Treatment with medication

Medication is usually the first treatment option that doctors recommend for heavy periods.

Treatment with medication:

• can be very effective
• often has fewer and less serious side effects than other treatments
• does not affect your ability to have children or cause early menopause
• is suitable for many women.

There are six types of medication used to treat heavy menstrual bleeding.

Tranexamic acid helps your blood to clot, which will reduce the bleeding. It comes as a tablet that you take during your period.

Non-steroidal anti-inflammatory drugs (NSAIDs) reduce the amount of prostaglandin in the lining of your uterus, as prostaglandin seems to contribute to heavy bleeding and pain. It also comes as a tablet that you take during your period.

Hormone-releasing intrauterine device (IUD) is a small, usually plastic device that sits inside your uterus and releases a small amount of progestogen (a drug that acts like the natural hormone progesterone). With each menstrual cycle the lining of your uterus becomes thick and spongy in preparation for pregnancy. When you don’t get pregnant, the lining sheds and you bleed it out. Protestogen works by reducing the thickness of the lining of your uterus.

The contraceptive pill releases substances that act like the natural hormones oestrogen and progesterone. These stabilise the lining of the uterus so that it doesn’t get so thick.  The Pill can be taken continuously so that you don’t bleed at all, or you can have a period each month. It comes as either a tablet you take daily or as a small, flexible ring that is put inside your vagina and slowly releases the medication. The ring is usually removed after three weeks to allow you to bleed and a new one is put in at the end of your period.

The progestogen-only pill (POP or mini-pill) also works by stabilising the lining of the uterus. If you take protestogen throughout your menstrual cycle, the lining of the uterus is never able to build and thicken and so there is very little to shed when it comes time for your period. 

Danazol is a tablet that stops the normal ovulation cycle and reduces your body’s oestrogen levels. It causes some women to stop menstruating completely.

Your treatment options summarised

	Benefits	Disadvantages
Tranexamic acid	Reduces bleeding by about 40 percent	Requires long-term use
NSAIDS	Reduces bleeding by about 30 percent Relieves period pain	May cause stomach upsets, nausea and diarrhoea Requires long-term use
IUD	Reduces bleeding by about 95 percent after at least three months use May reduce period pain Is also a contraceptive You don’t need to remember to take tablets You can have it removed It only has to be changed every five years	Often causes irregular bleeding or spotting in the first couple of months May cause acne, mood changes  and breast soreness May fall out but this is rare Although rare, it may push through your uterus and need to be removed in an operation May not be an option if you have fibroids 20 percent of women (one in five) ask for it to be taken out because of the side effects
Oral contraceptive pill	Reduces bleeding by about 40 percent May reduce period pain Helps keep periods regular Is also a contraceptive Can be used to skip your period entirely Reduces your risk of ovarian and endometrial cancer by about 50 percent	May cause nausea, breast soreness, headaches and changes to sex drive or libido May cause irregular spotting Not suitable for all woman (for example, those who are over 30 years old and smoke, or get blood clots in their veins (called thromboembolism) Requires long-term use
POP or mini-pill	Reduces bleeding by about 85 percent Works quickly and can be used as a short-term treatment or for periods that are particularly heavy	May cause bloating, mood swings and breast soreness May cause irregular bleeding Often requires long-term use
Danazol	Reduces bleeding by about 65 percent	May cause weight gain and acne

Investigation & treatment

If you are worried about your periods visit your GP. You are likely to be referred a gynaecologist.

The gynaecologist will generally do the following:

• ask you questions about the history of your health
• do a blood test
• examine your vagina and cervix, using special tongs (called a speculum). At the same time, they may take a tiny sample of your cervix for testing (called a Pap test)
• take an ultrasound of your pelvis. This usually involves putting a small wand (called atransducer) inside your vagina to take a picture of your cervix, uterus, endometrium and ovaries. If you haven’t had sex before, it is more likely that an external ultrasound will be done. Gel is put on the outside of your belly and a small handheld transducer is moved over the skin.

Further investigations may include a hysteroscopy and/or a curette.

A hysteroscopy uses a long thin telescope or camera (called a hysteroscope) that allows the doctor to see inside the uterus. The hysteroscope can show polyps, fibroids and endometrial thickening. A sample of the endometrium can also be taken for testing. A curette involves removing the top layer of your endometrium for testing and can be done at the same time as a hysteroscopy.

A hysteroscopy can be done under local or general anaesthetic. A curette is usually done under general anaesthetic.

Treatment 

There are a number of treatment options for heavy periods, including medication, surgery and radiology. Your doctor will recommend the best option for you based on your medical history and the reasons for your heavy periods.

Your treatment options will depend on:

• your age, health and medical history
• whether you want to have any (more) children
• how successful other treatments have been for you.

There are three main types of treatment.

• Medication to reduce or control the bleeding and pain. This usually involves taking tablets but sometimes an IUD is placed inside your uterus, which slowly releases the medication into your body.
• Surgery aims to stop the heavy bleeding by removing potential causes like the lining of your uterus (called an endometrial ablation), fibroids in your uterus (called a myomectomy) or your whole uterus (called a hysterectomy).
• Radiology and ultrasound treatments aim to reduce or stop heavy bleeding and pain by reducing and destroying fibroids.

What causes heavy periods

Diagnosing what causes heavy periods can sometimes be difficult. However, some physical condition affecting the uterus, such as fibroids and polyps, may cause heavy menstrual bleeding.

The more common reasons for heavy periods are:

• fibroids
• polyps
• endometrial hyperplasia
• endometrial cancer
• adenomyosis.

Fibroids

Fibroids are abnormal growths that form in the muscle of the uterus. They are very common and can occur in up to 80 per cent of women. They are often referred to as ‘tumours’, but the vast majority are not cancerous.

Fibroids are more likely to cause symptoms if they are large, if there are many of them or if they push on your other internal organs. Some women with fibroids have very heavy menstrual bleeding, pelvic pressure or pain that interferes with their life, and some women have problems with fertility and pregnancy. However, fibroid symptoms tend to get better after menopause.

Fibroids can bulge from the inside or outside of the uterus. They can range in size from microscopic to the size of a grapefruit or even larger. The majority of fibroids are small and do not cause any symptoms at all.

Polyps

Uterine polyps are usually non-cancerous (benign) growths of the lining of the uterus (the endometrium). They can also occur at the cervix. Polyps may cause heavy menstrual bleeding, bleeding between periods or bleeding after sexual intercourse. Occasionally, polyps can develop abnormalities, particularly in older women, so it is generally advised to remove them before they become dangerous.

Cancer, malignancy and hyperplasia

Some women may develop an abnormally thick lining of the inside surface of their uterus. This condition is called endometrial hyperplasia and it may cause heavy menstrual bleeding, irregular bleeding or a bloodstained vaginal discharge. In some cases, endometrial hyperplasia may progress to endometrial cancer, a condition that is more common after menopause but can occur in younger women.

Women are at an increased risk of developing endometrial hyperplasia or endometrial cancerif they:

• are over the age of 45 years
• are over 90 kg in weight
• have never had children
• have a family history of endometrial, ovarian or bowel cancer
• have polycystic ovarian syndrome
• carry a gene that increases their cancer risk (such as HNPCC).

Adenomyosis

Adenomyosis is a common cause of painful and heavy periods, and can have the same symptoms as endometriosis and fibroids. It occurs when the endometrial glands grow into the muscle of the uterus. As a result, the uterus grows larger, and it can be tender when you are examined. However, it is not easily diagnosed because ultrasound, hysteroscopy, keyhole surgery and magnetic resonance imaging (the common approaches used) will not pick it up all of the time. Women tend to be in their 30s when they are diagnosed.

Other uncommon causes for heavy periods include:

• an underactive thyroid
• the use of anticoagulant drugs
• some liver and kidney conditions
• blood clotting disorders, for example Von Willebrand’s disorder
• using hormone contraception such as the Pill or a prostestogen IUD.

Sometimes a reason for heavy periods is never found. In fact, for nearly half of all women with heavy periods all investigations will show that there is no obvious cause for their bleeding. This is referred to as Dysfunctional Uterine Bleeding and can happen at any age. It is more common in women in their late thirties, which may mean that it is related to hormonal changes as women get older.

What is a heavy period?

Heavy menstrual bleeding is defined as excessive menstrual blood loss that interferes with a woman's physical, social or emotional quality of life.

A period is heavy if you are:

• passing lumps of blood (or clots) that are larger than a 50 cent coin
• bleeding so much that you have to change your pad/ tampon every hour 
• having to get up most nights to change your pad/tampon
• having to put a towel in your bed or use large maternity pads when you sleep
• bleeding through clothing
• bleeding that lasts more than eight days.

Heavy periods can lower your iron levels and red blood cells so you may:

• feel tired more easily 
• feel weak or dizzy
• be short of breath and have chest pains.

Heavy periods can generally be managed using hormone therapies or surgery. Your doctor or gynaecologist can talk to you about options that suit you. 

If you are worried about heavy menstrual bleeding

• See your doctor, nurse or gynaecologist (specialist in women’s health).
• Talk to them about the changes to your period.
• Tell them about any medications or contraceptives you are using.

They will most likely:

• ask you questions about the history of your health
• examine you
• do a blood test.

Complementary & alternative therapies

There are many alternative approaches that aim to improve the experience of menstruation. Some are supported by good evidence while others may simply improve women's sense of wellbeing.

Physical therapies

Research suggests some physical therapies such as local heat application (heat packs), TENS (transcutaneous electrical nerve stimulation), acupuncture and acupressure are helpful for reducing menstrual pain and cramps. Physiotherapy may also be helpful for lower back pain associated with PMS.

Yoga and mindfulness meditation

If you are stressed, you are more likely to suffer severe symptoms of PMS and experience poorer quality of life. Regular relaxation may be helpful in reducing severe PMS. Yoga has been used for thousands of years as a wholistic approach to health and wellbing. Some women may find yoga helpful in easing menstrual pain.

Massage

A small study found that weekly massages over five weeks improved the level of pain and mood disorders and reduced fluid retention experienced by women during their menstrual cycle.

Herbal remedies

Some herbal remedies may have benefits for women with PMS. It's very important to check with your doctor that it is safe to use herbal remedies and treatments, particularly if you are taking other medication.

Listed below are the best-researched herbs for the treatment of PMS, and the possible risks associated with taking them. 

Chaste tree or Chasteberry (Vitex agnus-castus) (VAC)

• Relieves PMS symptoms: irritability, mood alteration, anger, headache, breast fullness and discomfort, abdominal bloating.
• May help regulate menstrual cycle; PCOS.    
• Dose: 20 mg  VAC extract, one capsule daily    
• Generally safe but may cause gut disturbance and rash.
• Avoid in pregnancy.

St John’s wort (Hypericum perforatum)    

• Relieves depression, mood disorders, premenstrual disturbed mood.    
• Dose: 300 mg two to three times daily.   
• Avoid taking with oral contraception, anticonvulsants and other antidepressants. 
• Check with your doctor if St John's wort interacts with your medication. 
• Avoid in pregnancy. 
• May cause dry mouth, gastrointestinal discomfort, skin rash.

Evening primrose oil (Oenothera biennis)    

• May help reduce breast discomfort.    
• Avoid if you suffer seizures or epilepsy.

Red clover (Trifolium pretense)    

• May relieve premenstrual breast pain.    
• Dose:  40–80 mg daily.   
• Avoid if taking blood thinners or if you have suffered oestrogen-sensitive tumours such as breast cancer.

Traditional Chinese medicine    

• May help with PMS, hormonal disturbance.    
• Must be prescribed by a trained Chinese herbalist.    
• Check with a Chinese health practitioner about contra-indications and side effects.

Sleep, sunshine & vitamin D

Sleep, sunshine and vitamin D play a vital role in our general health and may help to improve our menstrual health as well.

Studies have found that sleep disturbance is common in women who suffer severe PMS. Poor sleep can also contribute to mood disturbance, hormone irregularities and disturbed menstrual cycles. You may be able to improve your sleep with the following:

• Exercise daily.
• Avoid stimulants such as coffee and green tea later in the day.
• Avoid heavy meals or spicy foods just before bed, especially if you are prone to reflux symptoms.
• Develop a regular bedtime routine.
• Relax before bed with a warm bath or shower.
• Deal with any stress or worries that might be keeping you awake by speaking with a friend, or ask your GP for a referral to a counsellor.
• Reduce your stress with yoga or meditation.
• Valerian, passionflower and chamomile teas may help induce sleep.
• Melatonin supplements may be helpful in some cases.
• If you continue to have trouble sleeping, see your GP.

Sunshine and vitamin D

Sunshine may play a role in regulating hormones and sleep patterns by affecting the melatonin circadian rhythm. Melatonin is a hormone produced in the pituitary gland,  from the chemical melanin. Melanin is produced in the skin through sun exposure. Melatonin helps with inducing sleep.

Sun exposure is also an important source of vitamin D. Ninety per cent of the vitamin D we get comes from skin exposure to sun, and less than ten per cent from food sources such as fortified milk, eggs and some fish. Early research suggests that vitamin D may help normalise menstrual cycles, and may help relieve muscular pains and mood disorders such as depression.

Vitamin D is important for bone health, and adequate blood levels are required for calcium absorption for the prevention of osteoporosis. Ask your GP about checking your vitamin D blood levels, especially if you are dark-skinned (pale-skinned women don’t need as much sun exposure), spend more time indoors or wear clothing to cover your skin for religious or cultural reasons.

Exercise, diet & periods

Diet and exercise bring a range of health benefits as well as improving your experience of having periods. 

Exercise

Studies have found that women who exercise regularly are less likely to suffer menstrual pain, cramps and mood disturbance. We are not certain why exercise is helpful for PMS but studies demonstrate that exercise can release ‘happy’ hormones such as serotonin and endorphins, which may explain the benefit.

Diet

A growing body of evidence suggests diets rich in omega-3 fatty acids such as fish, calcium and vitamin D, and low in animal fats, salt and caffeine may reduce the risk of troublesome PMS symptoms. Avoiding salt can help reduce fluid retention, abdominal bloating, breast swelling and pain. High caffeine intake can cause irritability, poor sleep and menstrual cramps.

A healthy diet is high in vegetables (five serves daily), fruit (two serves per day), nuts, seeds, fish (up to three servings per week) and other sources of omega-3 foods such as flax or chia seeds, low-fat dairy food, proteins such as legumes and eggs, and a variety of wholegrains such as rice (brown, basmati, doongara), traditional rolled oats, buckwheat flour, wholegrain breads (rye, essene, spelt, kamut), wholemeal pasta, couscous, millet or amaranth.

Lean meat (red meat or chicken) is an important source of iron and protein, especially for women with heavy periods. Avoid saturated fats such as butter, cream, bacon and potato chips; limit salt and caffeine. Drink more water and herbal teas such as chamomile.

Increase your intake of calcium-rich foods such as nuts, low-fat dairy products, fish with bones such as salmon and sardines, tofu, broccoli and bok choy.

Nutritional supplements

Many women take supplements such as vitamins, minerals and amino acids to help with symptoms of PMS; however, not all supplements have been shown to help. Below is a list of supplements for which studies have demonstrated some scientific evidence for benefits, although with all of them, more research is required. Check with your doctor to ensure there are no risks with you trying these supplements. Some supplements may interact with medication.

Vitamins B6 and B1

• May help with PMS.
• Reduces pain, cramps and mood disturbance.    
• Do not exceed 50 mg of vitamin B6 daily or 100 mg vitamin B1.
• Best if combined as a multi-B vitamin, not as single nutrients.   
• Avoid high doses of vitamin B6 (more than 50 mg per day) and prolonged use, as this can cause nerve toxicity such as tingling, burning and shooting pains.

Vitamin E (natural alpha-tocopherol)    

• May help reduce pain and menstrual blood flow.    
• Dose: 200 IU vitamin E daily; commence two days prior to periods and continue for three days from onset of periods.    
• May cause gut upset.
• Avoid high doses over 400 IU daily. 

Vitamin D    

• May help regulate your cycle, relieve muscle pains, improve moods.    
• Dose: 1000 IU daily or more; check with your doctor, who will advise a suitable dosage for your needs.   
• Vitamin D toxicity is rare and may occur when taking very high doses of vitamin D. This results in raised blood calcium levels leading to feelings of malaise, loss of appetite, feeling thirsty, constipation or diarrhoea, abdominal pain and muscle weakness, fatigue, confusion.

Magnesium    

• Relieves menstrual cramps.
• Improves premenstrual mood changes, especially irritability and anxiety. 
• May help with muscle relaxation, muscle cramps and sleep.    
• Dose: 300 mg one or two times daily (best taken at night with calcium).    
• May cause diarrhoea and loose stools; reduce dosage if this occurs.
• May cause palpitations.
• Avoid if you have renal problems.
• May lower blood pressure and cause heart arrhythmia, drowsiness and weakness in high doses.

Calcium    

• May help with PMS.
• Reduces menstrual cramps, fluid retention, mood disorders and food cravings.
• Dose: 1200 mg daily.   
• May cause constipation and flatulence.
• Avoid if you have renal disease or suffer high blood calcium levels.
• May interact with blood pressure and heart tablets.

Zinc    

• May help relieve menstrual pain, cramping, depression.
• May aid immune system.  
• Dose: 30 mg one to three times daily.    
• May cause nausea, gastrointestinal upset, metallic taste in mouth.
• Avoid long-term use.

Fish oils    

• May relieve menstrual pain, cramping, depression.    
• Dose: 1 g taken one, two or three times daily.   
• May cause nausea and gastrointestinal upset. 
• In high doses, may ‘thin’ period blood (this may be useful if you suffer dark, thick menses). 
• Avoid if allergic to seafood.