Heavy Periods

This is a common presenting complaint. The average GP can expect about 100 women to consult each year for menstrual problems (female GPs 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: 15th August 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

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

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.