Heavy Periods

This is a common presenting complaint. The average practice of 4 GPs can expect about 400 women to consult each year for menstrual problems (female clinicians rather more) and many of these will be for menorrhagia. Normal menstrual blood loss is 20–80 ML. In practice, measurement is not feasible, so the definition rests on what the woman reports, although some efforts can be made to establish whether or not the bleeding is ‘excessive’.

Published: 2nd August 2022 | Updated: 29th September 2022

Differential diagnosis

Common Diagnoses

  • Dysfunctional Uterine Bleeding (DUB)
  • Cervical or Endometrial Polyps
  • Endometriosis
  • Fibroids
  • Puberty and Perimenopause

Occasional Diagnoses

  • Hypothyroidism (and Hyperthryoidism)
  • IUCD
  • Iatrogenic (Contraceptives, Hrt)
  • Cystic Glandular Hyperplasia (Metropathia Haemorrhagica)
  • Chronic PID

Rare Diagnoses

  • Adrenal Disorders and Hyperprolactinaemia
  • Liver Disease, Especially Alcoholic
  • Clotting Disorder
  • Endometrial Carcinoma
  • Tuberculous Endometritis

Ready reckoner

Key distinguishing features of the most common diagnoses

DUBPolypsEndometriosisFibroidsPuberty/Perimenopause
Long HistoryPossiblePossiblePossiblePossibleNo
Long CyclePossibleNoNoNoPossible
PVE: TenderNoNoYesNoNo
Very Painful PeriodsNoPossibleYesNoPossible
PVE: Enlarged UterusNoNoPossibleYesNo

Possible investigations

Likely: FBC.

Possible: TFT, ESR/CRP, transvaginal ultrasound and, after referral, endometrial sampling and hysteroscopy

Small Print: LFT, HVS, clotting studies, endocrine assays

  • FBC to check for anaemia and thrombocytopenia. WCC may be elevated in PID.
  • Check possible thyroid dysfunction with TFT.
  • ESR/CRP: Elevated in PID.
  • LFT: If clinical suspicion of liver disease.
  • Clotting studies: If other history of abnormal bleeding or bruising.
  • Transvaginal ultrasound useful for confirming fibroids and suggesting endometrial pathology.
  • HVS very occasionally useful in chronic PID with discharge.
  • Endocrine assays: For hyperprolactinaemia or adrenal disorders
  • Investigation after referral is likely to include endometrial sampling and/or hysteroscopy.

Top Tips

  • Self-reporting of the heaviness of the menstrual flow is notoriously unreliable. Attempt an objective assessment by enquiring about the number of pads or tampons used, flooding and the presence of clots, and by checking an FBC for iron-deficiency anaemia.
  • Establish the woman’s agenda. This presentation may be the passport to a prescription (e.g. the contraceptive pill in a young woman) or to discussion of a specific anxiety (e.g. fears about possible cancer or a need for hysterectomy).
  • Don’t forget to enquire about a ‘long-forgotten’ coil
  • In a young woman who has painless heavy periods, is otherwise well and has no other relevant symptoms (such as intermenstrual bleeding or pelvic pain), it is reasonable to make a presumptive diagnosis of DUB and treat empirically.

Red Flags

  • Establish whether the problem really is simply ‘heavy periods’; if the bleeding is chaotic, or there is also intermenstrual or post-coital bleeding, the chances of a structural lesion are much higher – ensure the patient is appropriately investigated.
  • Blood clots suggest significant bleeding; do not forget to arrange an FBC
  • Menorrhagia with secondary dysmenorrhoea, dyspareunia and pelvic tenderness on examination suggest endometriosis or chronic PID.
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Website disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter.

The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

For use by healthcare professionals only, working within their scope of professional practice. Nursing in Practice Reference is for clinical guidance only and cannot give definitive diagnostic information. Appropriate referrals should be made following individual practices protocols and employer expectations, locally agreed pathways and national guidelines.