Whether you’re used to them or not, heavy periods can be hard to manage. Frequently having to change tampons, double up on pads, and carry an extra set of clothes can really limit what you can do each day. Heavy periods are also common for many women during perimenopause, the time leading up to menopause.

In a survey conducted by ThisIsMenopause, many women described heavy menstrual periods as one of their primary perimenopausal symptoms:

• “Hot flashes, anxiety, and heavy periods are the things most impacting me.”
• “I have heavy bleeding, mood changes, hot flashes, night sweats, fatigue, and brain fog.”
• “At the moment, my period is incredibly heavy, heavier than it ever has been in my life, even after giving birth.”

Below, we discuss heavy bleeding during perimenopause, including why the menopausal transition can cause heavy periods and when to see your doctor.

What Qualifies as Heavy Menstrual Bleeding?

Healthcare providers use the term “menorrhagia” to refer to heavy menstrual bleeding. Your periods may be considered heavy if you:

• Have prolonged bleeding, or periods lasting more than seven days
• Lose about twice as much blood as what’s normal — 5 or more tablespoons compared to 2 to 3 tablespoons
• Bleed through at least one pad or tampon per hour for several hours
• Have to wake up during the night to change your pad or tampon
• Need to use more than one pad or tampon at once
• Pass red, pink, or brown blood clots several times that are quarter-sized or larger

Other symptoms may include severe cramping or abdominal pain, tiredness, and shortness of breath. If you bleed heavily enough during your period that it negatively affects your quality of life, you likely have menorrhagia.

Heavy periods are common and affect between 27 percent and 54 percent of women who menstruate. They’re also more common in women who are closer to menopause.

Heavy Bleeding During Perimenopause

There are many reasons why you might have heavy periods. Hormonal imbalances are one explanation for this type of bleeding change because hormone levels are directly tied to menstruation.

Menstrual cycles, which normally last 21 to 35 days, are controlled by hormonal changes, especially the ovarian hormones estrogen and progesterone. If an egg isn’t fertilized after ovulation (when your ovary releases an egg), levels of these two hormones drop. This tells your body that you’re not pregnant and that it’s time to shed the uterine lining. Falling hormone levels cause your period to begin.

During perimenopause, estrogen levels start to fall. This disrupts the body’s balanced levels of estrogen and progesterone. Based on how your body reacts to the changing hormone levels, perimenopause can lead to bleeding changes, mood swings, problems sleeping, and night sweats.

According to the American College of Obstetricians and Gynecologists (ACOG), the hormonal fluctuations (changes) of perimenopause can cause irregular bleeding that’s lighter or heavier from month to month. These changes might be less noticeable at the start of perimenopause. Early on, you may also have spotting in place of regular menstrual bleeding. As you get closer to menopause, heavy or irregular bleeding may follow a missed period.

Several women surveyed by ThisIsMenopause noted that they experienced heavy bleeding alongside irregular periods:

• “My periods are so heavy and long.”
• “Heavy flows and cycles further apart.”
• “Heavy cycles and missed cycles.”

Managing Heavy Periods

The best way to manage heavy menstrual bleeding depends on its cause. According to ACOG, women’s health providers often recommend medications first to try to reduce heavy bleeding in perimenopause.

Medications

Here are some medications your doctor may recommend to help manage heavy menstrual bleeding:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) — If NSAIDs are taken before bleeding begins, they may be able to reduce menstrual blood loss by up to 50 percent. Examples include ibuprofen and naproxen.
• Oral contraceptives — Birth control pills and other forms of hormonal birth control can be used to regulate your hormones and bleeding.
• Intrauterine devices (IUDs) — Hormonal IUDs can help reduce bleeding.
• Menopause hormone therapy — Hormone therapy may also be recommended to treat bleeding.
• Nonhormonal options — Your doctor might recommend tranexamic acid (TXA) and iron supplements to manage bleeding. TXA can help reduce bleeding by helping your blood clot, while iron supplements can increase iron levels.

Other Treatment Options

If medications don’t help, your doctor may want to run tests to check for other causes of your heavy bleeding. Testing may include blood tests or imaging tests, such as a pelvic ultrasound. Your provider may also suggest a Pap smear, cervical culture, or endometrial biopsy to look for abnormalities in cell or tissue samples.

Your doctor may also recommend certain procedures to treat your bleeding, such as:

• Hysteroscopy — This procedure allows your doctor to see inside your uterus and remove abnormal growths.
• Endometrial ablation — This procedure destroys the lining of the uterus in a controlled manner.
• Surgeries — Surgical procedures like hysterectomy (removal of the uterus) and myomectomy (surgical removal of fibroids from the uterus) may also be recommended for heavy bleeding.

When To Talk to Your Doctor

Whether or not you’re in perimenopause, menstrual bleeding shouldn’t be so heavy that it affects your quality of life. You should talk to your doctor if your bleeding is heavy.

Your provider can help you get to the bottom of why your periods are heavy and recommend treatment options. It’s especially important to talk to your doctor if you notice any bleeding after menopause (not having periods for one year). Bleeding after menopause is abnormal and needs to be checked by a doctor.

In some cases, heavy menstrual bleeding can require emergency care. Seek urgent care if you have heavy bleeding and symptoms of anemia, such as chest pain, trouble breathing, or dizziness. Severe blood loss can lead to anemia, which can be life-threatening.

Other Causes of Heavy Bleeding

Perimenopause is a common cause of heavy bleeding, but there are other possible causes, including:

• Endometrial atrophy — Thinning of the uterine lining caused by low estrogen levels
• Endometrial hyperplasia — Thickening of the uterine lining that can lead to cancer
• Polyps — Benign (not cancerous) growths within the uterus, cervix, or cervical canal
• Endometrial cancer — A common cancer that affects the lining of the uterus, often called uterine cancer, and is often easier to treat when found early

Other possible causes of bleeding pattern changes include:

• Medical conditions that affect hormones, such as thyroid disease and polycystic ovary syndrome (PCOS)
• Anovulation (lack of ovulation)
• Infections, such as sexually transmitted infections
• Benign growths, such as fibroids and adenomyosis (uterine lining tissue that grows in the wall of the uterine muscle)
• Complications of pregnancy, such as miscarriage
• Cervical cancer
• Certain medications, such as birth control pills and injections, IUDs, hormone therapy, and blood thinners
• Other medical conditions, such as kidney disease, liver disease, and pelvic inflammatory disease

Talk with your doctor if you’re having heavy bleeding during perimenopause. Your provider can help find the cause and recommend treatment options. With the right care, it’s often possible to reduce heavy bleeding and improve your quality of life.