Menorrhagia is one of the leading causes of outpatient gynecological visits, accounting for up to 30% of office visits annually in the United States. Despite its prevalence, many women endure the debilitating effects of heavy menstrual bleeding, often dismissing it as a "normal" part of their menstrual cycle. This common but misguided perception leads to unnecessary suffering and significant health risks. Menorrhagia is not just an inconvenience; it is a medical condition that deserves attention and proper treatment.
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What Is Menorrhagia?
Menorrhagia is excessively heavy or prolonged menstrual bleeding. It is one of the most common types of abnormal uterine bleeding (AUB).
Normal menstruation lasts an average of three to seven days and results in the loss of 35-40 milliliters of blood.
In contrast, heavy bleeding refers to:
- Menstrual periods that last longer than seven days
- Blood loss of over 80 mL during each period
Menorrhagia Signs & Symptoms
Women who report needing to change a pad or tampon every 2-3 hours and/or passing clots at least the size of a quarter are likely to have menorrhagia (54).
Signs and symptoms of menorrhagia include:
- Soaking through at least one pad or tampon every hour for several hours in a row
- Needing to double up on pads to control menstrual flow
- Needing to change pads and tampons during the night
- Bleeding for longer than one week
- Needing to restrict normal activities due to heavy menstrual flow
- Constant lower abdominal pain during periods
- Fatigue or shortness of breath (symptoms of iron deficiency anemia)
Root Causes of Menorrhagia
Hormonal imbalances, particularly excess estrogen relative to progesterone (estrogen dominance), can lead to AUB. During a healthy menstrual cycle, a delicate balance between estrogen and progesterone builds the lining of the uterus (endometrium), which is then shed during menstruation. Hormonal imbalances can lead to excessive thickening of the endometrium, causing heavy menstrual bleeding. Factors such as thyroid dysfunction, polycystic ovarian syndrome (PCOS), insulin resistance, and perimenopause can cause hormonal imbalances that result in menorrhagia. Additionally, anovulatory menstrual cycles (absence of ovulation) may result in menorrhagia due to an associated progesterone deficiency that occurs when an egg is not released during the menstrual cycle.
Pelvic pathologies that can cause abnormal, heavy bleeding include fibroids, polyps, endometriosis, adenomyosis, endometrial hyperplasia, and cervical or uterine cancer. Pregnancy complications, sexually transmitted infections, pelvic inflammatory disease (PID), and endometritis can also be responsible. Menorrhagia is a common side effect of nonhormonal contraceptive intrauterine devices (IUDs). (37)
Systemic conditions, including liver disease, kidney disease, and clotting disorders, can also cause heavy menstrual bleeding (25).
Medications that interact with platelets and coagulation factors should not be overlooked as a cause of menorrhagia. Some medications with menorrhagia as a listed side effect include:
- Anticoagulants and blood thinners
- Oral contraceptive medications
- Tamoxifen
- Tricyclic antidepressants
- Antipsychotics
- Corticosteroids
How to Diagnose Menorrhagia
The challenge with diagnosing menorrhagia is that each person may think of "heavy bleeding" in a different way. Therefore, doctors are responsible for asking specific questions regarding the duration and volume of bleeding to screen for and diagnose menorrhagia.
Step 1: Quantify Menstrual Bleeding
Patients should be asked the start and end dates of their periods. Menstrual bleeding lasting longer than seven days is a key indicator of menorrhagia.
Several tools can help quantify blood loss during menstruation. The Pictorial Blood Assessment Chart (PBAC) is a widely used tool in clinical studies to quantify menstrual blood loss based on the number and saturation level of sanitary products used. Patients fill out the chart, indicating the degree of saturation (light, moderate, or heavy) of each pad or tampon used. The total PBAC score can help estimate blood loss volume. A score over 100 is suggestive of menorrhagia.
Blood loss during periods can also be estimated by calculating the number of sanitary products used. This involves the patient tracking the number of menstrual products they saturate each day during their periods. The volume capacity of these products varies based on their type, size, and brand. In general, fully saturated menstrual products hold the following volumes of blood:
- Regular pad or tampon: 5 mL
- Super pan or tampon: 10 mL
- Menstrual cup: 30-60 mL
- Menstrual disc: 60-80 mL (19, 53)
Step 2: Labs & Imaging to Rule Out Underlying Causes of Heavy Menstrual Bleeding
Standard guidelines for the evaluation of menorrhagia encourage ordering and performing the following tests and imaging (20, 47):
- hCG to rule out pregnancy
- Complete blood count (CBC) with an iron panel to screen for iron deficiency and anemia
- Comprehensive metabolic panel (CMP) to assess liver and kidney function
- Coagulation screen (including PT/INR and PTT) to rule out clotting disorders
- Thyroid-stimulating hormone (TSH) to evaluate thyroid function screen
- STI screening for gonorrhea and chlamydia
- Pelvic exam and pap smear to assess for vaginal and cervical abnormalities, including cervical cancer
- Pelvic imaging, which may include ultrasound, MRI, or hysteroscopy
- Endometrial biopsy to rule out uterine cancer, if indicated by lab and imaging results
Step 3: Comprehensive Hormone Panel
Follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen, and progesterone regulate the menstrual cycle. Imbalances in any one or all of these can result in heavy menstrual bleeding. Testing these hormones can reveal such imbalances and guide treatment strategies. Blood tests are generally performed first. Examples include:
- Female Hormone Panel by BostonHeart Diagnostics
- Female Hormone Panel by Precision Point
- FSH & LH, Estradiol (E2), and Progesterone Progesterone by Access Med Labs
Other hormonal imbalances, such as elevations in prolactin and testosterone, can interfere with ovulation and menstrual cycle regularity. Testing these hormones can help in diagnosing conditions like prolactinoma or PCOS:
- Testosterone, Free & Total w/ SHBG by Access Med Labs
- Prolactin by Access Med Labs
Because female hormones fluctuate throughout the menstrual cycle, one of the downsides of blood testing is that a single test may be insufficient in catching hormonal imbalances responsible for AUB. Salivary and urine tests are more convenient and less invasive testing methods that can accurately evaluate estrogen and progesterone levels. These tests allow patients to collect various samples over the course of their menstrual cycle to better track hormonal fluctuations and patterns suggestive of estrogen dominance, PCOS, and anovulatory cycles:
- DUTCH Cycle Mapping (Dried Urine) by Precision Analytical (DUTCH)
- Rhythm by Genova Diagnostics
- Saliva Hormone Female Evaluator (11 Days) by Access Medical Labs
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Treatment Plan for Menorrhagia
Doctors can use the following outline to guide their menorrhagia treatment recommendations.
Step 1: Stop Bleeding
Here's Why This Is Important:
For patients who are actively bleeding at the time of evaluations, the doctor's primary goal should be to implement therapy that stops and controls bleeding to prevent excessive blood loss, anemia, and hemodynamic instability.
How Do You Do This?
Hormonal and nonhormonal pharmacologic therapies are available as first-line options for acute, severe uterine bleeding:
- Tranexamic acid
- Intravenous conjugated estrogen
- Combined oral contraceptive pills
- Medroxyprogesterone acetate
Dilation and curettage (D&C), which can reduce bleeding within one hour, is the preferred procedure for controlling acute menorrhagia in patients who are unresponsive to the above therapies (54).
Once acute bleeding has been controlled, maintenance therapy can be recommended to prevent excessive bleeding during future periods. Pharmacologic options include:
- Levonorgestrel-releasing intrauterine system
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Tranexamic acid
- Combined oral contraceptive pills
- Cyclic oral medroxyprogesterone acetate
Uterine tonic, astringent, and oxytocic herbs can also significantly reduce menstrual bleeding. These herbal remedies are often used in combination to have a synergistic effect. For example:
- A tincture containing red raspberry (uterine tonic) and yarrow (astringent) can be dosed 30 drops twice daily during the luteal phase of the menstrual cycle.
- When bleeding begins, the patient can be instructed to take 30 drops of a shepherd's purse tincture every 30 minutes for up to six doses.
Limited data also supports reducing menstrual bleeding by taking 250 mg of ginger three times daily, starting four days before menstruation and repeating for three menstrual cycles.
Step 2: Correct Iron Deficiency Anemia
Why Is This Important?
Menorrhagia leads to excessive blood loss, which depletes iron stores and causes iron deficiency anemia; in turn, iron deficiency can exacerbate heavy menstrual bleeding by impairing blood clotting, creating a vicious cycle. This interplay worsens the severity of menorrhagia and the degree of anemia over time. (36)
How Do You Do This?
Supplemental iron can be used to prevent and treat iron deficiency anemia.
Research shows that iron in the form of ferrous bisglycinate, dosed 25 mg daily, is effective in preventing iron deficiency anemia.
Medical guidelines recommend prescribing 120 mg of elemental iron, in divided doses, daily or every other day for three months for adults with iron deficiency anemia.
Additionally, iron-rich foods should be incorporated into the diet, especially during menstruation, to offset iron loss that occurs through bleeding. Examples of iron-rich foods include:
- Red meat
- Liver
- Eggs
- Seafood
- Eggs
- Fortified grains
Vitamin C enhances the absorption of iron by the gastrointestinal tract. Conversely, phytates (in bran), polyphenols (in certain fruits and vegetables), tannins (in tea and coffee), calcium (in dairy), and oxalates (in spinach, beans, and nuts) inhibit iron absorption. (10)
Step 3: Balance Hormones
Why Is This Important?
Because hormonal imbalances are often at the root of the condition, restoring hormonal equilibrium can help regulate the menstrual cycle and reduce excessive bleeding. This step is integral for the long-term cessation of menorrhagia without reliance on pharmacologic, herbal, or procedural interventions.
How Do You Do This?
The following dietary recommendations have been associated with improved estrogen metabolism and elimination, helping to treat and prevent estrogen dominance:
- Add: soy, omega-3 fatty acids (fatty fish, flaxseeds, chia seeds, walnuts), cruciferous vegetables
- Eat: at least 29 grams of dietary fiber daily
- Drink: green tea
- Avoid: added sugars, processed foods
Regular aerobic and resistance training exercise, followed by appropriate time for rest and recovery, has been shown to positively affect circulating estrogen, progesterone, and testosterone levels. This may be an especially important treatment recommendation for patients with PCOS, given that aerobic exercise is known to improve insulin sensitivity, reduce blood sugar levels, and help maintain a healthy weight.
High levels of psychological stress can affect menstrual regularity through the actions of cortisol, which can interfere with the signaling system that controls the production of reproductive hormones (58). Research suggests that stress-reducing mind-body therapies, including acupuncture and yoga nidra, help treat menstrual irregularities and AUB.
Certain supplements can complement these foundational lifestyle modifications to favorably support optimal estrogen and progesterone levels:
- Chaste tree (standardized extract) 200-400 mg daily
- Diindolylmethane (DIM) 100-200 mg daily
- Bioflavonoids 1,000 mg twice daily
The Risks of Untreated Menorrhagia
Blood loss due to heavy periods is the most common cause of iron deficiency anemia in menstruating individuals. Anemic patients can experience symptoms including:
- Fatigue
- Exercise intolerance
- Pale skin
- Headaches
- Dizziness
Untreated iron deficiency anemia holds the potential to cause chronic fatigue, restless legs syndrome, heart problems, and pregnancy complications.
Menorrhagia is associated with poorer quality of life and productivity and high healthcare costs (54). At least 50-70% of hysterectomies performed before age 60 are due to menorrhagia.
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Key Takeaways:
- Menorrhagia is one of the most common health concerns women face, but it should not be accepted as normal.
- A multimodal functional medicine approach to treating abnormal uterine bleeding identifies and addresses the factors leading to heavy menstrual flows. Diet, exercise, and natural supplements can effectively address the hormonal imbalances that are most often at the root of this women's health complaint.
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