice from your GP or healthcare professional as soon as possible to check whether there may be an obvious cause for your heavy bleeding, and to discuss treatment options that could benefit you.

Based on your responses, you don't have any symptoms that need further investigation or may require treatment. However, if you are still concerned about any symptoms that you do have it always best to seek advice from your GP.

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Always speak to your doctor or nurse for personal medical advice. Health information in this website is intended as general information and for UK audiences only. It is not intended to replace a consultation with a healthcare professional, nor is it intended to provide specific medical advice.

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All contents © Bayer 2016. All rights reserved. Date of preparation: February 2017