Heavy periods in perimenopause: when flooding is not just the transition

How to judge whether yours is heavy

Clinical guidance deliberately defines heavy menstrual bleeding by its impact rather than by millilitres, because nobody measures. If bleeding interferes with your physical, emotional or social life, it is heavy and it warrants help.

Practical markers that usually meet the threshold:

• Soaking through a pad or tampon every hour or two
• Needing double protection, or a pad and a tampon together
• Getting up at night to change protection
• Passing clots larger than a 10p coin or a quarter
• Bleeding for more than seven days
• Planning your life around where the bathroom is

The iron problem nobody joins up

This is the most useful thing on this page. Heavy perimenopausal bleeding is a leading cause of iron deficiency in women in their forties, and iron deficiency causes fatigue, breathlessness on exertion, palpitations, poor concentration, hair shedding, restless legs and headaches.

Every one of those is also on the perimenopause symptom list. So the same woman is told her exhaustion is hormonal, when a ferritin test would have named it.

Ferritin can be low while haemoglobin is still normal, meaning iron stores are depleted before anaemia appears. Ask for ferritin specifically, not just a full blood count.

What needs excluding

Heavy bleeding is usually hormonal in perimenopause, but the structural causes are common enough that an examination and often an ultrasound are appropriate rather than optional:

• Fibroids, common by the late forties and a frequent cause of heavy bleeding
• Adenomyosis, causing heavy bleeding with a dragging pain
• Polyps in the womb lining or cervix
• Endometrial hyperplasia, a thickened lining that can precede cancer
• Thyroid disease and bleeding disorders, both easily tested

That there are options is the point

Heavy perimenopausal bleeding is treatable, and the number of women who endure it for years because they assume it must be tolerated until periods stop is the reason this page exists.

Recognised approaches range from non-hormonal medication taken during the period, through hormonal options including the intrauterine system, to procedures where structural causes are found. Which is appropriate depends on the cause, your contraceptive needs and your preferences, which is a conversation rather than a recommendation this page can make.

When to see someone

Book if bleeding is limiting your life, and ask for ferritin and a full blood count regardless of how the rest of the appointment goes.

Seek urgent care for soaking through protection every hour for several hours, dizziness or fainting with bleeding, or breathlessness at rest.