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Heavy and Irregular Flow

Most people will experience changes in their menstrual cycles during perimenopause. It might be more/fewer days of bleeding, heavier or lighter bleeding, some bleeding between periods (irregular) and changes in cycle lengths — the number of days between periods.

What is heavy or irregular flow?

Heavier Flow: more bleeding than usual during your period. Everyone’s amount of flow is different. So heavy flow for you is based on your normal flow.
Irregular Flow: bleeding or spotting that occurs between your periods.
Abnormal Uterine Bleeding (AUB) is the term healthcare providers use to refer to heavier or irregular flow.
WLB 2020 SURVEY RESULTS

Changes in Menstrual Flow

  • Much heavier
  • Slightly heavier
  • Slightly lighter
  • Much lighter
  • Some heavier and some lighter
  • Unsure
  • No changes

1,298 total responses

3 things to know about heavy and irregular flow

  • If you have heavier flow for a long time it can lead to anemia which needs to be treated with iron supplementation.** Signs of anemia are fatigue, shortness of breath when you climb stairs or looking paler than usual.

  • Most often some heavy or irregular flow is normal during perimenopause, but if you have a dramatic increase in the amount of flow during your period (more than 80 ml), if periods are getting heavier and heavier over time, if you have more than 8 days of bleeding or irregular bleeding between periods, it should be evaluated by a health care provider to understand the cause.

  • Some fibroids depending on location and growth of the endometrium into the uterine wall (aka adenomyosis) are common as we age, and these can lead to heavy and/or irregular bleeding.

How do I know if my flow is too heavy?

It might require a check-in with your healthcare provider.

If you soak a super tampon or pad in 3-4 hours, you have a normally heavy flow.

But if you are going through a super tampon or pad in 1-2 hours or you need a tampon and a pad to get through the night, your menstrual flow is considered heavier than normal and you should see your provider to check for anemia (low iron) and rule out anatomic causes.

WLB 2020 SURVEY RESULTS

These data are based on 1,298 participants in the Women Living Better Survey.

  • LRS = the late reproductive stage and MT = the Menopause Transition.
  • These are two stages along the path to menopause (the final menstrual period).
  • During the LRS periods are still coming monthly, but subtle changes to cycle length and flow begin.
  • Once you are in the MT, menstrual cycle changes are more noticeable.

Changes in Cycle Length

  • Getting shorter
  • Getting longer
  • Cycle length changes inconsistent
  • No changes to cycle length
  • Other changes
Key things to notice about cycle length changes by stage
  • In the LRS, the most noticeable change is shortening cycle lengths (periods coming closer together)
  • In the MT, the most noticeable change is inconsistent cycle lengths followed by lengthening cycles (a longer time between periods)
  • Far fewer MT respondents reported no changes to their cycle lengths (7%)

Changes in Amount of Menstrual Flow

  • Much heavier
  • Slightly heavier
  • Slightly lighter
  • Much lighter
  • Some heavier and some lighter
  • Unsure
  • No Changes
Things to notice about flow changes by stage
  • In both the LRS and MT, about 30% of participants report much heavier flow and another 30% report some days are lighter and some days are heavier, accounting for 60% of responses.
  • In the MT, more participants (17%) report lighter flow than in the LRS (11%)

How common is heavy and irregular flow?

AUB is a common gynecologic complaint affecting 10 to 30% of reproductive-age women.2

Menometrorrhagia, defined as excessive and prolonged uterine bleeding occurring at irregular and/or frequent intervals, occurs in up to 24% of women aged 40-50 years.3

WOMEN’S VOICES

Fluctuation in flow of period. One month very heavy. Then the next two months light flow.

WOMEN’S VOICES

Very Heavy flow with somewhat erratic cycles.

WOMEN’S VOICES

Increased cycles, having 2 per month at times. Longer cycles, heavier bleeding.

WOMEN’S VOICES

More clotting in heavy flow days.

Do I have heavy flow?

Total period blood loss of 80ml is considered normal flow 1.

Regular tampons

A regular tampon holds 5 ml of blood

16 regular tampons x 5 ml of blood = 80 ml normal flow

If you used only regulars, 16 tampons during your period = normal flow.

More than that = heavy flow.

Super tampons

A super tampon holds 12 ml of blood

6 to 7 regular tampons x 12 ml of blood = 72 to 84 ml = normal flow

If you used only super tampons, 6 to 7 tampons during your period = normal flow.

More than that = heavy flow.

Most of us use a combination, of products and often we don’t use all the absorption of a product either. But these should be guides to tell whether you are losing more than 80 ml.

Using a menstrual cup is another way to assess your amount of flow.

Remedies for heavy and irregular flow

Here are some remedies to consider for heavy flow caused by hormonal changes. You’ll need to consult your healthcare provider when you move beyond NSAIDs.

NSAIDs (Motrin, Advil, generic) can reduce flow

Reduce flow by inhibiting the effects of prostaglandin. Take 200-400 mg with a meal (to protect your stomach) at the first sign of cramps. Cramps signal the beginning of prostaglandins rising, and it’s best to get ahead of them. The earlier you start NSAIDs the better. If you know when your period is coming, starting ahead of time can reduce heavy flow. NSAIDS have been proven to reduce flow by 25%.5, 6

Tranexamic acid by prescription

If NSAIDs don’t reduce your flow and help your cramps, your doctor can prescribe tranexamic acid. Tranexamic acid reduced flow by 54% in one study.7

Progestin IUDs and oral progestins to reduce heavy flow

Progestin IUDs (e.g. Mirena®, Liletta®) and oral progestins both have been shown to significantly reduce heavy flow. A recent meta-analysis suggests that a progestin IUD is the best first-line treatment for heavy flow (heavy menstrual bleeding).9

Low-dose birth control pills to reduce flow

Low-dose birth control pills are a commonly prescribed remedy and have been shown to reduce flow.10 Some women with high estrogen in early perimenopause will find the pill exacerbates their symptoms, however.

Progestogens are used by some healthcare providers to treat heavy flow

Prometrium™ (progesterone USP) is the bioidentical form. Medroxyprogesterone acetate often referred to as MPA (Provera™, Depo-Provera™) is a synthetic progestogen. And a progestin-only mini-pill is also sometimes used to treat heavy flow.

Endometrial ablation is an in-office procedure

Endometrial Ablation is an in-office procedure performed by a gynecologist to ablate (burn or freeze) the lining of the uterus.

  • This results in significantly reduced flow or often no flow at all.
  • A recent study reported high satisfaction with the procedure among 408 women and no difference in whether they had it performed in an office setting or as a day procedure under general anesthesia. 

WLB advisors pointed out these possible drawbacks to ablations

  • If it is done early in the transition, bleeding can come back. 
  • Those who have had an ablation and then develop any postmenopausal bleeding become very complicated to manage since a healthcare provider cannot get back into the uterine cavity to look as it’s all scarred over, so many women wind up with a hysterectomy.

I had an endometrial ablation for heavy flow, and it worked! I was anemic and needed to do something. I now have no flow, and while it’s nice in many ways, it’s odd not to bleed at all and harder to track whether other symptoms are cyclical.

WLB Community Member

Hormones & heavier flow

Higher estrogen during perimenopause can cause heavier than normal menstrual flow.4  But these symptoms can be due to hormonal changes or anatomical causes, and it’s important to determine which it is.

Hormonal causes: the higher estrogen4 or absent ovulation causes extra tissue to build up on the uterine walls (endometrium). When the cycle ends and the endometrium sheds, there is more to shed and thus heavier flow.

Anatomical causes: heavy flow may result from abnormal cell growth, fibroids (benign tumors of the uterine wall), endometriosis (migration of endometrial tissue to other pelvic structures), or endometrial polyps. Adenomyosis (endometrial lining grows into the uterine wall)

It is important to consult with your medical care provider to determine which of these is causing your heavy flow and find the best course of action.

ADDITIONAL RESOURCES

REFERENCES

  1. Hallberg L, Hogdahl AM, Nilsson L, Rybo G. Menstrual blood loss – a population study. Variation at different ages and attempts to define normality. Acta Obstet. Gynecol. Scand. 45(3), 320–351 (1966
  2. (Minalt N, Canela CD, Marino S. Endometrial Ablation. 2022 Dec 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29083707.)
  3. Donnez J. Menometrorrhagia during the premenopause: an overview. Gynecol Endocrinol. 2011 Dec;27 Suppl 1:1114-9. doi: 10.3109/09513590.2012.637341. Erratum in: Gynecol Endocrinol. 2012 Feb;28(2):156. PMID: 22182054.
  4. Moen MH, Kahn H, Bjerve KS, Halvorsen TB. Menometrorrhagia in the perimenopause is associated with increased serum estradiol. Maturities. 2004 Feb 20; 47(2):151-5.
  5. Fraser IS, McCarron G, Markham R, Robinson M, Smyth E. Long-term treatment of menorrhagia with mefenamic acid. Obstet Gynecol. 1983 Jan; 61(1):109-12.
  6. Lethaby A, Augood C, Duckitt K. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000(1):CD000400.
  7. Bonnarand  B. L. Sheppard. Treatment of menorrhagia during menstruation: randomised controlled trial of ethamsylate, mefenamic acid, and tranexamic acid. BMJ. 1996 Sep 7; 313(7057): 579–582.
  8. Bianchi P, Guo SW, Habiba M, Benagiano G. Utility of the Levonorgestrel-Releasing Intrauterine System in the Treatment of Abnormal Uterine Bleeding and Dysmenorrhea: A Narrative Review. J Clin Med. 2022 Oct 1;11(19):5836. doi: 10.3390/jcm11195836. PMID: 36233703; PMCID: PMC9570961.
  9. Bofill Rodriguez M, Dias S, Jordan V, Lethaby A, Lensen SF, Wise MR, Wilkinson J, Brown J, Farquhar C. Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis. Cochrane Database Syst Rev. 2022 May 31;5(5):CD013180. doi: 10.1002/14651858.CD013180.pub2. PMID: 35638592; PMCID: PMC9153244.
  10. Curlin HL, Anderson TL. Endometrial Cryoablation for the Treatment of Heavy Menstrual Bleeding: 36-Month Outcomes from the CLARITY Study. Int J Womens Health. 2022 Aug 10;14:1083-1092. doi: 10.2147/IJWH.S371044. PMID: 35983177; PMCID: PMC9379116.
  11. Ghoubara A, Gunasekera S, Rao L, Ewies A. Re-intervention and patient satisfaction rates following office radiofrequency endometrial ablation: a comparative retrospective study of 408 cases. J Obstet Gynaecol. 2022 Jul;42(5):1358-1364. doi: 10.1080/01443615.2021.1965560. Epub 2021 Oct 23. PMID: 34689685.