Prolonged menstrual bleeding - Causes, Treatment & When to See a Doctor

What is Prolonged Menstrual Bleeding?

Prolonged menstrual bleeding, also called **menorrhagia** or **hypermenorrhea**, refers to menstrual flow that lasts longer than 7 days or results in excessive blood loss (generally >80 mL per cycle). It can affect women of any reproductive age and often interferes with daily activities, sleep, and quality of life. Although many women assume “heavy periods” are normal, persistent or worsening bleeding should be evaluated because it may signal an underlying medical condition.

Common Causes

The reasons for prolonged bleeding are diverse and can be grouped into hormonal, structural, systemic, and iatrogenic (medication‑related) categories. Below are the most frequently encountered causes:

• Hormonal imbalances – anovulatory cycles, polycystic ovary syndrome (PCOS), or thyroid disorders can disrupt the normal estrogen‑progesterone feedback loop.
• Uterine fibroids (leiomyomas) – benign smooth‑muscle tumors that increase surface area for endometrial shedding.
• Adenomyosis – endometrial tissue grows into the uterine muscle, leading to a bulky uterus and heavy bleeding.
• Endometrial polyps – localized outgrowths of the uterine lining that can bleed easily.
• Coagulation disorders – inherited conditions such as von Willebrand disease or platelet function defects.
• Medications – anticoagulants (warfarin, direct oral anticoagulants), antiplatelet agents (aspirin, clopidogrel), and certain hormonal contraceptives.
• Intrauterine device (IUD) – particularly copper IUDs, which can increase menstrual flow.
• Pregnancy‑related issues – miscarriage, ectopic pregnancy, or placental abnormalities can present with prolonged bleeding.
• Systemic diseases – liver disease, chronic kidney disease, or uncontrolled diabetes that affect clotting pathways.
• Cancer – rarer but serious causes such as endometrial, cervical, or ovarian cancer.

Associated Symptoms

Prolonged bleeding rarely occurs in isolation. Women often notice one or more of the following accompanying signs:

• Feeling faint, light‑headedness, or dizziness (possible anemia)
• Fatigue or reduced exercise tolerance
• Shortness of breath on exertion
• Pelvic pressure or a feeling of fullness in the lower abdomen
• Irregular menstrual intervals (e.g., spotting between periods)
• Clots larger than a quarter (≈ 2 cm) in diameter
• Painful cramps (dysmenorrhea) that are worse than usual
• Signs of iron‑deficiency anemia: pale skin, brittle nails, restless legs

When to See a Doctor

While occasional heavy periods can be normal, seek medical attention promptly if you notice any of the following:

• Bleeding that lasts > 7 days or requires changing a pad/tampon every hour.
• Soaking through one or more sanitary products every hour for several consecutive hours.
• Presence of large clots (≥ 1 inch) or bright‑red “spurting” streams.
• Symptoms of anemia: persistent fatigue, shortness of breath, dizziness.
• Bleeding after intercourse, between periods, or after menopause.
• History of bleeding disorders, liver disease, or recent start of blood‑thinners.

Diagnosis

Evaluation begins with a thorough history and physical exam, followed by targeted testing. The goal is to identify an underlying cause, assess severity, and rule out serious pathology.

1. Medical History

• Duration, frequency, and quantity of bleeding (patient‑reported “pad‑count” is useful).
• Family history of bleeding disorders, fibroids, or cancers.
• Medication list – especially anticoagulants, NSAIDs, hormonal therapy.
• Recent weight change, stress, or significant illness that might affect hormones.

2. Physical Examination

• General assessment for pallor, tachycardia, or low blood pressure.
• Abdominal and pelvic exam to feel for enlarged uterus, adnexal masses, or tenderness.

3. Laboratory Tests

• Complete blood count (CBC) – evaluates anemia and platelet count.
• Serum ferritin and iron studies – gauge iron‑deficiency severity.
• Thyroid‑stimulating hormone (TSH) – screens for hypothyroidism.
• Coagulation profile: PT/INR, aPTT, and von Willebrand factor assay if a bleeding disorder is suspected.
• Pregnancy test – to exclude early pregnancy complications.

4. Imaging & Procedural Tests

• Transvaginal ultrasound – first‑line imaging to detect fibroids, polyps, adenomyosis, or thickened endometrium.
• Hysterosonography (saline‑infusion sonography) – improves visualization of intrauterine lesions.
• Magnetic resonance imaging (MRI) – useful for detailed mapping of fibroids or adenomyosis.
• Endometrial biopsy – indicated for women > 45 years or with risk factors for endometrial cancer.
• – direct visualization and possible removal of polyps or small fibroids.