Menorrhagia: Heavy menstrual bleeding. Excessive bleeding, either in a number of days or in the amount of blood, or both.
Blood loss per normal menstrual period is 20 to 60 ml, with the average expected blood loss to be around 30 to 40 ml. Excessive blood loss of 80 or more ml is considered excessive and increases one’s risk for iron deficiency anemia [1,2]. It’s difficult to know how many ml of blood one is actually losing during a menstrual cycle. Many women who report heavy bleeding during menses are in fact within the normal range, or even in the light range. Conversely, in one study 40% of women with blood loss of greater than 80 ml (excessive uterine bleeding) thought their periods were normal or even light! [2,3,4]
Using a menstrual cup may be the easiest way to tell how much blood you are actually losing. A menstrual cup like the Moon Cup, Luna Cup, Diva Cup or The Keeper holds up to one ounce (30 ml). Most women likely change their cup before it hits the 30 ml mark, so recording how much blood is in the cup every time you change it would be required to get an accurate measurement. Some cups have a line indicating 7.5 ml and 15 ml.
A normal size tampon holds about one teaspoon (5 ml), so soaking 16 or more tampons during a menstrual cycle would be considered excessive bleeding. The average 30-40 ml blood loss would soak between six and eight regular tampons. A “super” tampon can hold 10 ml of blood, therefore, eight or more soaked “super” tampons would be considered excessive. BTW, I don’t think there is anything super about a tampon. It has been my experience that tampons increased my cramping. I’ve been using unbleached cloth pads for four years now and love them.
Blood collected in a pad is a bit more difficult to calculate. Depending on the brand, a pad can hold between 5 and 15 ml, but most women don’t wait until the pad is soaked to change it.
Another indication that you may have excessive blood loss is if you feel faint or dizzy when you stand up. As I mentioned above, excessive blood loss can lead to iron deficiency anemia, so get your blood hemoglobin and serum ferritin levels checked before taking iron supplements. Too much iron can be toxic.
NORMAL RANGES VS. OPTIMAL RANGES: “If you take a look at your blood work you will see your result and then you should see a range next to it. These ranges tend to vary from lab to lab so they can be quite confusing. You want to focus on the optimal range. This is a narrower range that you should aim for in order to achieve better hormonal and overall health.”- Nicole Jardim, Women’s Hormonal Health Coach.
For example, my lab indicates that the normal range for ferritin levels is between 15-150 ng/ml. The optimal range is much more narrow and is 70-90 ng/ml (especially if there is hair loss). And HemoglobinA1C: Most ranges say it should be less than 6% but optimally you should aim for less than 5.4%.
Possible causes of heavy menstrual bleeding may be but are not limited to:
- miscarriage
- thick endometrial lining (excess estrogen buildup). The thickness of your endometrial lining can be confirmed via ultrasound.
- uterine fibroids can prevent the uterus from contracting effectively and lead to excess bleeding. submucosal fibroids, which make up about 10% of fibroids, are the type that is usually associated with heavy bleeding.
- low progesterone or no progesterone from anovulatory cycles. If you aren’t ovulating, your corpus lutem is not forming and therefore not producing progesterone.
- endometrial polyps (small growths)
- IUDs
- vitamin A deficiency
- malignancy
- infection. Although, it’s rarely the cause.
- adenomyosis
- bleeding disorders
- low thyroid function
- immature endocrine system (first few years of menstruating)
- perimenopause-ovaries may be less sensitive at this stage, so the hypothalamus doesn’t get the signal to send out LH, therefore ovulation doesn’t happen, but the uterine lining keeps building up until it eventually sheds. This is a time when estrogen is higher than normal and progesterone is lower than normal. Check out this article from the Center for Menstrual Health and Ovulation Research for information on how your doctor may be able to help you reduce your heavy heavy bleeding.
- hyperglycemia (high blood sugar) interferes with hypoxia-inducible factor (HIF). The more of this you have, the faster you heal and cut off the bleeding.
- If you have dysfunctional uterine bleeding (DUB), it would be helpful to know if you are ovulating or not. The causes of ovulatory and anovulatory DUB are different, so knowing your body can give you clues to what is going on.
- Anemia! Yes, heavy bleeding can cause anemia, but anemia can also cause heavy bleeding! As Dr. Jennifer Karon-Flores explained, “Basically, iron helps with platelet aggregation, so in absence of enough iron, platelets decrease and don’t work as well. Also, the arterioles in the endometrium get poor signaling in this environment, which further enhances the bleeding.” Here is a study that explains the mechanisms at play.
- Item of Interest: NIH funds studies to assess potential effects of COVID-19 vaccination on menstruation
As you can imagine, knowing the cause of heavy menstrual bleeding is crucial in order to address the problem at its root. Knowledge is power, it pays to know your body! When you understand your body, you become an active participant in the healing process. If you think you may have a serious pathology, please consult your physician.
A useful tool to use to recognize imbalances in the reproductive system is fertility charting. Taking Charge of Your Fertility by Toni Weschler is an excellent guide, or working with a fertility awareness counselor.
If you are considering ablation for heavy periods, read this first, Women Get Burned by Quick Fix For Heavy Periods.
Slow Flow Supplement by Vitanica has helped me tremendously during times of excessive bleeding.
Also check out my Womb Care online self-care course to learn how to do uterine massage, pelvic alignment techniques, and other supportive modalities for uterine health. Registration is now open!
Sources
1. Harlow S: Menstruation and Menstrual disorders, IN: Goldman M, Hatch M, eds.: Women and Health, San Diego, Academic Press, 2000
2. Botanical Medicine for Women, Dr. Aviva Romm
3. Baker S: Menstruation and Related Problems and Concerns, In: Youngkin E, Davis M, eds: Women’s Health: A Primary Care Clinical Guide, Stamford, CT, Appleton & Lange, pp. 140-160 1998
4. Hallberg L: Menstrual blood loss: a population study, Acta Scand Obstet Gynecol 45:321-351, 1966
5. Vitamin A in the treatment of menorrhagia
6. Triad of Iron Deficiency Anemia, Severe Thrombocytopenia, and Menorrhagia—A Case Report and Literature Review
Thanks for the great info. Is there ever a time that heavy bleeding would be considered normal, or would it generally be a cause for concern? I have been working on alignment and other pelvic floor health and feel completely great but, there has been a huge increase in my menstrual flow, and I can fill several cups daily, so my flow is very heavy for 2 days straight, and then generally normal the remainder of the week. I have no other adverse symptoms and have otherwise only experienced benefits. So could it be that correcting my alignment has fixed my flow and it is normal now rather than before? I really feel great otherwise so I would be curious if you thought this was more than likely a sign of an issue than the new normal? Thanks again, I love your articles!
How many ML are you bleeding in a cycle? Have you had your ferritin checked and ruled out the above causes? Sometimes one could feel fine but have an underlying issue brewing.
It is possible that alignment has improved flow, but shouldn’t cause excessive bleeding.
Thank you for the post! I have a concern about my blood loss during my period. I am 14 years old and bleed through at least 5 super tampons per day. That seems just way too much to me. Should I visit a doctor and ask about whether an extra iron intake would be recommendable or not? Or is the amount not that worrisome?
It could be considered excessive if that is going on for 2 or more days. Getting your ferritin checked may be a good idea.
This is just from around 8 am yesterday to 12:30 AM today (16 1/2 hours)
I’m estimating that a full (even though it was actually overflowing) diva cup holds 20 mL.
I have been having to empty it every 1 1/2 – 2 hours. I have been keeping track. It was overflowing full 6 times. It was at / around the 15 mL mark twice and it was approx. Halfway between the 7.5 mL mark and the 15 mL mark once (lets call it 10 mL).
So by my calculations, in the past approx. 17 hours it has been 160 mL.
My menstruation is highly irregular and sometimes it is extremely heavy, like today, and sometimes it is so incredibly light that the diva cup isn’t neccessary because pantyliners are sufficient (like for the past 4 cycles prior to this one).
Some months I don’t even get a period and some months I get 2 or 3 periods and sometimes my period will last a month or two.
My mom says it runs in our family. This is nothing new to me. I’ve been dealing with cycles like this since I was 11 years young.
Doctors have never really helped, never want to listen, always think that I’m exaggerating. Kept telling me that I want losing as much blood as I thought I was even though I kept flooding out not just tampons and pads, but adult diapers too.
Diva cup allowed me to measure and keep track of my flow and it’s even heavier than I thought.
Can some body point me in the right direction to get some real professional help or someone will actually help me instead of thinking that I’m making stuff up or exaggerating? Thanks in advance.