Heavy Periods

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

Ready Reckoner

Key distinguishing features of the most common diagnoses

Long HistoryPossiblePossiblePossiblePossibleNo
Long CyclePossibleNoNoNoPossible
PVE: TenderNoNoYesNoNo
Very Painful PeriodsNoPossibleYesNoPossible
PVE: Enlarged UterusNoNoPossibleYesNo

Possible Investigations


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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