For some women, one of the more frustrating consequences of perimenopause is the onset of heavy menstrual bleeding. This is especially true for women who may never have experienced a heavy flow before or are experiencing blood clotting for the first time. While heavy menstrual bleeding is a major inconvenience and a cause for concern, believe it or not, changes in your bleeding pattern during perimenopause are not unusual. Fortunately, our medical expert is here to explain why you may be bleeding so heavily, how it can affect your health, and what treatment options are available to help improve your quality of life.

I’m 49 years old and thought my period should be ending by now. Why am I bleeding so heavily?

The transition into menopause, known as perimenopause, is just that—a transitional period. While a small percentage of women may find that their periods stop suddenly, most will experience menstrual irregularities and other symptoms, such as hot flashes, night sweats, and brain fog during this phase. A change in bleeding pattern is one of the most common experiences. In fact, 70% of office visits to the gynecologist during perimenopause and menopause are for bleeding problems.

If you are experiencing a heavy menstrual flow, this falls in the category of what is referred to as abnormal uterine bleeding or AUB. Heavy menstrual bleeding is one type of AUB characterized by heavy blood flow during your regular period or periods that last more than eight days for several months.

I’ve always had heavy periods, how can I tell if my bleeding is excessive?

You can gauge if your blood flow is excessive in several ways. Ask yourself if you are: 1). changing sanitary protection every 1-2 hours or using more than 20 pads or tampons per cycle; 2). having to wake and change protection during the night; 3). passing clots that are bigger than one inch and having bleeding that lasts longer than eight days.

These guidelines may be helpful, but ultimately you are the best judge of what is heavy bleeding for you. Don’t hesitate to consult your doctor if you are concerned about excessive menstrual bleeding. This way, you can be reassured that the blood loss you are experiencing is not having an adverse effect on your health.

I’ve never had blood clots before. What are they and should I be concerned?

Heavy menstrual bleeding can lead to the formation of blood clots. This happens when blood pools in the uterus or vagina and coagulates, in the same way blood clots when you cut your finger. While it’s not unusual to get blog clots with heavy menstrual bleeding, it is not normal to have blood clots larger than a quarter. Be sure to consult your healthcare provider if you experience large blood clots during or outside of your period.

I feel faint and fatigued from bleeding so heavily. Are there vitamins or supplements I can take?

Over time, persistent heavy bleeding can lead to iron deficiency anemia and symptoms of fatigue, weakness, lightheadedness, shortness of breath, and chest pain. In rare cases, a sudden onset of severe vaginal bleeding can lead to low blood pressure and shock. A complete blood count (CBC) test will determine if you have developed anemia. A CBC will also check if you have an adequate number of cells called platelets which, if low, may be a cause of bleeding. Your doctor may also check the blood level of a protein called ferritin that stores iron—a low ferritin level means low iron stores.

Taking vitamin C simultaneously and eating foods rich in vitamin C will improve your system’s ability to absorb iron. Remember, iron deficiency is not reversed overnight and can take several months to correct. Making sure your diet includes foods that are rich in iron is also helpful. Breakfast cereals, whole grains, seafood, red meats, pork, chicken, and vegetables such as mustard greens, chard, and spinach are just some of the many iron-rich foods. 

Are there medical procedures to stop or reduce my heavy bleeding?

Yes, there are many options for treating heavy menstrual bleeding. Hormonal treatments come in several forms. An intrauterine device (IUD) that releases a 20-microgram-per-day formulation of a hormone called levonorgestrel (Mirena) is considered the most effective treatment that reduces blood loss by 71 to 95%. Birth control pills can also decrease blood loss by up to 69% and help regulate bleeding if irregular periods are a concern. Continuous dosing with oral progestins is another effective hormonal treatment that can reduce blood flow by 87%.

There are also two effective non-hormonal treatment options. Tranexamic acid (Lysteda) can decrease blood loss by 26 to 54%, and the familiar nonsteroidal anti-inflammatory drugs can also lead to between 10 to 52% reduction in blood loss. You take these medications during your period. Endometrial ablation is a surgical option that has been reported to work as well. Your doctor may recommend a myomectomy, a surgical procedure for removing fibroids if these contribute to the bleeding. Hysterectomy, a removal of the uterus vaginally or abdominally, is a definitive surgical procedure that women also choose.

Why is my PMS worse than ever?

Premenstrual symptoms such as breast tenderness, abdominal bloating, nausea, and headache are common and often mild. However, 20-40% of women will experience severe symptoms that are disabling. In addition to the physical symptoms, depression, anxiety, poor concentration, and irritability can have a detrimental effect on your quality of life. This more serious group of symptoms is referred to as premenstrual dysphoric disorder (PMDD). PMDD leads to severe daily disability in up to 14% of women. Women can experience PMDD symptoms up to 7 days before their period starts, and symptoms usually subside when menstruation begins. Perimenopause does not protect against PMS or PMDD.

A 2014 study including 100 perimenopausal women between 43 and 53 years of age found that 95% of women reported PMS, and 23% of women met the PMDD criteria. So, you are not alone. There are a lot of theories about what causes PMS/PMDD, though the common belief is that it is a combination of biological and psychological factors. Various approaches are used to help alleviate symptoms, and you should talk to your doctor about the value of exercise, a healthy diet, and potential drug and alternative treatments in helping to cope with your symptoms.

When should I talk to my doctor?

Because there are many causes of heavy vaginal bleeding, you should feel comfortable consulting with your doctor at any time. You don’t need to wait months or until you develop symptoms of dizziness or lightheadedness to contact your doctor. You can use the recommendations provided for gauging how heavy the bleeding is, but remember that you are the best judge of what is normal for you.

Heavy menstrual bleeding can have a significant impact on your quality of life, and there are many treatment options available that can help you through this transitional period. If your heavy menstrual bleeding is concerning you, there’s no need to delay seeking help from a qualified medical professional.

Margueritte Mabry is a medical writer who writes about health topics related to women’s health and alternative medicine. She is also an award-winning short fiction author. She received her M.D. from Temple University School of Medicine and completed a four-year residence in Obstetrics and Gynecology at Mount Sinai School of Medicine in New York City.

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