Heavy periods can happen during perimenopause because bleeding may become heavier or lighter as cycles change [1]. That does not identify the cause. Polyps, fibroids, adenomyosis, bleeding disorders, infections, pregnancy complications, some medications and cancers can also cause heavy menstrual bleeding [2]. A workup can include blood tests and imaging. Bleeding through two or more pads or tampons each hour for two to three hours in a row calls for prompt professional evaluation [2].
What changes during perimenopause?
Perimenopause is the transition before menopause, when estrogen levels start to decrease [1]. It usually begins in the mid-40s, though it may start as early as the mid-30s or as late as the mid-50s [1]. Cleveland Clinic gives an average duration of about four years, with an upper end of eight years [1].
During perimenopause, a cycle may become longer or shorter than usual. Bleeding may also become heavier or lighter [1]. Cleveland Clinic advises contacting a provider about bleeding that is very heavy, soaks a pad every one to two hours, lasts longer than usual, happens between periods, follows sex, or occurs when periods are less than 21 days apart [1].
Menopause is reached after 12 months in a row without a menstrual period [1]. The fact that cycles change during perimenopause does not tell you whether fibroids, polyps, adenomyosis or another cause is present [2].
What counts as heavy bleeding?
Cleveland Clinic describes typical menstrual blood loss as about 2 to 3 tablespoons. Heavy bleeding is more than 5 tablespoons [2]. Other signs include a period lasting longer than seven days, soaking through a pad or tampon every hour for several hours, needing more than one pad at a time, changing protection in the middle of the night, or passing clots the size of a quarter or larger several times a day [2].
Write down the length of the bleeding, how often you change protection, whether you need more than one pad, whether you change protection overnight, and whether you pass clots the size of a quarter or larger [2].
What else can cause heavy bleeding?
Cleveland Clinic lists hormone imbalance, polyps, fibroids, adenomyosis, infections, pregnancy complications, bleeding disorders such as von Willebrand disease, liver or kidney disease, cancers and some medications, including blood thinners, among the causes of heavy menstrual bleeding [2].
A uterine fibroid, also called a leiomyoma, is muscle and tissue that grows within the uterine wall or on its outer surface [4]. Fibroids may be intramural, submucosal, subserosal or pedunculated [4]. Cleveland Clinic lists excessive or painful bleeding during periods and bleeding between periods among the symptoms associated with fibroids [4].
Tests used to find or assess fibroids include ultrasonography, MRI, computed tomography, hysteroscopy, hysterosalpingography, sonohysterography and laparoscopy [4].
In an ultrasound-screened cohort of 1,364 women, the estimated cumulative incidence of uterine fibroid tumors by age 50 was over 80% for Black women and nearly 70% for white women [5]. The same source reports that fibroid tumors developed at earlier ages in Black women than in white women, and that most Black and white women in the United States developed them before menopause [5].
Could heavy bleeding cause anemia?
Heavy bleeding can cause tiredness or shortness of breath from blood loss, which may lead to anemia [2]. Iron-deficiency anemia is usually caused by bleeding. Blood loss from periods is one listed cause, and people with heavy periods have an increased risk [3].
Cleveland Clinic lists fatigue, headaches, irritability, muscle cramps, pale skin, pica, shortness of breath, a sore tongue, spoon-shaped nails and a fast heart rate among the symptoms of iron-deficiency anemia [3]. Write down what you notice.
Blood work for iron-deficiency anemia includes ferritin and total iron-binding capacity [3]. Ask whether those tests are part of the blood work being considered for your bleeding [3].
Which tests can be used?
The published workup for heavy bleeding includes pelvic ultrasound, blood tests, transvaginal ultrasound, MRI, Pap test, cervical culture, endometrial biopsy, sonohysterogram and hysteroscopy [2]. Ask which test is being considered and what question it is meant to answer.
Perimenopause is usually identified from symptoms, age, medical history and a physical exam [1]. Follicle-stimulating hormone testing can help, but hormone levels rise and fall erratically during perimenopause [1]. Ask what information the test would add in your situation.
What treatments might come up?
Cleveland Clinic lists iron supplements, NSAIDs, birth control, hormone therapy, GnRH agonists, desmopressin, tranexamic acid, hysteroscopy, a D and C, myomectomy, uterine artery embolization, endometrial ablation and hysterectomy among treatments for heavy menstrual bleeding [2].
A review found that tranexamic acid reduced fibroid-associated heavy menstrual bleeding, but did not treat the fibroid directly, and no long-term treatment data were available [6]. The same review found limited direct data for contraceptive hormones and a lack of evidence for progestogens in treating fibroid-associated heavy menstrual bleeding [6]. Data were sparse for the levonorgestrel intrauterine system, although one trial found it reduced menstrual bleeding more than a combined oral contraceptive [6].
The review also reported decreased menstrual bleeding, pelvic pain and leiomyoma size in women treated with elagolix or relugolix [6]. Medication manages symptoms. GnRH agonists and antagonists can reduce fibroid size while treatment continues, but medication does not remove fibroids, and symptoms return after effective therapy stops [6].
What should you know about procedures?
A myomectomy removes fibroids while preserving uterine tissue, so pregnancy remains possible [7]. The approaches listed by Cleveland Clinic are hysteroscopic, laparoscopic or robotic, and open abdominal myomectomy [7]. Recovery varies by approach, from a matter of days after a hysteroscopic myomectomy to about two to four weeks after a laparoscopic myomectomy and up to six weeks at home after an open myomectomy [7]. Fibroids can appear again after a myomectomy [7].
Uterine artery embolization is described as a minimally invasive treatment used most often for fibroid-related vaginal bleeding [8]. Cleveland Clinic reports that as many as 90% of patients are back to normal activities inside 10 days, with most resuming activity in the first one to two weeks [8]. It also reports symptoms in 32% of people five years after the procedure, and permanent shutdown of menstrual cycles in about 1% to 5% of people [8].
A hysterectomy removes the uterus and, most likely, the cervix [9]. After surgery, a person cannot become pregnant and will not have a menstrual period [9]. The ovaries are not always removed. Whether they are removed depends on the type of surgery and its reason [9]. Recovery generally takes four to six weeks [9].
Ask what tissue is removed or preserved, what recovery period applies to the proposed approach, and whether symptoms can return.
Can a tracker help at the appointment?
Use the table to record what happens. Leave the cells blank until you have something to add.
| Date | Pads or tampons during the heaviest hour | How long bleeding lasted | Clots | Fatigue, shortness of breath or other symptoms |
|---|---|---|---|---|
Write down whether bleeding happened between periods or after sex [1]. Record whether you changed protection during the night [2]. For symptoms, use words such as none, mild, moderate or severe.
What to do next
- Start a written record with the date, the number of pads or tampons used during the heaviest hour, how long the bleeding lasted, clots, and symptoms.
- Write down whether the bleeding lasts longer than seven days, happens between periods, follows sex, or returns less than 21 days after the prior period [1][2].
- Open the appointment with: “My cycles are changing, but my bleeding is heavy, and I want a workup.”
- Ask whether blood work should include ferritin and total iron-binding capacity [3].
- Ask whether a pelvic ultrasound or transvaginal ultrasound is needed [2].
- Ask which test is meant to find or assess fibroids, and whether an endometrial biopsy, sonohysterogram or hysteroscopy is being considered [2][4].
- If bleeding reaches the urgent threshold described above, seek prompt professional evaluation [2].
- Tell the clinician if you have fatigue, headaches, pale skin, shortness of breath, a fast heart rate or another listed symptom of iron-deficiency anemia [3].
Related on Ruby: fibroid symptoms and perimenopause symptoms.
Sources
- Cleveland Clinic, Perimenopause. https://my.clevelandclinic.org/health/diseases/21608-perimenopause
- Cleveland Clinic, Menorrhagia (heavy menstrual bleeding). https://my.clevelandclinic.org/health/diseases/17734-menorrhagia-heavy-menstrual-bleeding
- Cleveland Clinic, Iron-deficiency anemia. https://my.clevelandclinic.org/health/diseases/22824-iron-deficiency-anemia
- Cleveland Clinic, Uterine fibroids. https://my.clevelandclinic.org/health/diseases/9130-uterine-fibroids
- Baird 2003, High cumulative incidence of uterine leiomyoma in black and white women, PubMed. https://pubmed.ncbi.nlm.nih.gov/12548202/
- Barseghyan 2023, The efficacy of medical management of leiomyoma-associated heavy menstrual bleeding, F&S Reports, PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC10958631/
- Cleveland Clinic, Myomectomy. https://my.clevelandclinic.org/health/treatments/15448-myomectomy
- Cleveland Clinic, Uterine artery embolization. https://my.clevelandclinic.org/health/treatments/17954-uterine-artery-embolization
- Cleveland Clinic, Hysterectomy. https://my.clevelandclinic.org/health/treatments/4852-hysterectomy