Menorrhagia: Heavy menstrual bleeding. Excessive bleeding, either in a number of days or in the amount of  blood, or both.

The average 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.

What I learned in Nicole Jardim’s 8-weeFix Your Period Course is that there is a “normal” range for blood/saliva test results and an “optimal” range. 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%.  In the Fix Your Period-PMS home study course, Nicole covers much more including optimal Vitamin D, DHEA, Cortisol, Testosterone, glucose, C-reactive, IGF-1, FSH, LH, progesterone, estradiol and more…pretty much most any test range you need to know when it comes to optimal hormonal balance.  She walks you through step by step ways of correcting hormonal imbalances via lifestyle and diet. This course is a wonderful companion course to the manual therapy I offer.

Possible causes of heavy menstrual bleeding may be, but 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.
  • low progesterone or no progesterone from anovulatory cycles (the root cause is lack of ovulation, not low progesterone). If you aren’t ovulating, your corpus lutem is not forming and therefore not producing progesterone.
  • endometrial polyps (small growths)
  • IUDs
  • malignancy
  • adenomyosis
  • bleeding disorders
  • aspirin or oral anticoagulants
  • low thyroid function
  • saunas during and right before your period can increase menstrual bleeding
  • 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.
  • 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. 

As you can imagine, knowing the cause of the heavy menstrual bleeding is crucial in order to address the problem at the root.  If you think you may have a serious pathology, please seek the attention of a physician.

Knowledge is power, it pays to know your body! When you understand your body, you become an active participant and authority in the healing process. Another useful tool to use to recognize imbalances in the reproductive system is through fertility charting.


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

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