Heavy Menstrual Bleeding: A Serious Health Issue Underestimated

Excessive menstrual bleeding is a serious health problem. We have only recently begun to understand its causes and how it can be treated.

From the age of 12-13, Michelle Elston spent the most difficult days of her period sleeping in the school nurse's office. She faced severe pain as blood soaked through her pads. She says, 'I was taught that this was normal. It's something you have to learn to deal with.'

She felt weak when she couldn't cope with her period like her friends. Only after she turned 40 did she realize it wasn't her fault. She had an unusually heavy menstrual flow. When menstrual bleeding affects daily life, doctors call it heavy menstrual bleeding, which is a serious medical condition.

Studies worldwide show that 10-30% of women of reproductive age suffer from heavy menstrual bleeding like Elston. Due to infrequent complaints or lack of understanding about what constitutes heavy bleeding, studies suggest that up to half of women of reproductive age may have this problem. Excessive bleeding can also indicate other health issues. Ignoring it can lead to serious consequences like anemia.

However, researchers have only recently begun to study the harms of heavy menstrual bleeding in depth. They are seeking better identification and treatment. A search for the term 'menstrual blood' in 'PubMed,' a database of biomedical research publications, yielded only about 400 publications in the last decade. For comparison, there are over 15,000 publications related to semen.

Jackie Maybin, a gynecologist at the University of Edinburgh in Scotland and program director of 'The Missed Vital Sign,' a research initiative on heavy bleeding, says, 'There are years, if not decades, of research left for women. And I think that time has now come.'

• How much bleeding is excessive?

For researchers, bleeding more than 80 milliliters per cycle, passing blood clots larger than a US coin, or menstruating for more than seven days is considered heavy bleeding. 

However, for menstruating individuals, there are no validated or metric systems to translate practical ways of measuring bleeding. For example, there are no clear criteria for how many times to go to the bathroom, how many pads or tampons to change, or the number of stained undergarments.

Some doctors use charts showing progressively more stained pads and tampons to help patients estimate their bleeding. But this is also not accurate, as not all menstrual products are the same, and their absorbency varies greatly.

As a result, it is not easy to determine how much menstrual bleeding is excessive. In most cases, doctors have to determine heavy bleeding based on how much it affects the patient's quality of daily life.

Dr. Adwoa Christie, a clinical professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco, says, 'Sometimes patients don't even realize that the amount of bleeding they are experiencing is not normal and can actually be treated.'

Elston's clothes and bedding were regularly stained with blood. Once, even the white chair in a mobile phone store got stained. She felt she was doing something wrong and perhaps needed different products to stop the bleeding.

She was made to accept that painful abdominal cramps and blood stains during menstruation were normal. In other parts of the world, menstrual taboos and stigma are even deeper.

Hemantha Senanayake, Emeritus Professor in the Department of Obstetrics and Gynecology at the University of Colombo, Sri Lanka, and head of the Asian Society of Endometriosis and Adenomyosis, says, 'I think many people in my field don't complain about this. Perhaps due to the normalization of pain and social stigma, they don't come to the doctor.'

Gynecologists ask detailed questions to detect heavy bleeding. However, doctors in other fields may overlook these signs. It took Elston nearly 30 years to get her heavy bleeding diagnosed, and she is not alone in experiencing this problem.

• Heavy bleeding is not just a symptom

While heavy bleeding is a problem in itself, it is primarily a symptom of a larger health issue. It can be caused by various factors including polyps, fibroids, cancer, blood disorders, ovarian problems, and uterine disorders like endometriosis. It is also considered normal during the onset of menstruation and menopause when the body's hormonal balance is changing, although it should be addressed.

Treating these conditions can reduce heavy bleeding, but scientists still don't fully understand how these problems increase bleeding. Maybin says that fibroids are non-cancerous lumps that grow in the uterine muscle, 'There has been a lot of research on fibroids, but for example, research on why they cause heavy bleeding has not been done.'

On the other hand, untreated heavy bleeding can create new problems like iron deficiency. Iron is an essential mineral for healthy cells, immunity, muscles, skin, hair, and nails. As iron levels decrease, problems like brain fog, dizziness, shortness of breath, easy bruising, and hair loss can occur.

Thus, the effects of heavy bleeding extend beyond the menstrual period. Studies estimate that over 40% of women with heavy bleeding also have iron deficiency. Elston found herself within this statistic. 

She always felt cold and often craved ice cubes. This is a peculiar but clear sign of iron deficiency that researchers have not yet fully understood. If left untreated, iron deficiency can lead to anemia. In such cases, the bone marrow does not have enough iron to produce the hemoglobin needed for red blood cells to carry oxygen throughout the body. This is a serious condition that may require blood transfusions in extreme cases.

Senanayake states that bleeding is a major cause of maternal mortality in low and middle-income countries. In such a situation, if iron deficiency anemia is not resolved before pregnancy, the body's ability to recover from blood loss is reduced. It can also harm fetal brain development.

• The cost/impact of heavy bleeding

Although scientific recognition of the medical seriousness of heavy bleeding is growing, little research has been done on what it is like to live with this problem.

Emily Young, an associate professor of psychology at Sheffield Hallam University in the UK, also experienced heavy bleeding like Elston. Due to heavy blood loss, she has fainted more than once. She always carried a change of clothes because she could menstruate at any time. However, her doctors assured her that her periods would normalize after childbirth. Inspired by two decades of neglect from healthcare professionals, she is now researching the experiences of others with heavy bleeding.

Young says, 'It's not just an inconvenience. It's the compulsion to structure your entire life around your menstrual cycle.'

For a study to be published in 2025, Young examined online forum posts from individuals with heavy bleeding to highlight similar experiences. What she saw ranged from infuriating to painfully humorous. Many posts described individuals needing multiple blood transfusions before doctors recognized the severity of their condition.

Other posts contained vivid descriptions, such as: 'Yes, if someone used Luminol (a chemical used in forensics to detect blood at crime scenes) in my bathroom, I would surely go to jail because they would dig up my yard to find dozens of murder victims.'

There were also posts about having to miss school or work due to heavy bleeding, or not having a healthy sex life. Some posts mentioned mental health issues, while others, according to Young, were heartbreaking, mentioning suicidal thoughts due to menstruation being so severe and life-altering.

For transgender men or non-binary individuals, menstruation can be very painful in itself, and heavy bleeding adds 'salt to the wound.' Julie Jaffray, a pediatric hematologist at Rady Children's Hospital, University of California San Diego, says, 'We see many transgender patients who identify as men, yet they have problems with heavy bleeding. Which is an even more frightening experience for them.'

Ultimately, the overall impact of heavy bleeding on individuals' personal lives hinders education and work, and its effects spread throughout society. According to Elston, she often missed school during her periods. Although her mother insisted she go to school, she would lie down in the nurse's room.

In the UK, teenage girls with heavy bleeding miss an average of nine school days per year. Senanayake estimates this number could be even higher in low and middle-income countries like Sri Lanka. Girls in impoverished areas may be forced to attend schools without facilities to change or dispose of menstrual products.

In adulthood, this means missing workdays and opportunities. Elston, a telehealth therapist in New York City, lost a client the last time she had to shorten her session during a difficult period. 'The pain was so severe, I couldn't even hear what she was saying,' Elston says, 'I told her directly, I can't complete this session.' After hanging up the phone and getting out of her chair, she saw a pool of blood beneath her.

Maybin says, 'Women with heavy bleeding miss work for an average of 3.6 weeks per year. This is costing the economy billions. If we can solve this problem for women... we will truly be doing the right thing for everyone in society.'

• Treatments and tests

There is still much work to be done to get this on the right track. Erika Mars, a professor in the Department of Obstetrics and Gynecology at the University of Michigan Medical School, says that while treatments for heavy bleeding are available, they are not sufficient. She says, 'We have frighteningly few treatment options.'

The treatment for heavy bleeding depends on its underlying cause. If the bleeding is not too severe, non-steroidal anti-inflammatory drugs like ibuprofen can reduce the flow. There are also hormonal treatments like birth control pills or hormonal intra-uterine devices (IUDs), which are among the most effective treatments for reducing menstrual bleeding.

Although these methods are quite accessible, there are some barriers to their use. For example, inserting an intra-uterine device can be painful. Birth control pills worked for Elston, but due to negative family perceptions about pills, she had to wait until she was older. Only after going to college did she get a doctor's prescription.

Maybin says that hormonal treatments don't work for everyone, and people often stop using them due to side effects like breast pain and mood changes. People can also use non-hormonal medications like tranexamic acid, which helps stop bleeding. Jaffray says, 'The problem is that they are like band-aids and don't address the root cause.'

Medication doesn't always solve the problem. In her mid-30s, Elston stopped taking birth control pills for a while. Her periods then returned with even greater intensity, along with significant mood swings.

Finally, she saw a gynecologist who performed an ultrasound and identified some potential causes. Elston recalls, 'The doctor said, stop the birth control pills. You have seven or eight large fibroids in your uterus, and you may also have endometriosis.' Endometriosis is a painful condition in which endometrial tissue, which normally lines the uterus, grows outside the uterus.

Consequently, she opted for a hysterectomy, surgically removing her uterus entirely. In fact, heavy bleeding is one of the most common reasons for hysterectomy. She is happy with her choice, and her story of heavy bleeding ends with a solution.

However, a hysterectomy is a major surgery, it is permanent, and it makes pregnancy impossible. This becomes particularly problematic when healthcare providers prioritize fertility over the patient's health.

Young says that one woman in her research had three children and her husband had undergone a vasectomy. However, her doctor refused a hysterectomy to treat her heavy bleeding, citing the possibility that the woman might divorce and marry another man who wanted children.

The frustration and discomfort with the treatment methods for her patients inspired Maybin to lead 'The Missed Vital Sign.' This is a global research program funded by the health philanthropy 'Wellcome Leap.' The program's name reflects the recognition that changes in menstruation can be the first sign of other health problems, making it a vital sign like blood pressure, body temperature, or heart rate.

Over the next three years, a team of 13 researchers will work to reduce the average five-year delay in the diagnosis and treatment of heavy bleeding worldwide to five months.

As a step towards that goal, Maybin wants to explore the mechanisms behind heavy bleeding and its causes. Another key focus will be to improve the identification of this condition. Some projects will involve searching for biomarkers (chemical indicators of heavy bleeding) in menstrual fluid, developing smart sensors to monitor bleeding using menstrual products, or using data from smartphones and wearable devices to assess the risk of iron deficiency.

Maybin believes it is the right time for this project, thanks to new and emerging research technologies like rapid genome analysis. She says, 'These technologies have not been used to improve women's health before. I think now is the time for us to do it.'

Similarly, Jaffray has worked to bring hematologists into the field of heavy bleeding, emphasizing the need for blood specialists to work with gynecologists to manage this condition. For example, 'The Foundation for Women and Girls with Blood Disorders' is helping to improve and expand the care of women and girls at hemophilia treatment centers in the US.

But a crucial aspect of this progress is ensuring that individuals with heavy bleeding can actually access new diagnostic methods and treatments. That's why Mars is working with Black and Hispanic women in her local community, who are at higher risk of anemia than white women in the US. She hopes that by working with trusted community members, her latest study will find ways to connect people with the care they need and increase general awareness about these conditions.

Researchers are increasingly realizing the urgency of prioritizing heavy bleeding in research and medicine to help women and all menstruating individuals live to their full potential, without 'brain fog' from iron deficiency and without missing work or school. Elston says, 'We need to be taken more seriously. We need proper care so that we can exercise our equal right to live in this world.'

BBC