Heavy bleeding with menstrual periods, officially known as menorrhagia, can mean heavy flow or longer periods or both. Most of the time, heavy menstrual bleeding does not mean that something has gone terribly wrong or that your life is endangered, but you and your doctor will want to figure out the cause, which can be either hormonal or anatomical. Perhaps you have a fibroid, or perhaps for some reason you are not ovulating.

It is difficult to know what is meant by “heavy” bleeding, because what seems like threatening blood loss to one woman does not bother someone else. Almost everyone seems to overestimate her own blood loss, especially women who tend to worry about their health in general, and every day at work I get at least one phone call from someone who says she is bleeding heavily.

A research study that weighed tampons and pads to determine blood loss during periods showed that the heavier bleeders in the group lost about 4.5 fluid ounces (135 ml, or roughly a half cup) of blood each month. Some doctors suggest that you can consider yourself to be bleeding heavily if you have to change a thoroughly soaked super tampon every hour for twenty-four hours; others suggest a standard of every half hour for six hours. Even though this rate of loss could be considered heavy, it is not life threatening.

Your physician can gauge your blood loss by using a hematocrit, a measure of the proportion of red blood cells in the blood. The normal hematocrit in women is somewhere between 37 and 40. (For men it is in the mid to high 40s.) Anything below 30 might be worrisome. If you lose a significant amount of blood, your hematocrit will fall, indicating objectively how much you have lost.

Courtney comes into the office sure that she is bleeding heavily enough to be in serious trouble. I send her to the lab for a blood count, and her hematocrit turns out to be a very high 43. Courtney was not anxious about her health, but she simply had no basis for comparing her bleeding with “heavy” bleeding.

On the other hand, one of my partners got a call from the emergency room in a local hospital about a patient who had an episode of heavy bleeding during a period and ended up in the hospital with a hematocrit of 16. The hematocrit drops by roughly three points for each unit (pint) of blood lost, so to get to a hematocrit of 16 when she started out with 37, this woman would have lost seven units of blood, well over half her blood volume.

When you call your gynecologist because of heavy bleeding, try to quantify what is happening. If you tell me you are wearing a super tampon plus a pad and have to change them every hour, something has to be done. If you say you are changing a maxipad every two hours, I can see why you are upset, but I can assure you that your bleeding is not dangerous unless it goes on for weeks. Between those extremes I have to make a judgment call.

A small percentage of women bleed heavily enough during their periods to lower their hematocrit slightly, but as long as it stays in the range of 35 or 36, the blood loss will not threaten their health or keep them from their normal activities.

What can you do to maintain your red-blood-cell count during heavy periods?

If you can live with your heavy periods but worry about becoming anemic, you can boost your blood count by taking iron pills, available over the counter at your drugstore. Start with 325 mg of iron sulfate daily, more than is recommended for pregnant women and enough in many cases to maintain a hematocrit of 37-40 despite heavy periods. Have your doctor check your hematocrit again after a month or two. If it is still too low, you probably need more iron. Most women cannot absorb more than three 325-mg tablets of iron sulfate daily.

To optimize the amount you absorb, take iron tablets on an empty stomach, an hour before a meal or several hours afterward. If they upset your stomach, take them with food. Supplementary iron can make you constipated, so drink plenty of fluids, get lots of exercise, and eat fiber-rich foods, including bran, whole-grain breads and cereals, and fresh fruits and vegetables (with their skins).

If you are not afflicted with heavy bleeding, it is fairly easy to get enough iron in your diet, especially if you eat red meat. But if you are trying to avoid anemia in the face of heavy bleeding by increasing dietary iron, you will have to pay careful attention to what you eat. Many foods contain iron, but not all iron is absorbed equally.

There are two kinds of iron. Heme iron, which makes up about 40 percent of the iron in animal tissues, is found in meat (especially liver and red meat), poultry, and, to a lesser extent, fish. Nonheme iron is found in dairy products, egg yolks, dark green vegetables, legumes, and grains, and is used to enrich flour and cereals.

Your body absorbs about 30 percent of the heme iron in your diet, but only 5 percent of the nonheme iron. Cooked broccoli, for example, contains 1.8 mg of iron per cup, of which only 5 percent actually gets absorbed. Therefore, to get 15 mg, the daily requirement for menstruating women who do not have heavy bleeding, you would have to eat more than 160 cups of broccoli to reach the recommended iron level. This silly example shows how carefully you have to plan if you want to get enough iron without eating red meat or taking supplements. A nutritionist may be able to help you reach your goal.

What diseases or medical conditions cause heavy bleeding?

Fibroids, noncancerous muscular growths in the uterus, can cause heavy bleeding and are fairly common in older women. (For more about fibroids). Polyps, estrogen-stimulated growths of the endometrium that stick out into the uterus, can also produce significant bleeding. They tend to be small and may be attached to the uterine wall by means of a pedicle (a small stalk). Sometimes they protrude through the cervix into the vagina. Usually diagnosed via a D&C (Dilation and Curettage), they can be removed surgically from the wall of the uterus, often during the Dilation and Curettage. Hypothyroidism (too little thyroid hormone) can cause very heavy menstrual bleeding. Women with hyperthyroidism (too much thyroid hormone), on the other hand, usually have very light periods.

Certain blood diseases, including von Willebrand’s disease (an inherited clotting disturbance), can also cause heavy bleeding. This disease is uncommon and generally not much of a problem. But it can be risky during labor and delivery, surgery, or a tooth extraction, so alert your doctor if you know you have von Willebrand’s disease. It is easy to detect, by drawing blood to test for clotting factors.

Endometrial polyps

Endometrial polyps

Can an intrauterine device cause heavy periods?

Women who use an intrauterine device for birth control often have heavy menstrual periods, with an increase in both the flow and the length of the period. They may also have premenstrual spotting and bleeding between periods. If you are using an intrauterine device and bleed or spot between periods, tell your doctor so that the two of you can make sure that the intrauterine device is indeed the culprit — not some other condition.

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