Heavy Periods in India: Causes, Diagnosis, and Treatment Options

Heavy periods are the most common reason Indian women seek gynaecological care — and one of the most commonly undertreated. Women frequently normalise their heavy bleeding: "my mother and sister were the same," "it's just the way I am." In reality, heavy menstrual bleeding (medically termed menorrhagia or abnormal uterine bleeding, AUB) is a clinical symptom with identifiable causes and effective treatments. No woman should simply accept flooding periods, anaemia, or days of incapacity every month.

How Heavy Is Too Heavy?

Clinical definition of heavy menstrual bleeding: blood loss above 80 ml per cycle, or bleeding that significantly interferes with quality of life. In practical terms:

• Needing to change a pad or tampon every 1 to 2 hours for several consecutive hours
• Passing clots larger than a 50-rupee coin
• Bleeding through clothing despite protection
• Needing to double up protection (pad and tampon simultaneously)
• Significant limitation of activities during menstruation
• Symptoms of iron deficiency anaemia (fatigue, shortness of breath, pallor)

Any of these indicates a clinically significant level of bleeding that warrants investigation.

The PALM-COEIN Classification of AUB

Modern gynaecology uses the PALM-COEIN classification of abnormal uterine bleeding to systematically identify the cause:

• Polyp (uterine endometrial polyp): A localised overgrowth of the endometrium — extremely common, easily treated by hysteroscopic polypectomy.
• Adenomyosis: Endometrial tissue within the myometrium — a major cause of heavy, painful periods (see dedicated article).
• Leiomyoma (fibroids): Particularly submucosal fibroids — heavy bleeding is the most common fibroid symptom.
• Malignancy and hyperplasia: Must be excluded in women over 40 with AUB and in any woman with risk factors for endometrial hyperplasia (obesity, PCOS, tamoxifen use).
• Coagulopathy: Bleeding disorders — von Willebrand disease is the most common, found in approximately 10 to 15% of women with heavy periods. Often undiagnosed. A family history of bleeding tendency or heavy periods since menarche should prompt coagulation screening.
• Ovulatory dysfunction: Irregular or absent ovulation (from PCOS, thyroid disease, hyperprolactinaemia) causes irregular, sometimes heavy bleeding from unopposed oestrogen stimulation of the endometrium.
• Endometrial: Primary endometrial disorder — endometrial inflammation, altered prostaglandin balance, or other intrinsic endometrial causes of heavy bleeding without a structural explanation.
• Iatrogenic: Medication-related — anticoagulants, copper IUDs, SSRIs, and tamoxifen can all cause or worsen heavy bleeding.
• Not yet classified: Rare causes.

Investigation of Heavy Periods

• Full blood count: To assess haemoglobin and detect anaemia. Ferritin to assess iron stores (low ferritin often precedes anaemia).
• TSH: To exclude hypothyroidism — a significant cause of heavy periods.
• Prolactin: To exclude hyperprolactinaemia.
• Coagulation screen: PT, APTT, fibrinogen, von Willebrand factor antigen and activity — if clinical suspicion of a bleeding disorder.
• Pregnancy test: Heavy bleeding may be the presentation of a miscarriage or ectopic pregnancy.
• Pelvic ultrasound: To assess for fibroids, adenomyosis, endometrial polyps, and endometrial thickness.
• Hysteroscopy: The gold standard for evaluating the uterine cavity — identifies polyps, submucosal fibroids, and endometrial abnormalities that ultrasound may miss.
• Endometrial biopsy: Indicated in women above 40 with AUB, or any age with risk factors for endometrial hyperplasia — to exclude malignancy or pre-malignancy.

Treatment Options

Medical Treatment

• Tranexamic acid: An antifibrinolytic — reduces menstrual blood loss by approximately 50% in women with heavy periods. Taken during menstruation only. Non-hormonal and well tolerated. A very useful first-line treatment for heavy bleeding without a structural cause.
• NSAIDs (mefenamic acid, naproxen): Reduce prostaglandin-mediated heavy bleeding by approximately 25 to 30%. Also provide pain relief. Taken during menstruation.
• Combined oral contraceptive pill: Regulates cycles, reduces blood loss by 40 to 50%, provides hormonal cycle control. A good option for women also wanting contraception.
• Mirena IUS (levonorgestrel IUS): The most effective medical treatment for heavy periods — reduces blood loss by 80 to 90% in most women and eliminates periods in approximately 35 to 40%. Highly effective for both fibroids-related and adenomyosis-related heavy bleeding.
• Norethisterone (oral progestogen): Used cyclically (days 5 to 26 of the cycle) to suppress endometrial proliferation. Less effective than Mirena but an option when IUS is not appropriate.

Surgical Treatment

• Hysteroscopic polypectomy: Removal of endometrial polyps under direct hysteroscopic vision — a day procedure, highly effective.
• Hysteroscopic myomectomy: Removal of submucosal fibroids — the most important structural cause of heavy periods.
• Endometrial ablation: Destruction of the endometrial lining using heat, radiofrequency, or other energy — reduces or eliminates menstruation permanently. Appropriate for women who have completed their family and do not want a hysterectomy. Not suitable for women wishing to conceive.
• Hysterectomy: Definitive surgical cure for heavy periods — appropriate for women who have completed their family and have not responded to, or prefer not to try, less invasive options.

Frequently Asked Questions

Q1. I have had heavy periods since my teens. Is this normal?

Heavy periods since menarche (the first period) should raise specific suspicion of an underlying bleeding disorder — particularly von Willebrand disease. This is significantly underdiagnosed in India. A haematology coagulation screen should be part of the investigation. Additionally, heavy periods since menarche may reflect a family history of abnormally heavy menstruation — worth documenting.

Q2. The Mirena coil made my periods lighter but I now want to conceive. What happens when it's removed?

The Mirena IUS can be removed at any time by a clinician. Fertility returns promptly — typically within one menstrual cycle. The Mirena does not impair future fertility. Heavy periods may return after removal, particularly if they were related to underlying fibroids or adenomyosis that were not definitively treated. Discussing fertility plans before having the Mirena fitted is always useful so that the appropriate long-term strategy can be planned.