Losing too much blood

Is Your Menstrual Flow Too Heavy?

When you get your period, it may seem like a lot of blood loss. But because it’s impossible (or at least impractical) to actually measure your menstrual flow, it can be hard to know whether yours falls within what’s considered a normal amount — or if it indicates heavy menstrual bleeding, called menorrhagia.

“Very often, women do not realize that they are having heavy bleeding because it’s a normal amount of blood for them,” says Viviane Connor, MD, a gynecological surgeon at Cleveland Clinic Florida in Weston, Fla. “But it’s not normal. I’ve seen women come in very, very anemic, with a low blood count, because they are flooding — they are very nearly hemorrhaging.”

Though open to great variation, the “average” period occurs every 28 days, lasts about 4 days (plus or minus 2 or 3), and produces a total blood loss of about 2 to 3 tablespoons. But when it comes to heavy menstrual bleeding, the amount of blood lost is not as important as the impact on the woman’s life, says Dr. Connor.

“A normal menstrual cycle does not interfere with a woman’s ability to function normally,” she explains. “If she’s concerned about having to run to the bathroom frequently or if she’s experiencing a lot of pain or discomfort, that is not normal.”

The Signs of Menorrhagia

These are the signs and symptoms of a heavy period:

  • Your period lasts more than seven days.
  • You go through more than six or seven tampons or pads a day.
  • You are losing so much blood that you become anemic. (Anemia is a condition that occurs when your blood does not have enough iron, making you tired.)
  • You get painful menstrual cramps. Heavy bleeding can cause the uterus to contract, which causes cramps.
  • You get menstrual blood clots. Although, clots smaller than the size of a quarter are normal.

Women can experience heavy menstrual bleeding at any age, but it may occur more often as you near menopause and begin to skip periods — so when you do bleed, the flow may be heavier than normal.

Next Steps When You Have Heavy Menstrual Bleeding

If you find that your life is put on hold once a month because of your period — you’re constantly worried about leaking through your pad, or cramps have you doubled over — schedule an appointment with your primary care doctor or ob-gyn. There are many causes of heavy menstrual bleeding, ranging from hormonal imbalances to uterine fibroids, which are noncancerous growths that can appear during childbearing years. Heavy bleeding can also be effectively treated, even if there isn’t an underlying medical condition causing it. Treatments include over-the-counter medications, hormonal treatments like low-dose birth control pills, and nonhormonal medications.

However, many women are not aware that there are options for heavy periods, and some even avoid discussing it with their doctor out of fear or embarrassment. But there’s no reason to put your health on the back burner or your lifestyle on hold because of heavy menstrual bleeding. Talking openly with your doctor will get you the answers you need and the treatment to manage your heavy periods — so you can stop dreading that time of the month.

What causes internal bleeding?

Bleeding most often occurs due to injury or wound, and depending upon the circumstances, the amount of force required to cause bleeding can be quite variable. Some people can experience spontaneous bleeding not necessarily related to any injury, wound, or trauma.

Blunt trauma

Most people understand that falling from a height or being involved in a car accident can inflict great force and trauma upon the body. If blunt force is involved, the outside of the body may not necessarily be damaged, but enough compression may occur to internal organs to cause injury and bleeding.

  • Imagine a football player being speared by a helmet to the abdomen. The spleen or liver may be compressed by the force and cause bleeding inside the organ. If the hit is hard enough, the capsule or lining of the organ can be torn, and the bleeding can spill into the peritoneum (the space in the abdominal cavity that contains abdominal organs such as the intestines, liver, and spleen).
  • If the injury occurs in the area of the back or flank, where the kidney is located, retroperitoneal bleeding may occur.
  • The same mechanism causes bleeding due to crush injuries. For example, when a weight falls on a foot, the weight doesn’t give, nor does the ground. The force needs to be absorbed by either the bone or the muscles of the foot. This can cause the bone to break and/or the muscle fibers to tear and bleed.
  • Other structures are compressible and may cause internal bleeding. For example, the eye can be compressed in the orbit when a fist or ball hits it. The globe deforms and springs back to its original shape. Rarely, intraorbital hemorrhage (caused by orbital trauma) may occur.

Deceleration trauma

Deceleration may cause organs in the body to be shifted inside the body. This may shear blood vessels away from the organ and cause bleeding. This is often the mechanism for intracranial bleeding such as epidural and subdural hematomas and subarachnoid hemorrhage or bleeding. Force applied to the head causes an acceleration/deceleration injury to the brain, causing the brain to “bounce around” inside the skull. This can tear some of the small bridging veins on the surface of the brain and cause bleeding. Since the brain is encased in the skull, which is a solid structure, even a small amount of blood can increase pressure inside the skull and decrease brain function. The shaking within the skull may also cause bleeding within the brain tissue itself (intracerebral hemorrhage).

Organs within the abdominal cavity are often attached by a pedicle (stalk) to arteries and veins that provide blood supply. In a deceleration injury, the pedicle can shear off, tearing the blood vessels, causing bleeding.


Internal bleeding may occur with broken bones that contain bone marrow in which blood production occurs. These bones have a rich blood supply, and significant amounts of blood can be lost with fractures. The break of a long bone such as the thighbone (femur) can result in the loss of one unit (350 cc to 500 cc) of blood. Flat bones such as the pelvis require much more force to cause a fracture. The trauma from the fracture can tear many blood vessels surrounding the structure, which causes massive internal bleeding.


Bleeding in pregnancy is never normal. Bleeding during the first trimester of pregnancy is a sign of a potential miscarriage, and is not uncommon. Moreover, vaginal bleeding during the first few weeks of pregnancy may be a possible symptom and sign of a tubal or ectopic pregnancy. In an ectopic pregnancy, the placenta and the fetus implant in the Fallopian tube or another location outside of the uterine cavity. As the placenta grows, it erodes through the tube or other involved organs and may cause fatal bleeding unless the ectopic pregnancy is recognized and treated.

Bleeding after 20 weeks of pregnancy may be due to placenta previa or placental abruption, and urgent medical care should be accessed. Placenta previa describes the situation in which the placenta attaches to the uterus close to the opening of the cervix and may cause painless vaginal bleeding. Abruption occurs when the placenta partially separates from the uterine wall and causes significant pain with or without bleeding from the vagina.

Bleeding after surgery

Whenever a surgeon cuts into the body, the potential for immediate and delayed bleeding exists. When the operation is near completion, the surgeon tries to make certain that all bleeding has been controlled. This can be done by identifying and tying off blood vessels with sutures or using staples or clips to maintain hemostasis (hemo=blood + stasis=inactivity, lack of flow). Cautery can be used to burn blood vessels to prevent them from bleeding. A little bleeding can be expected in most situations.

Sometimes, however, bleeding may occur after the surgery is performed. Blood vessels that have been cut may go into spasm with no evidence of bleeding. They may relax and begin bleeding many hours or days after the completion of a procedure. Similarly, sutures, staples, or clips can dislodge and allow a blood vessel to bleed. Many times the bleeding is self-limited as the body is able to repair itself. On occasion, the patient needs to be returned to the operating room so that the surgeon can explore the area and find the bleeding site. Depending upon the situation, an interventional radiologist may be able to find the bleeding blood vessel and repair it.

Spontaneous bleeding

Internal bleeding may occur spontaneously, especially in those people who take anticoagulation medications or who have inherited bleeding disorders. Routine bumps that occur in daily life may cause significant bleeding issues.


Internal bleeding in the gastrointestinal tract may be caused as a side effect of medications (most often from nonsteroidal anti-inflammatory drugs such as ibuprofen and aspirin) and alcohol. These substances can cause inflammation and bleeding of the esophagus, stomach, and duodenum, the first part of the small intestine as it leaves the stomach.

Alcohol abuse

Long-term alcohol abuse can cause liver damage, which may cause bleeding problems through a variety of mechanisms including decreased protein and clotting factor production. Cirrhosis, or scarring of the liver, changes blood flow to the liver and leads to portal hypertension (increased pressure within the blood vessels that supply the liver).

Esophageal varices (swollen blood vessels around the esophagus) may develop when the liver’s blood supply is altered, which has a tendency to make the swollen blood vessels that line the esophagus bleed. Moreover, alcohol directly irritates the lining of the stomach, which leads to inflammation that can cause bleeding.


Muscle Bleeds in the Arms and Legs

Bleeding into the muscles in the arms, legs, and thighs can occur in people with hemophilia and other severe bleeding disorders. The bleeding can start after the muscle is hit, is sprained, or you get a shot in the muscle. With severe hemophilia, it can also happen for no clear reason (called a “spontaneous” bleed). Muscle bleeds can cause a lot of blood loss inside your body. As the blood builds up inside, it can press against nerves and blood vessels and cause serious problems.

Signs that you are having a muscle bleed:

  • You have trouble moving your arm or leg.
  • You have pain in the muscle. A small child may refuse to use his arm or leg. He may crawl instead of walk. An older child may complain that he has a pulled muscle.
  • The muscle feels tight or swells up.
  • The muscle feels warmer than other areas of skin.
  • Even when you are resting it, your muscle feels tight or tense when you touch it.
  • The leg or arm feels numb or tingles. When bleeding puts pressure on a nerve, your leg or arm may “go to sleep”.
  • The skin over the muscle changes color or becomes blue.
  • The veins in your arms or legs look bigger than usual.

The last three signs listed above may mean that blood is putting pressure on a nerve. If you have any of these three signs, call your doctor right away!

How to treat a muscle bleed:

  • Take enough factor to raise your level to 40% after you get hit or have a sprain or at the first signs that you may be having a muscle bleed.
  • If you still have symptoms (signs of bleeding), take another dose of factor 24 hours after the first dose if you have hemophilia A. Take another dose 48 hours after the first dose if you have hemophilia B.
  • You can rest your arm or leg at first to allow the factor to stop the bleeding. As soon as the pain lets up, begin moving the limb to exercise the muscles. Strong muscles help to protect your joints and reduce joint bleeds.

Remember these things, too:

  • The muscles deep inside your body can bleed without showing any bruising on the skin.
  • A muscle bleed that is not treated can destroy the muscle and cause crippling. As the muscle dies, scar tissue takes its place. The smaller muscle and tough scar tissue can pull joints and bones out of place. Then you may not be able to flex your foot, extend your knee, bend at the hip, stretch out your arm, or straighten your fingers.
  • Exercise can help keep the injured muscle from shrinking.
  • If you don’t treat a muscle bleed with factor, the blood can build up around the muscle and press against the nerves. This can cause serious nerve damage.
  • Bleeding from a muscle can block the normal blood flow in an arm or a leg. If this happens, nerves and blood vessels in the lower part of the limb can be damaged. For example, a bleed in your forearm can cause harm to the nerves and blood vessels in your hand.
  • Putting an ice pack over the muscle may help ease the pain. Ice will not stop the bleeding – you must take factor. A sack of frozen peas or a wet washcloth that has been kept in the freezer makes a handy ice pack. Don’t hold ice directly on your skin.
  • Don’t ever take a medicine that has aspirin in it for pain. Aspirin slows down blood clotting. It makes it hard for your platelets to stick together.
  • Putting heat on the muscle or letting your arm or leg hang down won’t stop or slow down a muscle bleed.

How to prevent muscle bleeds:

  • Follow your own healthy exercise program to keep yourself in shape. Exercising at least three times a week will build up muscles and keep them strong. Talk to your doctor or physical therapist before starting a body-building program lifting weights. They can also tell you if you need special exercises to get damaged muscles back in shape.
  • Your doctor may want you to do prophylactic treatment with factor while you recover from a muscle bleed. Prophylactic treatment means to take factor before you have a bleed to help prevent it.

Call your doctor or treatment center if:

  • You have any of these signs of pressure on a nerve or blood vessel:
      • numbness (no feeling) in part of your arm or leg
      • a tingling feeling in part of your arm or leg
      • skin that feels colder than the rest of your body
      • swelling or darkening of the skin that doesn’t go away when you think it should
  • The symptoms of your muscle bleed last over three days.

Menorrhagia is to periods what a waterfall is to a trickle. If you have menorrhagia, your period is less of a typical flow and more of a relentless gush that feels impossible to keep up with. This condition, which affects around one in five people in the United States, is bleeding on a whole other level.

If your period is abnormally heavy, lasts for longer than seven days, or both, you probably have menorrhagia.

In 2007, a group of experts published a paper in the journal Fertility and Sterility in an attempt to create a consistent definition for abnormal bleeding. The paper defines losing more than 80 milliliters of blood (the equivalent of about 1/4 of a 12-ounce can of soda) as abnormal blood loss. But what does that translate to in real life? “We do not attempt to actually measure blood loss milliliter by milliliter,” Christine Sterling, M.D., ob/gyn and women’s health expert, tells SELF. “Instead, we rely on the patient’s description of her bleeding.”

Maybe your periods have always spanned longer than a week, or you’re used to expelling blood clots as big as a quarter or larger. Perhaps you’ve come to see it as normal that you bleed through one or more pads or tampons many hours in a row, or that you have to change them in the middle of the night unless you want to ruin your mattress. Even if you’ve experienced these symptoms all your life, they’re not normal. They’re classic signs of menorrhagia, and you don’t have to live with them.

Menorrhagia isn’t just an annoyance—it can interfere massively with everyday life. People with menorrhagia often can’t take part in their usual activities during their period because there’s so much blood loss and cramping, says the CDC. You might even feel tired, low on energy, or get out of breath because you’ve lost so much blood. If any of these symptoms sounds familiar to you, you need to see a doctor for evaluation.

Once you see your doctor, they can ask questions and run tests to figure out the cause of your menorrhagia.

They’ll want to know what other symptoms you’re experiencing, so don’t hold back. Giving your doctor details can help them narrow down the list of potential causes and decide on the best course of testing.

In an attempt to figure out your bleeding, your doctor may administer a pregnancy test, board-certified reproductive endocrinologist Mark P. Trolice, M.D. tells SELF. Abnormally heavy bleeding can be a sign of a miscarriage or ectopic pregnancy (a potentially life-threatening pregnancy outside the uterus, usually located in the fallopian tube). Even if you think you’re not pregnant, it’s good to rule it out.

They might also do blood work to check for anemia, Dr. Sterling says. Anemia happens when you don’t have enough healthy red blood cells in your body. It can occur due to heavy menstrual bleeding that causes you to lose too much blood, and it’s the cause of those seemingly random symptoms like low energy and fatigue. “You do not have to have anemia to have menorrhagia, but it does speak to the severity of the condition,” Dr. Sterling says.

Blood work can also help doctors see whether you might have a thyroid condition like hypothyroidism (when your thyroid doesn’t release enough hormones). Since your thyroid influences so many systems in your body, having hypothyroidism can make your period a beast. It can also lead to symptoms like fatigue, constipation, weight gain, and memory troubles.

On Your Health

Female Bleeding: When Should You See a Doctor?


Posted in

  • Ask the Doctor
  • Female Health

Thankfully, most of the time your period will come and go without causing much fuss. But what about those times when your cycle gets thrown out of whack and you have abnormal bleeding? Should you be concerned?

Every woman is different when it comes to her cycle. However, when period changes happen – such as a heavier or lighter flow than usual or timing abnormalities – it can be hard to decide if you need to call your doctor or if what you’re experiencing is in the range of normal.

It’s a good idea to always track your menstrual cycles, including how heavy your flows are, how long they last and how many tampons or pads you use during a single cycle. This information can be useful for your doctor.

We spoke to INTEGRIS OB-GYN Dr. Elise Schrop to get her insights on a scary topic. What causes abnormal bleeding, just what is “abnormal” anyway, and when should you consult your doctor?

“Abnormal bleeding is a very common problem for women,” Dr. Schrop says. “In fact, about a third of office visits to the gynecologist are for abnormal bleeding. It can happen to women of all ages but most commonly occurs in the first several years after a young woman starts having a period and as women start to make the transition to menopause.”

What is considered normal menstrual bleeding?

Most woman have a definition of what “normal” looks like for them. Many women already know that on average, menstrual periods last four to seven days, with a normal cycle occurring every 21 to 35 days. But did you know this interesting fact? Blood loss during a period averages about 40 ccs, or the equivalent of only three tablespoons.

What is abnormal?

A menstrual cycle may be labeled abnormal if any of the following problems occur.

  • Your periods occur less than 21 days apart (polymenorrhagia)
  • Your periods occur more than 35 days apart (oligomenorrhea)
  • You miss three or more periods in a row
  • Your blood flow is much heavier or lighter than usual
  • Your periods last longer than seven days
  • You experience excessive pain, cramping, nausea or vomiting during your periods (dysmenorrhea)

When should you see a doctor about abnormal bleeding?

“You need to see a doctor if you don’t have a monthly period or have more than one period per month. Feeling lightheaded or dizzy when you stand is also concerning,” says Dr. Schrop. She also urges women to see a doctor if they experience bleeding after going through menopause, or if they experience bleeding while pregnant.

Finally, Dr. Schrop says to see a gynecologist if you are experiencing any of the following:

  • Bleeding that requires more than one tampon or sanitary pad in an hour, for several hours in a row
  • Bleeding or spotting between periods
  • Bleeding after having sex
  • Severe pain
  • Fever
  • Abnormal discharge or color
  • Unexplained weight gain or loss
  • Unusual hair growth
  • New onset of acne
  • Nipple discharge

What is menorrhagia?

A blood flow of 80 ccs (five tablespoons) or more that lasts longer than seven days may signal that you have menorrhagia — excessively heavy and prolonged menstrual periods. With menorrhagia, women may find they need to use several tampons and/or sanitary pads per hour throughout the day or wake up in the middle of the night simply to change the pad.

If heavy and prolonged periods interfere with living your daily life consult your doctor. Excessive blood loss can also lead to anemia, an iron deficiency, and may signal other medical conditions. Anemia can cause fatigue, pale skin, shortness of breath or dizziness.

What is metrorrhagia?

Bleeding that occurs between periods or is not directly associated with your normal menstruation is referred to as metrorrhagia. This can consist of light or heavy bleeding or spotting that may be accompanied by abdominal pain or cramps. Metrorrhagia is more common for teenagers and women nearing menopause.

Why are there bleeding irregularities?

“The most common causes depend on your age,” Dr. Schrop says. “Commonly, bleeding irregularities can come from not ovulating regularly (irregular ovulation can be caused by several things, including abnormalities of the uterus and pregnancy). Less commonly, bleeding irregularities can indicate pre-cancer or cancer.”

Other causes of bleeding irregularities

Stress and lifestyle changes – Stress and lifestyle changes, such as gaining or losing weight, dieting, changing exercise routines, traveling, illness and other disruptions to your normal daily routine can impact your menstrual cycle and cause irregularities.

Birth control – Going on or off birth control pills can affect your menstruation. Some women may experience irregular periods or miss periods for up to six months after stopping birth control pills. Other forms of birth control, such as IUDs, can cause period irregularities (lighter or heavier flows) or cause your period to stop. Birth control pills that only contain progestin (no estrogen) may cause bleeding between periods.

Medications – Some anti-inflammatory drugs, anticoagulants (blood thinners), hormone medications or steroids can affect menstrual bleeding.

Hormone imbalances – An excess of estrogen and progesterone can cause heavy bleeding. This is most common for girls in the first year or so of having her first period and for women nearing menopause.

Uterine polyps or fibroids – Uterine polyps are small growths in the lining of the uterus, while fibroids are tumors that attach to the wall of the uterus. Both are usually benign (noncancerous) but can cause heavy bleeding and pain during periods.

Pregnancy complications – Pregnancy should interrupt normal menstruation although some spotting during the first trimester is often no cause for concern. Bleeding heavily during pregnancy may be a sign that you are experiencing a miscarriage or an ectopic pregnancy (when a fertilized egg implants itself in the fallopian tube rather than the uterus). Consult your doctor right away if you experience bleeding during pregnancy.

Endometriosis – Endometriosis occurs when the endometrial tissue that lines your uterus begins to grow outside the uterus, sometimes growing on the ovaries, fallopian tubes, intestines or other digestive organs. This condition can cause painful bleeding, cramps and painful intercourse.

Pelvic inflammatory disease – Pelvic inflammatory disease (PID) is a bacterial infection that can cause heavy vaginal discharge with unpleasant odor, irregular periods, pelvic or lower abdominal pain, fever, nausea, vomiting or diarrhea.

Polycystic ovary syndrome – Polycystic ovary syndrome occurs when the ovaries release abnormal amounts of androgens (male hormones), causing cysts to form. These ovarian cysts can cause hormonal changes that can prevent ovulation and menstruation from occurring. Women with PCOS may experience irregular periods or stop menstruating completely.

Premature ovarian insufficiency – Premature ovarian insufficiency occurs in women under 40 whose ovaries do not function properly, causing their menstrual cycle to stop prematurely (similar to menopause). This can occur in women being treated for cancer with chemotherapy and radiation or those who have a family history of the condition.

Treating abnormal periods

Treatment for abnormal or irregular period bleeding will depend on your overall health and the cause of the abnormality.

Dr. Schrop says, “At home, taking NSAIDs such as ibuprofen during periods of heavy bleeding can lessen bleeding and control pain, but will not resolve any underlying problem. Taking a warm bath or using a heating pad might provide some temporary relief, but there is nothing women can do at home to resolve abnormal bleeding without seeing a gynecologist.” Also, it’s important to note that aspirin is not recommended to treat menstrual pain as it can cause heavier bleeding.

Dr. Schrop reminds women they do not have to live with abnormal bleeding. “There are many different conditions that can cause abnormal bleeding,” she says. “You will only be able to determine the cause after a visit with your gynecologist and appropriate tests are done. It can take several visits to complete the evaluations and explain treatment options.”

Medical treatment for abnormal bleeding may include hormones such as estrogen or progestin to control heavy bleeding, low-dose birth control to control bleeding, iron supplements to treat anemia caused by heavy bleeding or an intrauterine device (IUD) to lessen heavy bleeding.

For more severe issues, surgery or even a hysterectomy (the removal of the uterus) may be necessary to correct bleeding irregularities.

If you’re concerned about abnormal period bleeding, find an INTEGRIS OB-GYN near you. Dr. Schrop practices at INTEGRIS Canadian Valley Women’s Care. For more information on female health, check out the INTEGRIS On Your Health blog.

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