Heavy periods are common as a woman approaches menopause, and can also happen to teenagers when their periods first begin. Periods then can also be irregular. At those times of life, we don’t do work-ups for unusual conditions. But we might if periods are becoming progressively more painful (see Painful Periods), and certainly if we find abnormalities on pelvic exam, or if bleeding is so heavy that blood counts are getting low.
Causes of Heavy Menstrual Periods
|• Uterine Fibroids (aka leiomyomas)|
• Copper IUD (ParaGard®, etc.)
|• Bleeding Disorders (various diseases; esp. xxxxVon Willebrand Disease, also Leukemia)|
• Previous C-Sections
• Endometrial Cancer (if >45 y.o.)
As a first step, we do a physical exam, and a Complete Blood Count (CBC). We’d likely order a TSH for Hypothyroidism, even though it’s almost always normal (most hypothyroid women have normal periods). If we feel a large uterus, we obtain an Ultrasound; we’d also get one if the CBC shows a low hemoglobin level, because that would indicate a more serious degree of blood loss (Anemia).
The Ultrasound will easily diagnose structural abnormalities like Fibroids. It might also show Adenomyosis, which can be hard to distinguish from Fibroids. An MRI can help tell the difference, but that would only be obtained if a woman desired surgery (often a hysterectomy). Surgery for either condition would be for comfort, not life-saving (unless bleeding was so great). A special ultrasound called sonohysterography may be ordered for irregular bleeding (see Irregular Periods), but is usually not done for simply heavy periods.
Clotting problems can be tricky to identify (medically, we call them “Bleeding Disorders,” because if blood can’t clot as it should, it’s easier for bleeding to occur). They’re due to conditions that affect either the Platelets, or a series of clotting proteins made by the liver. Diagnosis may be as simple as asking a woman if she takes Aspirin (one dose can interfere with platelets for a week), or daily NSAIDs (ibuprofen, naproxen, etc.). Diseases with low platelet counts will easily show on the CBC.
It’s more complicated to diagnose other chronic bleeding disorders not related to platelets. So we’d only search for those if bleeding was enough that a woman had to constantly take iron to maintain hemoglobin levels (by the way, not all Anemia is from blood loss; see link if interested). First step would be blood tests for prothrombin and partial thromboplastin times (PT and PTT).
But Von Willebrand Disease, the most common bleeding disorder in women, requires special tests. Since interpretation can be tricky, we might refer to a Hematologist for the work-up (& treatment if positive; see link to get an idea of complexity in diagnosis). We refer women who have no other cause for heavy periods, and periods so heavy that they either cause chronic Anemia, or interfere with work (on the job or at home), exercise, or social activities. We’d obviously refer anyone with a family history of bleeding disorders.
In one study of women with heavy uterine bleeding, about 1 in 300 had Leukemia (blood cancer). Most had a sudden, new, very heavy period, causing fatigue and/or shortness of breath. The CBC showed abnormal white blood cell and/or platelet counts in addition to anemia. They were referred to hematologists for diagnosis.
Other causes of heavy periods include the Copper IUD (ParaGard®), but not ones with progesterone (Mirena®). Women who’ve had a C-section, more commonly several, may have scars in the uterus that make periods heavy. This would be a “diagnosis of exclusion,” meaning all other causes have been ruled out. Endometriosis causes heavy periods, but they’re usually painful; see Painful Periods.
See also Heavy Menstrual Periods for the clinician’s condensed thought-process when face-to-face with a patient.