Heavy Bleeding During Periods (Menorrhagia): Causes, Warning Signs and Treatment

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Very common, and under-reported. In a door-to-door survey of 119 women in Puducherry, about 17 out of every 100 had heavy periods. Many more women live with heavy periods and never mention them, because the women around them had the same and they think it is normal.

The bigger problem in India is what heavy periods do to iron levels. About 57 out of every 100 Indian women aged 15 to 49 are anaemic, according to the National Family Health Survey (NFHS-5, 2019 to 2021). In Maharashtra the figure is about 54 out of every 100 (54.2 percent). Heavy periods are one of the reasons, and they are often missed because tiredness is treated as part of life. Our guide to nutrient deficiency in Indian women covers the wider picture of iron, vitamin D and B12.

Clots are a common worry. When blood collects in the uterus or vagina faster than the body can keep it liquid, it forms clots.

• Small clots now and then on the heaviest day are normal.
• Repeated clots larger than about 2.5 cm, especially with flooding or leaking, are a sign of heavy bleeding (NHS).

Clots by themselves do not tell us the cause. Fibroids, adenomyosis, hormonal causes and bleeding disorders can all produce clots. What matters is how often they come, whether this is new for you, and what else is happening.

Make a note of when clots happen and roughly how big they are. If you are comfortable, a photo on your phone helps.

Very large clots or tissue-like pieces after a missed period can be a miscarriage. Take a pregnancy test and see a doctor the same day.

Yes. Every heavy period takes iron away. Over months, iron stores run out and iron-deficiency anaemia follows. It comes on slowly, so most women get used to feeling unwell without realising why.

Signs of anaemia include:

• tiredness that sleep does not fix
• breathlessness while climbing stairs
• dizziness or headaches
• a racing or pounding heartbeat
• pale skin, pale nails or pale inner eyelids
• hair fall and brittle nails
• craving ice or non-food things like mud, chalk or raw rice

Treating anaemia

Iron comes as tablets or, when needed, as an injection or drip. An iron drip raises iron faster and is useful when tablets upset the stomach, when anaemia is moderate, or before surgery. Blood transfusion may be required in severe anaemia.

Iron treats the anaemia. It does not stop the bleeding. If the bleeding is not controlled, the anaemia returns a few months after you stop iron, so both need treatment together.

Your doctor may also check ferritin, the blood test for iron stores, even if your haemoglobin looks normal. Iron stores can run low and make you tired before anaemia shows up. In July 2026, NICE removed its earlier advice against routinely testing ferritin in women with heavy periods, saying that advice was not justified because of the risk of iron deficiency in these women.

Heavy periods treatment usually starts with tablets taken only on bleeding days, hormone tablets or the hormone coil, with iron if you are anaemic; surgery is rarely the first step. Treatment has five aims: control the bleeding, correct the anaemia, treat the cause where possible, protect your fertility if you want a pregnancy in future, and give you back a normal routine. The right choice depends on the cause, your age, your health, whether you need contraception, and your plans for pregnancy.

Treatment options compared

Sources: NICE NG88, ICMR Standard Treatment Workflow. Please do not start any of these without a prescription; each one has situations where it is not safe.

1. Tablets taken only on bleeding days

Tranexamic acid helps the blood in the uterus to clot. A Cochrane review found it reduces menstrual blood loss by about 40 to 50 percent. It is not a hormone, it does not affect fertility, and you take it only on the heavy days of your period. Studies so far have not shown a raised risk of blood clots in women taking it for heavy periods, though few looked closely at this.

It is not suitable if you have ever had a blood clot (in a leg, lung, brain or eye) or have a condition that raises your clot risk, and it should not be taken with the combined pill, patch or ring (prescribing information). That is why it should be started only after a doctor checks your history.

Anti-inflammatory painkillers (NSAIDs) such as mefenamic acid or ibuprofen reduce both bleeding and cramps, though they work less well than tranexamic acid for bleeding (Cochrane). They help most when periods are both heavy and painful. They may not suit you if you have stomach ulcers, kidney disease or some types of asthma. India’s ICMR workflow allows tranexamic acid and mefenamic acid to be used together when heavy bleeding comes with pain.

2. The hormone coil (LNG-IUS)

The hormone coil, or levonorgestrel intrauterine system (LNG-IUS), for example Mirena, is a small, soft T-shaped device placed inside the uterus in the operation theatre, as a day-care procedure under short sedation. It releases a small dose of a progesterone-like hormone directly into the lining, and very little reaches the rest of the body.

• It is one of the most effective treatments for heavy periods, and reductions in blood loss of up to 90 percent have been reported (Cochrane).
• It also works as contraception for several years.
• It can be removed whenever you want to try for a pregnancy.
• NICE suggests considering it as the first treatment when there is no identified cause, only small fibroids (under 3 cm) that do not distort the cavity, or adenomyosis.

Expect irregular spotting for the first three to six months. Many women then have very light periods, and some stop having periods altogether. This is safe and reverses once the coil is removed. Our procedures page explains how the coil is fitted.

“The study is the reason I discuss the coil with almost every woman who fits the eligibility criteria for the LNG-IUS (for example, Mirena), where surgery may not be the first choice.”
- Dr. Pallavi Kulkarni, MBBS, DGO, DNB (OB-GYN), DFP, MRCOG (UK), Fellowship in IVF

3. Hormone tablets

• Combined oral contraceptive pills make periods lighter, more regular and less painful, and also prevent pregnancy. They are not suitable if you are over 35 and smoke, or have migraine with aura, high blood pressure, or a history of blood clots.
• Progestogen tablets (progesterone-like hormones) are usually taken from day 5 of the cycle for three weeks, repeated for four to six cycles. In India, norethisterone is commonly used to control a heavy episode. Your doctor will decide the dose and how long to take it (ICMR).
• Ormeloxifene is a non-steroidal tablet, which means it is not an oestrogen or a progesterone. It was developed in India and is used here for heavy bleeding; the ICMR workflow lists it as an option at specialist hospital level. It also works as a contraceptive.

4. Treating the cause

• Thyroid problem: treating the thyroid often settles the periods. Read more about thyroid disorders in women.
• PMOS: regular hormone treatment protects the lining from building up. Read why PCOS is now called PMOS.
• Bleeding disorder: managed together with a haematologist (blood specialist).
• Polyp or fibroid inside the cavity: removed by hysteroscopy (see below).

5. Procedures and surgery

When a structural problem is causing the bleeding, or medicines have not helped, these are the options:

• Hysteroscopic polypectomy: removing a polyp through a camera inside the uterus, with no cut on the tummy. Usually a day-care procedure.
• Hysteroscopic myomectomy: removing a fibroid that sits inside the cavity, also through the camera.
• Myomectomy (keyhole or open): removing fibroids from the wall of the uterus while keeping the uterus. This is the usual choice for women who want a pregnancy.
• Uterine artery embolisation (UAE): a radiologist blocks the blood supply to fibroids through a thin tube passed from the groin or wrist, and the fibroids shrink. Its effect on future pregnancy needs careful discussion.
• Endometrial ablation: destroying the lining of the uterus. It is only for women whose family is complete, because pregnancy afterwards should be avoided and you will still need effective contraception (NICE).
• Hysterectomy: removing the uterus. It stops periods permanently, but it is major surgery and cannot be reversed.

The operations themselves are described on our gynaecology procedures page, including polyp removal and biopsy, myomectomy and hysterectomy.

Teenagers

Heavy periods are common in the first two or three years after periods start, because ovulation is not yet regular. But heavy bleeding from the very first period can also be the first sign of a bleeding disorder, ACOG reports that about 1 in 5 teenage girls who are evaluated for heavy periods turn out to have a bleeding disorder, and advises that teenagers with heavy periods are checked for one. Take a teenager to a gynaecologist if her periods last more than 7 days, soak pads every hour or two, make her miss school, or leave her pale and tired. See our adolescent gynaecology clinic, and our guides to heavy and painful periods in teenagers and irregular periods in teenage girls.

Women with PMOS

PMOS often causes long gaps between periods because ovulation is irregular. The lining keeps thickening during the gap, so when the period finally comes it can be very heavy and last many days. A cycle of no period for three months, then flooding, needs proper treatment, not just a tablet each time to bring on or stop a period. Over the years an unprotected lining can thicken abnormally; regular hormone treatment or the hormone coil protects it. Heavy bleeding in PMOS can also have another cause, such as a polyp, so it still needs a scan.

Your 40s and perimenopause

As menopause approaches, ovulation becomes irregular, and periods can become heavier, longer or closer together. But fibroids, adenomyosis and polyps are also most common at this age, and the risk of a thickened lining rises. New heavy bleeding, bleeding between periods or bleeding after sex in your 40s should be checked, which usually means an ultrasound and often a sample of the lining (ICMR). If you have been told you need a hysterectomy, first read whether heavy periods need surgery. Read more in our guides to women’s health after 30 and irregular periods, or visit our menopause clinic.

After menopause

Menopause is usually diagnosed after more than a year with no period. Any bleeding after that, even a single spot, is not a period and must be checked; the NHS says you should not have to wait more than two weeks to see a specialist. Most of the time the cause is benign, such as thinning of the vaginal lining. Sometimes it is an early warning of cancer of the lining, which is very treatable when caught early.

Is it a period or pregnancy-related bleeding?

Light spotting around the time a period is due can be implantation bleeding in early pregnancy. It should be light and short. Heavy bleeding or clots in early pregnancy, heavy bleeding with a positive test or a missed period, or heavy bleeding after abortion pills needs a same-day medical review, because it can mean a miscarriage, an incomplete abortion or an ectopic pregnancy. Heavy bleeding after a normal delivery or C-section also needs urgent attention.

Bleeding after sex

Bleeding after sex is not part of heavy periods. It can come from the cervix, for example from an infection, a polyp or a cervical change, and needs an examination and, if due, a Pap or HPV test. Please do not ignore it, even if it is light.

The right product makes a heavy period easier to live with. But needing extra-large pads and still leaking is itself a reason to see a doctor.

A 2024 laboratory study tested how much blood different products hold (using donated blood in a lab, not real periods):

• Heavy or ultra pads, tampons and menstrual cups held roughly similar amounts, about 20 to 50 ml each.
• Menstrual discs held the most, about 61 ml on average.
• Period underwear held very little, about 2 ml, so on a heavy day it works only as a backup under a pad.

Practical tips:

• Use XL or XXL overnight pads at night, and lie on a dark towel or a waterproof sheet.
• Maternity pads or adult pull-up pants can help on the heaviest nights. There is no shame in using them.
• Menstrual cups hold more than most women expect and can be emptied every 4 to 12 hours depending on flow (Lancet Public Health review). On heavy days you will need to empty them more often.
• If you have a Copper-T or hormone coil and use a cup: coils have occasionally been pulled out while removing a cup, and the doctors who reported these cases advise breaking the suction first (Lancet Public Health review). Always break the suction by pressing the side of the cup before pulling it out, and check your coil threads if you are unsure.
• Keep a change of clothes and a few spare pads in your bag during your period.

See a gynaecologist if your periods are heavy month after month, or if they are affecting your work, sleep or energy. For bleeding that needs care the same day or in an emergency, see the warning signs above.

Book a regular appointment if:

• you have had heavy periods for two or more cycles in a row
• your periods last longer than 7 days
• you change pads every one to two hours, use two at once, or wake at night to change
• you pass clots larger than about 2.5 cm more than occasionally
• you feel tired, breathless or dizzy, or look pale
• you bleed between periods or after sex
• your periods have suddenly become heavier than they used to be
• heavy periods stop you going to work, college or family functions
• you have heavy periods and are trying to get pregnant

Go to an emergency department the same day if you have any of the emergency signs listed above. You may also find these helpful: When to Visit a Gynaecologist: 10 Signs You Must Know and Irregular Periods: How Many Days Late Is Normal?

What to bring to your appointment

• a record of your last two or three periods (dates, pad count, clots, night changes)
• any earlier ultrasound reports and blood test results
• a list of all medicines, including Ayurvedic or homeopathic ones
• your contraception details
• the questions you want answered

A good consultation should leave you knowing the likely cause, which tests you actually need, a plan to control the bleeding, and when to come back.

What will treatment cost?

Costs in Mumbai vary a lot. They depend on the cause, the tests needed, the medicine or device chosen, and, if a procedure is needed, the hospital, room type, anaesthesia and insurance. The hormone coil (LNG-IUS) device itself usually costs between ₹3,000 and ₹6,000. Because it is fitted in the operation theatre under short sedation, hospital, theatre and anaesthesia charges are extra. Many women do well on medicines alone. If a procedure is suggested, ask for a written estimate before you decide.