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Very Heavy Menstrual Flow

When periods are very heavy or you are experiencing “flooding” or passing big clots you have what doctors call menorrhagia. The purpose of this article is to define normal and very heavy menstrual bleeding, to explain what causes heavy flow, and to show what you yourself can do in dealing with heavy flow.

This, and the article called “Managing Menorrhagia—Effective Medical Treatments” for your doctor or health care provider, are to help you avoid surgeries for heavy flow (hysterectomy and endometrial ablation) if you can.

What is the normal menstrual flow?

In a randomly selected group of premenopausal women, the most common amount of menstrual flow (measured in a laboratory from all collected tampons and pads) was about two tablespoons (30 ml) in a whole period (1;2). However the amount of flow was highly variable—it ranged from a spot to over two cups (540 ml) in one period! Women who are taller, have had children and are in perimenopause have the heaviest flow (2). The usual length of menstrual bleeding is four to six days. The usual amount of blood loss per period is 10 to 35 ml. Each soaked normal-sized tampon or pad holds a teaspoon (5ml) of blood. That means it is normal to soak one to seven normal-sized pads or tampons (“sanitary products”) in a whole period.

How is Very Heavy Flow or Menorrhagia defined?

Officially, flow of more than 80 ml (or 16 soaked sanitary products) per menstrual period is considered menorrhagia. Most women bleeding this heavily will have a low blood count (anemia) or evidence of iron deficiency (1). In practice only about a third of women have anemia, so the definition of heavy flow can be adjusted to be more like nine to 12 soaked regular-sized sanitary products in a period (2).

What causes very heavy menstrual bleeding?

This is not clear. Heavy flow is most common in the teens and in perimenopause—both are times of the lifecycle when estrogen levels tend to be higher and progesterone levels to be lower. Progesterone is made by the ovaries after ovulation. However, even though you may be having regular periods, it doesn’t mean you are ovulating! The lining of the uterus or endometrium sheds during a period. Estrogen’s job is to makes the endometrium thicker (and more likely to shed) and progesterone makes it thinner. Therefore it is likely that heavy flow is caused by too much estrogen and too little progesterone. However, this has not been well shown.

The good news is that, in a large study of pre- and perimenopausal women, heavy flow was not caused by endometrial cancer. This means that a diagnostic test for cancer called a D & C (a surgical procedure in which the endometrium is scraped off) is not necessary (3). Heavy flow was most common and occurred in 20% of women ages 40-44 (3). In women ages 40 to 50, those with heavy flow commonly also have fibroids. However higher estrogen with lower progesterone levels causes both heavy bleeding and the growth of fibroids. Fibroids are benign tumors of fibrous and muscular tissue that grow in the muscle of the uterine wall; less than 10% come close to the endometrium and are called “submucus” fibroids. Only these rare fibroids could possibly influence flow. So fibroids are rarely the real cause for heavy flow and are not a reason to treat very heavy flow any differently.

Early in perimenopause when cycles are regular, approximately 25% of women will have at least one heavy period. Perimenopausal estrogen levels are higher and progesterone levels are lower (4;5). (See Perimenopause, the Ovary’s Frustrating Grand Finale.) Progesterone levels are lower because ovulation is less consistent and short luteal phases (the portion of the normal menstrual cycle from ovulation until the day before the next flow) with fewer than 10 days of progesterone are common in perimenopause (6).

Some rare reasons for heavy flow are an inherited problem with bleeding (like hemophilia), infection or heavy bleeding from an early miscarriage.

Can I figure out how much I’m bleeding?

The easiest way, knowing that one soaked, normal-sized sanitary product holds about a teaspoon of blood (= 5 ml), is to record the number you soak each day of your flow. Another very easy way to measure flow is to use a menstrual cup like DivaCup® that has markers for 15 and 30ml of blood loss. Keeping the Menstrual Cycle Diary or Daily Perimenopause Diary is a convenient way to assess the amount and timing of flow using either a count of soaked regular sized sanitary products (tampons or pads) or a measuring menstrual cup. (Note that less than half of all cups marketed world-wide have flow volume markings so look for one that has them). To accurately record the number of soaked sanitary products each day you need to recall the number you changed that were half full (let’s say three tampons and one pad) and multiply that (four X 0.5 = two) to give the number of fully soaked ones. A “maxi” or “super” tampon or pad holds about two teaspoons or 10ml of blood—therefore record each larger soaked sanitary product as a “2.” In addition, record your best judgment about the amount of flow where a “1” is spotting, “2” means normal flow, “3” is slightly heavy and “4” is very heavy with flooding and/or clots. If the number of soaked sanitary products totals 16 or more or if you are recording “4”s you have very heavy flow. To measure your flow using a menstrual cup with measurements, just add up the approximate amounts from each time you emptied it and record on the “# of pads/tampons” line.

What can I do for very heavy flow?

    1. Keep a record
      Make a careful record (see Diary, above) of your flow for a cycle or two. (Note—if flow is so heavy you start to feel faint or dizzy when you stand up, that is a reason to make an emergency doctor appointment.)
    2. Take ibuprofen
      Whenever flow is heavy, start taking ibuprofen, the over-the-counter anti-prostaglandin, in a dose of one 200mg tablet every 4-6 hours while you are awake. This therapy decreases flow by 25-30% and will also help with menstrual cycle-like cramps (7).
    3. Treat blood loss with extra fluid and salt
      Any time you feel dizzy or your heart pounds when you get up from lying down it is evidence that the amount of blood volume in your system is too low. To help that, drink more and increase the salty fluids you drink such as tomato or other vegetable juices or salty broths (like bouillon). You will likely need at least four to six cups (1-1.5 litre) of extra liquid that day.
    4. Take iron to replace what is lost with heavy bleeding
      If your doctor’s appointment is delayed or you realize that you have had heavy flow for a number of cycles, start taking one over-the-counter tablet of iron (like 35 mg of ferrous gluconate) a day. You can also increase the iron you get from foods—red meat, liver, egg yolks, deep green vegetables and dried fruits like raisins and prunes are good sources of iron. Your doctor will likely measure your blood count and a test called “ferritin” which tells the amount of iron you have stored in your bone marrow. If your ferritin is low, or if you ever have had a low blood count, continue iron daily for one full year to bring iron stores to normal.

What can my doctor do to evaluate heavy flow?

After asking you questions (and looking at your Diary or calendar records of flow) your doctor should do pelvic exam. If this is very painful, a culture should be taken to rule out infection that is a rare but serious cause for heavy flow. With the speculum a doctor see that bleeding is coming from the uterus and not from somewhere else.

What laboratory tests can my doctor order to assess heavy flow?

One of the consequences of heavy flow is loss of iron that is needed for hemoglobin to carry oxygen in red blood cells—low iron levels cause anemia (low hematocrit or hemoglobin which are commonly called “a low blood count”). Ferritin which shows how much iron is stored in the bone marrow could be ordered if heavy flow has been going on for a while, if you have started iron therapy, or you eat a vegetarian diet that tends to be low in iron. Ferritin can be low (because the savings account is empty) even if the hemoglobin and hematocrit are normal (the chequing account is not yet empty). Sometimes, heavy bleeding means a miscarriage so your doctor might order a pregnancy test.

What can my doctor do to treat heavy flow?

1. Progesterone or a stronger progestin therapy

Progesterone therapy makes sense because very heavy flow is associated with too much estrogen for the amount of progesterone. Progesterone’s job is to make the endometrium thin and mature—it antagonizes estrogen’s action that makes it thick and fragile. However, low doses given for two weeks or less a cycle are not effective (9). One study shows that very high doses of a strong progestin for 22 days a cycle decreased bleeding by 87%(10). I recommend starting treatment with oral micronized progesterone (Prometrium®) 300 mg at bedtime or medroxyprogesterone (10 mg) taken days 12-27 of the cycle. (See Cyclic Progesterone Therapy handout.). Always take progesterone for 16 days whenever you start it for heavy flow (even if flow starts before then). If needed, progestin can be started right away, at any time of the cycle and will slow or stop the bleeding.

Heavy bleeding is so common in perimenopause that when a woman over 40 is traveling or will be in a remote place, she should ask her doctor for a 16-day supply of 300 mg of oral micronized progesterone (or 10mg medroxyprogesterone tablets) to take with her.

You are likely in very early perimenopause if flow is extremely heavy, you already have anemia or it has been going on for a long time progesterone needs to be taken daily for three months. Take oral micronized progesterone 300 mg at bedtime daily and continued, every day, for three months. Flow will become irregular but decrease in amount over time. After that you can take cyclic progesterone for a few more months. Also remember to always take ibuprofen on every heavy flow day.

As flow gets lighter the progesterone therapy can be decreased to a normal dose and taken days 14-27 of the cycle. In perimenopause, especially in women with a history of acne and unwanted facial hair (PCOS or anovulatory androgen excess) it is often necessary to treat with daily progesterone therapy for three months to also decrease the risks for endometrial cancer. Following that it is wise to use a cyclic treatment for days 12 through 27 of the cycle for six more months.

2. Oral contraceptive pills
Although oral contraceptives are commonly used for heavy flow, they are not very effective, especially in perimenopause (8). Current “low dose” oral contraceptives contain levels of estrogen that, on average, are five times natural levels plus close to normal levels of progesterone-like medicines called progestins. Combined hormonal contraceptives (CHC) have not been shown to be effective for heavy flow perimenopause (13). In addition, they appear to prevent the important gain to peak bone mass during adolescence so should be avoided then. You would only choose to take CHC for heavy flow if you were not in perimenopause or adolescence and if you also needed contraception.

What other therapies can be added to progesterone if needed?

Thankfully there are two medical treatments for very heavy flow that have been shown to be both safe and effective in controlled trials. The first is the use of tranexamic acid, a medication that acts to increase the blood clotting system and decreases flow by about 50% (11). The second is a progestin-releasing IUD called “Mirena®” that decreases flow by about 85-90% (12). Both of these, studied over years, are nearly as effective as endometrial ablation, the surgical scrapping or destruction of the uterine lining, in controlled trials. Either of the emergencies therapies, tranexamic acid and Mirena®, should be used with cyclic normal dose progesterone, ibuprofen and extra salty fluid if needed.

Wrapping up section

In summary, very heavy menstrual bleeding means soaking 12 or more regular sanitary products in one period. About 25% of women in very early perimenopause or early menopause transition, some teens and a few women of other ages will experience this. No matter at what age heavy flow occurs, using a menstrual cup will help prevent embarrassing leaks and allow less frequent visits to the washroom. At present more than 50% of North American women with very heavy flow end up with a hysterectomy that can almost always be avoided. Very heavy flow can be helped by ibuprofen (1-2 tablets with every meal on every heavy flow day), extra salty things to drink, increasing dietary or supplemental iron and with cyclic progesterone or medroxyprogesterone. If flow is heavy in perimenopause progesterone will need to be taken daily for three months. Finally, a strong progestin-releasing IUD, Mirena® has been shown to be effective for both heavy flow and for contraception.

  1. Hallberg L. Menstrual blood loss. Acta Obstet Gynecol Scand 1966; 45:320.
  2. Cole SK Sources of variation in menstrual blood loss. J Obstet Gynaecol Br Commonw 1971; 78:933.
  3. Allen DG. Abnormal uterine bleeding and cancer Aust N Z J Obstet Gynaecol 1990; 30:81.
  4. Santoro N. Reproductive hormonal dynamics in the perimenopause. J Clin Endocrinol Metab 1996; 81:1495.
  5. Prior JC. Perimenopause: Endocr Rev 1998;19:397.
  6. Prior JC.Ovulatory changes with perimenopause. Novartis Found Sym 2002; 242:172.
  7. Fraser IS Treatment of menorrhagia with mefenamic acid. Obstetrics and Gynecology 1983; 61:109.
  8. Casper RF MinestrinTM on vaginal bleeding patterns in symptomatic perimenopausal women. Menopause 1997; 4:139.
  9. Preston JT Tranexamic acid and norethisterone in the treatment of ovulatory menorrhagia. Br J Obstet Gynaecol 1995; 102:401.
  10. Irvine GA. Randomised trial of the levonorgestrel intrauterine system and norethisterone for menorrhagia. Br J Obstet Gynaecol 1998; 105:592.
  11. Bonnar J Treatment of menorrhagia BMJ 1996; 313:579.
  12. Marjoribanks J Surgery versus medical therapy for heavy menstrual bleeding. The Cochrane Database of Systemic Reviews 2003; 3:1-65.
  13. Casper RF, Dodin S, Reid RL, Study Investigators. The effect of 20 µg ethinyl estradiol/1 mg norethindrone acetate (Minestrin™, a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause 1997; 4:139-147.

Normal and Abnormal Periods

What’s a Normal Period?

Menstrual periods are not the same for every woman. And a woman’s period can change throughout her lifetime. The timing, duration, and flow of periods can vary greatly, and it can be difficult to determine what’s normal and abnormal.

Here are some facts about periods:

  • A young girl’s first menstrual period, called menarche, is a milestone in puberty and usually occurs between the ages of 11 and 14 years
  • Girls who are just beginning to menstruate often have irregular periods and periods that fluctuate with light, moderate, or heavy flows
  • A young girl’s period tends to occur 21 to 45 days apart and last 4 to 7 days
  • As girls get older, on average, menstrual periods occur every 28 days, range from 21 to 35 days, and last 3 to 5 days
  • Typically, women lose about 30 mL to 45 mL (about 2 to 3 tablespoons) of blood during a period.
  • Typically, as women age, their periods occur less and less frequently until they stop altogether, called menopause

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What’s an Abnormal Period?

Keeping in mind the usual or occasional fluctuations in periods, here are some signs that a period may not be normal:

  • Bleeding for more than 7 days is not normal
  • A menstrual cycle lasting 90 days or longer in a woman not receiving a hormonal treatment is not normal
  • Menorrhagia is defined as blood loss greater than 80 mL per menstrual period, approximately 5.5 tablespoons or about one-third of a cup. This is not normal

In general, menorrhagia is characterized by heavy and prolonged periods—more than just one or two days of heavier-than-average bleeding. However, with the availability of super-absorbent pads and tampons, measuring blood loss can be imprecise. In practical terms, the menstrual bleeding of menorrhagia is so heavy that it requires more than one pad or tampon every one to two hours, frequently stains through underclothes and bed clothes, and may include passing blood clots one-inch thick in diameter.

For more information about heavy menstrual periods, go to Changing Roles in Treatment.

Tips and Tricks for Managing Your Heavy Period

Coping with heavy periods is no light matter for many women with a bleeding disorder.

Click on the tabs below for tips from young women on how they deal with the inconvenience and frustrations of heavy periods.

Daytime Strategies

  • When I’m out and about and active, I keep an emergency bag of:
    • At least 2 extra pairs of panties
    • An extra pair of jeans in my car at all times (younger girls may wish to keep this in a locker)
    • A long-sleeved sweater or jacket (in case of any accidents, this comes in handy to tie around your waist!)
    • Pads, tampons, and panty liners
  • I also carry a cute little cosmetics bag in my purse during the day. It’s chock full of pads, panty liners, and tampons at all times during the week. It’s discreet. So when you take it to the bathroom, it just looks like a little make up bag
  • I actually restock it every night before work the next day to make sure I am covered. Just be stocked at all times, wherever you’re going, so you can avoid a potentially embarrassing situation!
  • Things to avoid when your periods are heavy:
    • Thongs and going commando
    • Your favorite pairs of underwear, skirts, or lightly colored shorts or pants
    • Swimming
  • Most other daily activities I find are just fine. If you don’t feel up to doing something, just don’t
  • One of the problems I encountered with pads are limited mobility. I was in dance classes and if I moved around too much the pad would move out of place. I felt I had to constantly check to see if I needed to change; otherwise a sponge-like effect would happen when I sat
  • On my heaviest days, I would set alarm clocks during the night to make sure I would get up to change. Once I moved on to tampons I felt safer. I did run into some trouble at the beginning. So, I would suggest using light pads as well as tampons until you know more or less when you need to change
  • I’ve noticed that toward the beginning of my period, when I have more clots, I may sometimes need to change my tampon sooner. Clots cling to the outside, and I think it doesn’t allow the tampon to absorb as well
  • To this day I always use panty liners, just in case. I still have to get up at night to change; a tampon is not sufficient for overnight. I have even tried the tampons that hold more than the super size, but those just left me with soreness
  • I wear dark-colored pants during my period

The best way to deal with this huge change in your life is to be informed and educated.

Nighttime Suggestions

  • For sleeping, I actually put a doubled-up dark colored towel underneath my bottom – just in case I have some leakage. (It’s best to avoid these leaks because blood can be hard to get out of clothes and sheets)
  • I use tampons with panty liners during the day and use menstrual cups at night. They are not comfortable, but I feel fine sleeping through the whole night without having to worry about leakage
  • So that I don’t continuously ruin new ones, I have underwear dedicated to wearing at night during my period
  • To prevent ruining sheets, I used to sleep with an old blanket underneath me to absorb the blood if I bled though my overnight pads

Coping With Cramps

  • Disposable heating pads work really well against cramps. They stick under your clothes
  • Exercise. I know, easier said than done; but, exercise can have several benefits. When you exercise, your body releases endorphins that help counteract the cramp-producing chemicals that are part of the menstrual cycle. Also, engaging in your normal activities can get your mind off the pain

Some Laundry Advice

A laundering hint: very cold water helps to take out blood stains, and so does hydrogen peroxide. Try to rub out the stain using one or both before washing. Keep in mind that the dryer will set the stain in permanently.

Fels-Naptha® is a heavy duty laundry bar soap that removes blood. So does dish soap.

Talk to Others

My advice to you is this: I know that this is scary and that it’s weird and uncomfortable, but talk to someone—your mom, grandma, aunt, older sister, someone. You probably know someone who has gone through this as well. Talking to others will help you to better understand your body.

To print out a copy of these and other suggestions, go to Tips and Tricks for Managing Your Heavy Period

Every month a woman that is menstruating uses some kind of method to handle her blood flow. We can see the blood going into the pad, into the tampon or menstrual cup and into the toilet basin. But have you ever wondered about the actual amount of blood which your body expels during your period? What’s a normal flow, heavy flow or light flow? And have you ever wondered if other mammals also have periods? Why do humans need menstrual products to catch the blood, ever heard of ‘Natural Menstruation’? Can you do something for yourself about a heavy flow?

Here are some more facts about period blood.

The normal amount of human period blood

“Normal” can be a pretty difficult concept to handle and any deviation can make us feel “abnormal” and insecure about ourselves. This isn’t necessary. While it is important to pay attention to be healthy, each woman has a different body: short, tall, big pelvis, small pelvis, age, puberty, mother of three or progressing to menopause, on birth control or hormones or not, and… a different period! All such factors can have effect on the amount of period flow. Finally, what can be an issue for one woman can be absolutely normal for another woman. So let’s refer to the concept of “average” which includes the full range of menstruating woman and find the middle.

Most women experience a blood flow between 10-80 ml, during 2 to 7 days and the average amount of blood that a woman’s body expels during her menstruation can be found to be 35 ml. That is about 2 – 3 tablespoons (of 14ml) or 6 teaspoons (of 5ml). While that is the average, women have given varying reports from just a spot to over two cups (540ml!) in one menstruation (1).

So if you are somewhere within the range of 10-80 ml, you can probably feel yourself comfortably within the amount that most women bleed. If you feel unsure about your period you can consult a health practitioner. To learn more about heavy periods, .

These are the medical terms:

  • Hypomennorrhea = short or very light menstruation
  • Hypermennorrhea = extremely heavy or long (soaking 1 pad in 1 hour / 9-16 soaked pads in total)
  • Menorrhagia = flow of more than 80 ml (more than 16 soaked pads in total)
  • Polymennorrhea = more frequent than 21 days
  • Oligomennorrhea = infrequent menstruation
  • Metrorrhagia = spotting between menstruations
  • Amenorrhea = absent menstruation
  • Dysmenorrhea = painful menstruation

How much blood can a menstrual pad or tampon or cup hold?

A fully soaked normal size pad or tampon holds a teaspoon (5ml) of liquid (for a particular product brand please refer to the product information). For a usual length of menstruation of 4 to 6 days and the average of 35 ml that makes about 6 sanitary products, while the truth probably is that we have the habit of changing more frequently due to reasons of spilling, showering and changing clothes, or feeling uncomfortable and simply ready for a change. We rarely wait until it is really fully soaked. A menstrual cup holds about 25 ml, depending on the model and it is recommended to change every 6 to 12 hours.

How can I figure out how much I actually bleed during my period?

The possible methods for this are: measuring, weighing, chemical test.

  • If you are using a menstrual cup, this is easiest. Many cup models actually have metric lines for you to read how much liquid is inside once you take it out. Even if the particular cup doesn’t, it is easy to take a teaspoon and just measure the number of teaspoons (5ml) through pouring the blood onto it.

  • If you are using pads or tampons, measuring is a bit more tricky. You will have to estimate that one fully soaked, normal size sanitary product will hold about 5ml, (for a particular product brand please refer to the product information), add up all the products used while making your judgement paying attention to the number of items that you changed half full.
  • You can also weigh the pads or tampons after use, add up the amount and then subtract the weight of the same unused products. Using this method, note that the number can also contain sweat as well as other body fluids, and then again might be altered through evaporation of fluids. Dried blood weighs less than wet blood. And your results will be a weight rather than a liquid quantity.
  • The most exact method is a chemical process. This is not practical to be applied at home, but can be used for lab testing and scientific studies (2).

Do other mammals also have periods?

The answer is ‘yes, but’. All female mammals that produce offspring with a placenta, build up a uterine lining (the endometrium) in the fertile phase of their cycle and dismantle it in the infertile phase. Some species have an ‘estrous cycle’, in which, if no conception takes place, the endometrium fluids are reabsorbed into the body (covert menstruation). Other species, like the human have a ‘menstrual cycle’, where the body expels the endometrium lining (overt menstruation). Primates, some bat species and elephants also experience overt menstruation. But, here’s an inspiring detail: Before menstruating, humans do in fact also reabsorb two-thirds of the liquid in the endometrium (3).

Food for thought: If human beings actually do have the ability to reabsorb endometrial liquid, why do some women menstruate so much blood? Maybe there is something about human beings that can cause this? Could this possibly be a factor we can influence and reduce strong periods? Could we humans maybe also manage to live without menstrual products?

Can I do anything about a heavy flow?

In any case if you feel uncomfortable about the amount of your menstrual blood, you can refer to a health practitioner. While excess bleeding can be a sign for a health concern, in fact what you feel might be ‘a lot of blood’ might actually be alright. As mentioned above, every woman’s body is different and the amount of blood can also change throughout her menstruating years.

There are some health practitioners who mention using hormonal birth control pills to regulate menstrual bleeding, while others point out that this should really be reserved for health-threatening blood loss conditions, and not for popular comfort. They point out the warning that ‘the pill’ in general is a possibly disturbing intervention into a woman’s natural hormonal system with potential health concerns. Although this is not a topic for detailed discussion in this article.

However there are also more holistic possibilities to regulate a heavy menstrual flow.

  • Physical exercise can support a healthy menstruation: Something you might be able to do to help yourself is practice the AVIVA Method, a set of exercises developed by Aviva Steiner with a positive effect on a variety of complaints of the female reproductive system including heavy menstrual bleeding. Coming back to the ‘food for thought’ above, two-thirds of endometrial liquid can reabsorbed into the body before menstruation, and this could possibly be a factor to influence and reduce strong periods. The AVIVA Method aims also at supporting that very reabsorption and practicing women have reported lighter periods. The movements are meant to stimulate pelvic blood and lymphatic fluid circulation throughout the month, counteract the vicious cycle of fluid stagnation and thus support reabsorption of the endometrium before the remaining parts are broken down and menstruation occurs. And there is in fact something specific about human beings: We are an upright walking species, which means that stagnant fluids are more likely to accumulate in the lower pelvis region.

  • Healthy menstrual products can support a healthy menstruation: Along with the inspiration of above research which shows that body detox processes are important for a healthy menstruation and indicates a possible influence on the amount of period blood, this becomes further food for thought for your choice of menstrual management! In fact, we at Eco Femme as well as other cloth pad suppliers have been getting the matching feedback from women who report that after a couple of cycles their menstruation has become lighter and more pleasant with less blood and less cramping. It is possible that using a natural menstrual management product, meaning less exposure to harmful toxins, could be a self help if you are experiencing a heavy flow. You can help to protect your body from toxin exposure through the use of disposable menstrual products (read more here…). Besides taking care of our environment, if you are experiencing heavy periods, support your health and ‘Make the Switch’!

Food for thought: If human beings actually do have the ability to reabsorb endometrial liquid, could we humans maybe also manage to live without menstrual products? Have a look into our article about Natural Menstruation.

By Stephanie Kraus

Sources:

When is menstrual flow considered too heavy?

While some women can’t go for more than a couple of hours without rushing to the bathroom to avoid a “code red” incident, others can go hours without risking anything more than a slightly stained panty liner.

What’s “normal” and is it possible to control the flow?

When it comes to feminine hygiene product expenditures, whoever said life was fair? Every woman’s menstrual cycle differs in length, regularity, flow and duration. The cycle ranges from 21 to 45 days, with the average being 28, while the bleeding ranges from two to seven days, with the heaviest flow occurring in the first three days. Generally speaking, adolescents and women over 40 have the most erratic cycle lengths and bleeding intensity.

How is the heaviness of menstrual bleeding categorized?

If you were conducting scientific research, you would need to measure your monthly menstrual flow in millilitres, which is no easy task. The simplest way is to count the number of sanitary napkins or tampons you use and how often you change them:

  • Minimal bleeding: spotting or just a few drops
  • Mild bleeding: less than one saturated napkin or tampon in three or more hours
  • Moderate bleeding: more than one saturated napkin or tampon in under three hours
  • Heavy bleeding: more than one or two saturated napkins or tampons in one or two hours; this rhythm is normal for some women, but uncommon

If your flow is long-lasting and heavy (say, more than six maxi pads a day), and that’s not typical for you, you should consult a doctor.

Menorrhagia

Menorrhagia is the term used to describe menstrual flow that is abnormally long or heavy and often accompanied by cramps. When it occurs, you just can’t go about your day-to-day business, and you dread having your next period. The symptoms are:

  • Using up one or more pads or tampons every hour for several hours in a row
  • Having to double-up your pads
  • Having to wake up at night to change your pad
  • Expelling clots for several days in a row
  • Bleeding for more than a week
  • Adjusting your activities because of your menstrual flow
  • Showing signs of anemia: fatigue and shortness of breath

All kinds of health problems can cause menorrhagia: a uterine fibroma, a cycle in which ovulation doesn’t occur, polyps, intrauterine devices (except the Mirena, which has the opposite effect), medications, cancer, etc. It’s best to consult your doctor to get to the root of the problem. Most often, it’s caused by hormones. If it happens, try to uncover the origin of the imbalance, for example:

  • Puberty – hormone levels aren’t yet stabilized
  • You’ve changed contraceptive methods: going off the Pill, a new IUD, etc.
  • You’re over 40 and perimenopause is approaching

Don’t fret!

You might be surprised to learn that, in addition to looking for sales on pads and tampons, you can also influence your menstrual flow to improve your quality of life, while saving some money too!

A healthy diet can have a significant impact on cramps and bloating, and in some women, on the flow itself. For one, avoid white flour, sugar and processed foods, not just during your period, but throughout your cycle. Also try to choose foods rich in potassium, like bananas, papaya, potatoes (with the peel), sweet potatoes, lentils, salmon, soy milk and plain yogurt.

Keeping active also has an impact on the regularity and volume of menstrual flow, not to mention on health in general. Try to exercise for 20 to 30 minutes, five or six times a week. High-level athletes and women who engage in intense sports like running marathons often have very light to no menstrual flow.

Vitex is the go-to plant for re-establishing your hormonal balance. If you feel that your heavy menstrual flow is linked to a hormonal imbalance, give Vitex a try!

To avoid fatigue and the possibility of becoming anemic because of an overly heavy menstrual flow, consider Bio-Strath. It’s an excellent choice because it’s rich not only in iron, but also in B-complex vitamins, which are recognized for their beneficial effects on period-related problems.

If cramps prevent you from enjoying your favourite activities, make sure to get enough omega-3 fatty acids in your diet; they’re available in fatty fishes, flax seeds, soy and nuts, as well as in supplement form.

There’s no reason to let hormones get in the way of enjoying life. You don’t have to resign yourself to spending weeks doubling-up your pads, loitering near the bathroom and worrying about leaks. Try to get those hormones balanced by eating better and getting active. You’ll spend a little less on feminine hygiene products and more importantly, you’ll feel better.

Reference

What Size Tampon Do I Need? It Depends From Person To Person

We’ve all heard tampon horror stories, whether its getting toxic shock syndrome, forgetting a tampon for days, or even leaving a tampon in during sex. Thankfully, your chances of having health complications because of tampons are pretty slim, and they remain a popular menstrual hygiene option — a 2015 study found that 70 percent of women use tampons. Still, I avoided tampons until I was out of college because I was terrified of doing something wrong. My fears weren’t entirely irrational: If you don’t know what size tampons you need, you may be facing unnecessary stress on your period. It can be overwhelming to look at the tampon aisle at a supermarket and decide whether you need junior, super plus or something in between. If you’ve bought one tampon size and sworn off tampons as a result, it may be time to try again. So what tampon size should you be using? It really does depend.

Tampons aren’t supposed to hurt, and you shouldn’t be able to feel them once they’re inserted. According to the Palo Alto Medical Foundation, you should pick the smallest-size tampon available when you’re just starting out. You don’t have to use tampons when you’re menstruating, and some people are simply more comfortable with other menstrual hygiene products like pads, menstrual cups, or even period underwear. But if you do want to use tampons, you can make the experience super easy as long as you do some research beforehand.

You Should Be Comfortable

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We’ve already talked about tampons being comfortable, but I have to reiterate it: If you’re using the wrong-sized tampon, you are going to feel pain when you walk, sit down or attempt any sudden movements. I had so much discomfort the first time I used a tampon that I wondered whether my friends who swore by tampons were trolling me. It turns out I was using a tampon that was way too big for my flow. Knowing how tampons work can also give you an idea of what size might work best for you. Your tampon sits in your vaginal canal and expands when it feels moisture. If you’re using a tampon that’s too big, it’ll likely still be pretty dry when it’s time for removal, which can lead to pain.

You Shouldn’t Be Changing It All The Time

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You’ve probably heard that you shouldn’t leave your tampon in for more than eight hours, but how long should it stay up there? Dr. Jennifer Caudle, a family physician and Assistant Professor at Rowan University, told Bustle in 2016 that changing a tampon every four to eight hours is reasonable, although some doctors recommend changing it at least every six hours. If you’re changing your tampon more frequently than that, you may be using a tampon absorbency that’s too weak for your flow. Try moving up to a bigger size and see what happens. (If you’re still changing your tampon every two hours or less, it may be time to talk to a doctor just to make sure everything’s okay.)

You Should Be Leak-Free

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According to Kotex, tampons leak if they aren’t the right fit for your vagina or the tampon is getting full before you have a chance to change it. If you have a heavy flow, you may be more comfortable pairing a pad and tampon to avoid any leaking, or a tampon and period underwear to avoid stains, but a tampon that fits correctly should absorb all of your menstrual blood without leaks.

Going to the bathroom and seeing blood stains in your underwear is the worst, but being prepared for leaks can help you avoid any mishaps. If you go up a tampon size and you’re still leaking, it may be time to wear a pad or check out another kind of period protection like a menstrual cup. Tampons may seem mystifying if you haven’t found the right one for you, but all it takes is a bit of trial and error.

Tampon sizes indicate the amount of menstrual flow they can absorb. Common tampon sizes include junior or slim, regular, super, super plus, and ultra. A larger-capacity tampon should be chosen if the current size must be changed within a couple of hours. Tampon insertion should never hurt. If it does, it can indicate that you’re using too large a size of tampons.

Some women choose to wear several different tampon sizes to match the course of their menstrual cycle. In the beginning and end of the cycle, a lower level of flow may be present and adequately managed with smaller tampons.

During the middle days of your period, you may need to use larger-capacity tampons to match higher flow. Some women experience differences in their menstrual flow every month, making it important to keep several sizes on hand to prevent leakage.

Best tampons for first-timers

Using a tampon for the first time can feel intimidating or uncomfortable, and you may be concerned about breaking the hymen. Although a tampon shouldn’t affect your hymen, you may have some discomfort during the first few cycles of using tampons.

Many tampon manufacturers provide slim or junior tampons, the smallest tampon sizes available for first-timers to experiment with as their body adjusts to using them.

When selecting tampons for the first time, choose those with a minimally sized insertion applicator. Plasticized applicators may be more comfortable for less experienced women than cardboard inserters. If you’re new to tampon use, you can also select tampons that don’t use an applicator and instead let you place and position tampon using only your fingers to achieve a comfortable insertion.

First-time tampon users can use slim pads or panty liners to capture leakage. This backup allows you to get used to your unique menstrual flow and choose the right-sized tampon or tampons best suited to your needs. Active women may also want to consider sport tampons, which are designed to flex naturally during increased exercise. This flexibility ensures an inserted tampon fits well within the vagina and shifts during movement to prevent leaks.

Less experienced tampon users should take care to insert tampons only as deep as the applicator allows to prevent the tampon from becoming stuck when inserted too far. The string from a tampon should hang freely and make it easier to remove the tampon when it’s time to change.

How long can you safely leave in a tampon? We asked the experts

Image zoom Holly Hildret/Getty Images

You use ’em every month, and they’ve likely saved you from many an embarrassing situation. But one question we can’t help but always wonder is: How long can you safely leave in a tampon?

Because let’s be real, some days they stay inserted longer than you intended. Maybe your flow is so light you want to keep your tampon in as long as possible. Or maybe you don’t have easy access to a bathroom (lookin’ at you, all-day music festivals). And some days you may just plain forget it’s in there. It happens. We’re all human.

But how long can you safely leave the same tampon in? And what happens if you leave one in too long? HelloGiggles spoke with U by Kotex partner and OBGYN Dr. Jessica Shepherd, and Dr. Prudence Hall, Founder and Medical Director of The Hall Center, to get the 411 on safe tampon usage.

Dr. Shepherd says that a tampon can safely be left in place between four to eight hours, but there are certainly caveats to that. She says if a tampon is not changed frequently enough, the user might “experience an unpleasant odor.” However, there’s no clear-cut definition on what “unpleasant” means, and Dr. Shepherd strongly advises women to get to know what is normal for their bodies.

“Instead of ‘normal’ and ‘bad,’ try thinking of vaginal odor as ‘typical’ or ‘unusual’ for you – on your period or not,” she says. “Throughout your cycle your vaginal mucus changes and as it changes, the odor it may produce will change too. If you’ve recently experienced a change in your vaginal odor or that it’s become stronger, consider going to see your healthcare professional.”

Another important aspect of safe tampon use: Make sure you’re using the “correct absorbency tampon depending on your menstrual flow.” She explains how crucial this is, adding, “Tampons come in different absorbencies to suit the needs of varying menstrual flows.”

“The more absorbent something is, the more liquid it can soak up. Finding the proper absorbency to suit your needs, versus always selecting the most absorbent option, is important decrease any chance of infection. Use the lowest absorbency for your needs and pack a spare in your purse,” she advises.

And what about those super light days where you still want to wear a tampon but might not need to change it that often? Dr. Shepherd says,

“Even on light days, never go longer than eight hours without changing .”

Since many women have heard of TSS but may not know exactly what it is, we asked Dr. Shepherd to give us the lowdown. She told us, “TSS is caused by the bacterium called Staphylococcus Aureus, which exists normally in the nose, armpits, groin, or vagina of about a third of the healthy population. Sometimes certain strains of this bacterium give off a toxin. Although scientific data suggest that tampon usage increases the risk of TSS, tampons themselves have not been found to cause TSS.”

Though it can be fatal, TSS is actually extremely rare. Each year, fewer than 1 out of every 100,000 people contracts TSS, so you’re more at risk for those odors and discharge than contracting a fatal disease.

And while it is generally safe to wear tampons while you’re sleeping, Dr. Hall cautions women about keeping them in too long, saying, “Especially at night, I recommend giving your body a break from tampon use, and using pads. If you leave a tampon in too long, the tampon becomes a breeding ground for bacteria.”

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And as for those rumors from the medieval era that a tampon can get “lost” or disintegrate inside your body? Absolutely not true. If you forget that you’ve got a tampon in, simply remove it as soon as you remember. If you have difficulty removing it yourself, see a doctor and they can do it for you (don’t be embarrassed. It happens).

While dealing with our menstrual cycles can suck, at least we can generally rest-easy knowing that tampons are a convenient, discreet tool to help us live our lives a little more worry-free every day of the month. Hooray to that!

  • By Arielle Tschinkel

Patient Education

Heavy menstrual bleeding means that your periods are heavier or longer than usual. You may soak through a pad or tampon every 1 to 3 hours on the heaviest days of your period. You may also pass large, dark clots. And your periods may last longer than 7 days.

If you have heavy periods often, this can cause a problem called anemia. With anemia, your red blood cell count is too low. Red blood cells are needed because they help carry oxygen throughout your body. Severe anemia may cause you to look pale and feel weak or tired. You might also become short of breath easily.

There are many possible causes of heavy menstrual bleeding. Hormonal imbalance is the most common cause. Having benign growths in your uterus, such as fibroids or polyps, is another cause. Taking certain medicines or having certain health problems or bleeding disorders are also causes.

To treat heavy menstrual bleeding, your healthcare provider may prescribe medicines first. If these don’t help, you may need further testing and treatments.

Home care

Medicines

If you’re prescribed medicines, be sure to take them as directed.

  • To help control heavy bleeding, any of the following may be used:

    • Hormone therapy (this includes all methods of hormonal birth control such as pills, shots, cream, ring, patch, or hormone-releasing IUD)

    • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen

    • Antifibrinolytic medicines, such as transexamic acid

  • To help treat anemia, iron supplements may be prescribed.

General care

  • Get plenty of rest if you tire easily. Avoid heavy exertion.

  • To help relieve pain or cramping, try using a heating pad on the lower belly or back. A warm bath may also help.

Follow-up care

Follow up with your healthcare provider, or as advised.

When to seek medical advice

Call your healthcare provider right away if any of these occur:

  • Heavier bleeding (soaking 1 pad or tampon every hour for 3 hours)

  • Heavy bleeding that lasts longer than 1 week

  • Fever of 100.4ºF (38ºC) or higher, or as directed by your provider

  • Pain or cramping that gets worse instead of better

  • Signs of anemia such as pale skin, extreme fatigue or weakness, or shortness of breath

  • Dizziness or fainting

Treatment

Heavy Menstrual Periods (Menorrhagia)

Women of child bearing age have monthly bleeding called menstruation. It is also called menses or a period. During menstruation, the lining of the uterus (the womb) is shed along with some blood. Most women with bleeding disorders have very heavy periods that last longer than normal. The medical name for this is menorrhagia.

Women who have been diagnosed with a bleeding disorder often dread their monthly periods because of a large amount of bleeding that can occur during this time. It is not uncommon to have to change a pad/tampon every hour or so for the first day or two of the cycle. The bleeding can also last longer than a week and interfere with activities of daily living.

It can be embarrassing, annoying, and inconvenient to be bleeding heavily for several days. Many women fear they will leak through their clothing while in public and choose to stay home for the first day or two of their cycle. This means missing days of work or school which can create problems with employers or teachers. Fortunately, there are products available to help control the bleeding and avoid soiling clothing.

In the past, doctors had difficulty defining the normal amount of bleeding that should happen during a woman’s period. It is hard to measure. Women in a family with a bleeding disorder may think their periods are normal because they bleed just like their mothers and grandmothers did. Your doctor may give you a chart to mark how many tampons or pads you use each day of your period. A normal period lasts less than eight days.

Bleeding during your period is considered heavy if:

  • Your bleeding soaks through the pad or tampon in less than two hours.
  • Your clothes are often stained from leaking menstrual blood.
  • Your bleeding gets in the way of your doing your daily activities.
  • You pass large blood clots (bigger than one inch).

How to treat menorrhagia:

  • Treatment for menorrhagia depends on the type of bleeding disorder. Amicar®, Cyklokapron®, desmopressin, or even platelet transfusion may be used.
  • Stimate® nasal spray, if effective, may be used on the first day of the period.
  • Birth control pills or hormones can be used to control the periods. They also raise the clotting factor levels in some women with bleeding disorders.

Some women with menorrhagia are treated with hormones. They receive a combination of estrogen and progesterone. This causes thinning of the lining of the uterus (womb) so that there is less lining to shed during the monthly period. The longer you take the hormonal medication, the lighter and shorter your period becomes.

There are several forms of hormone medicine. You and your health care provider can decide which will work the best for you. Hormones can be taken in a daily pill or as an injection (shot) that is given every three months. Your health care provider can put a device in your uterus. This intrauterine device releases a hormone that helps control the bleeding. It can be left in place for up to five years.

There are several options of pills available. There are monthly packs so that you have a period once a month. There are three month packs so you have a period four times a year. There is a form that you take every day of the year. With this last option you don’t have a regular period but may have unscheduled and unexpected breakthrough bleeding. The unexpected bleeding is usually spotting. The option of unexpected spotting is inconvenient but it may be easier to live with than heavy bleeding. You know your body and your lifestyle better than anyone else and can choose what option will work for you.

When you desire to become pregnant you stop using the hormone medication. The length of time you are on the pills or intrauterine system will not affect the length of time it may take you to become pregnant. It is recommended to stop the injection form of the medication 18 months before you want to become pregnant. The injection form may take up to that amount of time to clear your body.
Menorrhagia may also be treated with surgery. One type of surgery that is used is endometrial ablation. The doctor uses heat, a laser, or radiowaves to remove the lining inside the uterus. This lining is called the endometrium. After it is removed, the menstrual flow usually decreases or even stops. Most women are not able to have children after endometrial ablation.

Removal of the uterus (hysterectomy) will stop menstrual bleeding completely, but it is a drastic step. Make sure you have discussed all other treatment options with your doctor.

Coping with menorrhagia

Products are available to help avoid blood leaking through your clothing. One can be found in the incontinence aisle at most discount and drug stores. This product is called Poise® Panties and it can be discreetly worn under clothing. Unlike the common perception of adult diapers, these are thin and worn as panties so there are no sticky tabs at the sides as found in some products. They are made to absorb a considerable amount of fluid and they are disposable. They can be worn in addition to a tampon to give you extra security when you are having heavy bleeding. They do not rustle when you walk or add bulk to your clothing. The top of the panty can be folded down to fit under low rise pants. They are a great option for your heavier flow days. If you have questions or need help locating products to manage your heavy periods, talk to the nurse at your hemophilia treatment center (HTC).

Teenage girls can often be embarrassed by the heavy flow and may not participate in sports or other activities for fear of having an accident. Physical exercise is an excellent way to overcome menstrual cramps if you suffer from those. It also improves muscle strength and can keep your heart healthy. Using super tampons in combination with the Poise® Panties will help prevent accidents while participating in sports or other physical activities.

Sometimes teachers will not allow girls to go to the bathroom as often as they need to when having their periods. Your bleeding disorder nurse can help educate the teachers by doing an educational in-service at your school. Once the teachers understand about your bleeding disorder and why you may need to make several trips to the bathroom during the day, they are more likely to excuse you from class to take care of your hygiene needs.

A woman with menorrhagia can lose a great deal of blood each month. She may become anemic. This means her blood has less than the normal amount of red blood cells. She can feel weak and tired. A simple blood test can check for anemia.

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