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Menstrual cycle health is a cornerstone of a woman's overall well-being. Heavy periods can significantly disrupt your quality of life.
Between 20-30 percent of women experience heavy bleeding, which is caused by a variety of conditions. Heavy periods can be particularly prevalent during perimenopause and are common issue that comes up in our clinic.
In this comprehensive guide, we'll delve into the causes of heavy periods in perimenopause and provide you with insights for reducing your flow from both a conventional and integrative medicine perspective.
Understanding Heavy Periods
Heavy menstrual bleeding, known as menorrhagia, is defined by the National Institute for Health and Care Excellence (NICE) as excessive and/or prolonged bleeding.
Heavy bleeding can look like this:
needing to change tampons or sanitary pads every two hours or more frequently on the heaviest days,
needing to use double period products,
large blood clots (bigger than 2.5cm diameter)
a heavy period that lasts over a week.
Heavy periods can have significant consequences for health and wellbeing including:
iron deficiency or anemia from blood loss,
fatigue,
dizziness/fainting or
disruption to school/work/sport/recreation activities
reduced quality of life.
Heavy periods can be common during perimenopause. They can occur every cycle or you may experience some cycles with normal blood flow and some cycles with heavier blood flow.
What Causes Heavy Menstrual Bleeding?
There are various causes of heavy menstrual bleeding, and they can be divided into 5 main categories:
hormonal causes
anatomical causes,
systemic conditions
infections and
medication side effects.
Understanding what is causing your heavy periods determines the best course of treatment.
Hormonal Causes
Imbalances in estrogen, progesterone, testosterone or insulin, can lead to anovulatory cycles or cycles with a lower progesterone to estrogen ratio. These hormonal shifts can lead to excessive or irregular shedding of the uterine lining. Such conditions can include:
Anovulation
Anovulation is the absence of ovulation, and it is a common cause of heavy periods.
Where anovulation occurs there is high estrogen with no progesterone to stabilise the uterine lining, resulting in a heavy period.
Luteal phase deficiency
Luteal phase deficiency is where the luteal phase of the menstrual cycle is shorter or has a lower progesterone production across the phase. The luteal phase typically occurs in the last 2 weeks prior to your next period.
A luteal phase deficiency means lower progesterone to estrogen resulting in a thicker endometrial lining, creating a heavier period. It can also contribute to difficulty conceiving and recurrent miscarriage.
Puberty and Perimenopause
During both puberty (as the brain - pituitary-ovary axis is kick starting) and perimenopause as the brain - pituitary - ovary axis is winding down) there is relative estrogen dominance during the cycle as the cycles start settling.
This relative estrogen: progesterone ratio can also occur with exposure to environmental chemicals (e.g. xenoestrogens) found in plastics, perfumes, cosmetics and persistent organic pollutants, as well as when there is increased body fat.
Other Hormone Related Conditions
These other hormonally related conditions can impact heavy bleeding during perimenopause as well as earlier in your life:
Polycystic ovary syndrome (PCOS)
PCOS is a hormonal disorder more commonly found in women of reproductive age.
PCOS is characterized by irregular menstrual bleeding, high levels of androgens such as testosterone or DHEA and and ovarian cysts.
There is also often insulin resistance. Both the higher insulin and testosterone interfer with the ovarian production of estrogen and progesterone in the normal cyclical manner so periods are infrequent and can be heavier as there is often no ovulation.
Endometriosis
Endometriosis is a common condition where tissue similar to the lining of the uterus grows outside the womb. This can cause heavy bleeding during periods, as well as pain and infertility.
Thyroid disorders
High prolactin
Insulin resistance/prediabetes/diabetes
Insulin resistance is more common in women during perimenopause. It can interfere with the brain-ovary axis and reduce ovulation, and therefore the levels of progesterone it can also be associated with weight gain.
Uterus Anatomy Factors
Anatomical factors refer to physical changes or abnormalities in the reproductive organs that can cause abnormal uterine bleeding.
These include:
Endometrial polyps, which are overgrowths of tissue in the lining of the uterus that can cause heavy or irregular periods.
Uterine fibroids, which are non-cancerous growths in the uterus that can cause heavy periods, pelvic pressure or pain, frequent urination, and constipation.
Adenomyosis, a condition where the tissue that lines the uterus grows into its muscular wall. This can lead to prolonged and heavy bleeding, as well as severe cramps and pain.
Endometrial hyperplasia: this is where the endometrial lining of the uterus becomes thickened due to an excess of oestrogen compared with progesterone.
Uterine or cervical cancer, which can cause abnormal bleeding or heavy bleeding.
Often polyps, fibroids, adenomyosis and endometrial hyperplasia are hormonally influenced, being driven by a higher estrogen environment and are more common to develop around perimenopause.
Infection
Pelvic inflammatory disease (PID) or sexually transmitted infections (STIs) or an infection of the uterine lining: endometritis can lead to inflammation and heavier bleeding with your periods.
Medical Conditions
You may have medical condition that impacts your periods: These can include:
Liver disease,
Kidney disease,
Thyroid dysfunction, hyperthyroid or hypothyroid
Insulin resistance interferes with the HPO axis to disrupt the menstrual cycle
Bleeding disorders such as von Willebrand disease or platelet dysfunction or leukaemia.
Chronic iron deficiency
Medications
Certain drugs may lead to heavier menstrual flow as a side effect. These can include:
Anticoagulants (blood thinners) such as aspirin, warfarin, clexane, clopidogrel, or heparin,
Nonsteroidal anti-inflammatory drugs (NSAIDs), used for pain relief, such as ibuprofen, naproxen, diclofenac.
Hormonal contraceptives, which may lead to breakthrough bleeding.
Antidepressants: SSRI such as sertraline and fluoxetine, tricyclic antidepressants
Antipsychotics such as olanzapine and quetiapine
Steroids
Some natural products can increase your blood flow like: fish oils, ginseng, garlic, and gingko.
Our Approach to Heavy Periods with Integrative Medicine?
Step 1: Investigate the Cause of Heavy Periods
Firstly, we need to work out what is causing your heavy periods. It is important that this is appropriately investigated to exclude reversible or serious causes of heavy menstrual bleeding.
We will need to take a history, often you will need a pelvic examination, cervical smear test, blood tests and sometimes imaging such as a pelvic ultrasound. If clinically indicated you may also need an endometrial biopsy.
Step 2: Treat Non-Hormonal Causes with the Appropriate Treatment
If an anatomical, systemic, infection or medication cause of bleeding is identified, these need to be addressed with the appropriate treatment for the condition.
Step 3: Treat Hormonal Causes of Heavy Periods
If these causes have been excluded and your heavy periods are due to hormonal effects in perimenopause, we can proceed to an integrative medicine approach to managing the hormonal imbalance contributing to heavy periods. The goal of this approach is to support the body to function optimally.
An integrative approach to heavy periods aims to support the hormones to function as optimally as they can for your stage of life.
Your management plan may or may not include conventional treatments depending on what is working for your body and your preferences. These may be especially important to use in the acute stage, especially if the bleeding is severe, to stop bleeding during investigations and to give your body a break from the heavy bleeding.
Conventional Treatment Options for Heavy Periods caused by hormonal changes
Conventional treatment for heavy periods relating to hormonal causes commonly range from medications to surgical interventions. These do not restore your appropriate menstrual cycles with normal flow but can reduce your bleeding.
Medications
Medications are usually first line treatment for heavy periods.
NSAIDS
Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can help reduce bleeding and pain by up to 50 percent.
However in some women they may increase bleeding as NSAIDS impair thromboxane-dependent platelet aggregation and prolong the bleeding time.
Tranexamic Acid
Tranexamic acid is a medication specifically used to reduce heavy bleeding by helping blood to clot. It only needs to be taken on the days you are having your period.
Contraceptives
Combined hormonal contraceptives are oral or patch birth control methods that contain estrogen and progesterone. These provide high hormone levels that inhibit the menstrual cycle hormonal cascade between the brain, pituitary gland and the ovaries.
Progestogen-only contraception such as the Depo-Provera shot, the Mirena intrauterine device (IUD), provide progestogen to thin the lining of the uterus and reduce heavy bleeding.
Mirena has been revolutionary in reducing hysterectomy in women for heavy bleeding and for those who want to continue to experience an ovulatory cycle - this often happens with mirena as it does not interefere with the brain-ovarian hormone axis, due to the low dose of progestogen (levornogestrel).
Progestogens
Non-hormonal synthetic progestogen such as provera (medroxyprogesterone) can e used cyclically to thin the uterine lining creating lighter periods.
Hormone Replacement Therapy
HRT can be used to boost the hormones that are declining as you go through perimenopause. Often your period can become lighter and shorter with HRT. Your dose may have to be adjusted over time to find your optimal dose.
Surgical Options
These options are usually used when medical treatments fail or are unsuitable.
Minimally Invasive Surgical Procedures
Endometrial ablation is a procedure that destroys the uterine lining and can be helpful if hormonal treatments do not work or cannot be used.
Other minimally invasive options may be available such as poly or fibroid removal if your situation suggests this.
Hysterectomy
A hysterectomy, the surgical removal of the uterus, is a definitive treatment for heavy periods, usually considered after other options have been exhausted and does come with risks including:
infection,
blood clot,
earlier menopause,
pelvic organ prolapse.
A Functional Medicine Approach to Heavy Periods caused by hormonal changes
Your medical history, symptom patterns and lab work helps us determine which hormones need supporting.
For many women with heavy bleeding, especially those in perimenopause, the issue is lack of luteal phase progesterone which is protective against heavy bleeding and occurs when there is a lack of ovulation, or if ovulation occurs but the corpus luteal does not generate adequate progesterone.
The most common approach in this situation is therefore to support estrogen metabolism at the same time as supporting increased progesterone in the luteal phase.
1. Phytoestrogens to reduce estrogen dominance
What you eat is more than nutrients. Food is also information. It communicates with your gut bacteria and with your genes to determine which bugs flourish in your gut and which genes will be expressed (switched on or off) to support hormone health.
Upgrade your diet to include more:
more plant-based foods,
healthy fats, and
adequate protein can support overall hormonal health.
Eating a diet high in plant foods contains an abundance of phytoestrogens which support hormone health. These include:
Nuts and Seeds: flaxseed, sesame seeds, pistachios, sunflower seeds, almonds.
Beans: edamame (soy beans), lentils, navy beans, kidney beans, pinto beans.
Fruit: dried prunes and apricots, peaches, raspberries, strawberries
Soy: miso, tofu, tempeh, soy milk
Vegetables: winter squash, green beans, collard greens, broccoli, cabbage.
Phytoestrogens can bind to the estrogen receptor but have a weaker effect than estradiol.
If phytoestrogens are consumed in abundance they can bind the estrogen receptors in preference to estradiol, reducing estradiol effects which can be beneficial for women who are having heavy bleeding due to higher estradiol:progesterone during their cycles.
So in women with higher estradiol, phytoestrogens can act anti-estrogenic to lower estrogenic effects in the body.
Related: Leanr more about an anti-inflammatory diet for menopause
2. Diindolylmethane (DIM) to reduce estrogen levels
DIM is a bioactive metabolite of indole-3-carbinol, a phytonutrient found in cruciferous vegetables, such as broccoli, cabbage, and Brussel sprouts.
DIM has been shown to have anti-inflammatory effects, anti-estrogenic effect by promoting the breakdown of estradiol, thus reducing its levels in the body. It particularly seems to be important in reducing estrogen metabolites associated with breast cancer (Chemopreventive properties of DIM in breast cancer 2016).
3. Support for Luteal Phase Deficiency
You can support the luteal phase deficiency during the entire menstrual cycle by incuding the folliwng foods in your diet:
Dietary Support with Phyto-gestins
There are a number of phytonutrients found in plant foods that have beneficial pro-progestogenic effects in the body. Another reason why eating a diverse plant-based diet can have positive impacts on your hormones.
Kaempferol: found in broccoli, spinach and kale, wild leeks or ramps, herbs such as dill, chives, and tarragon.
Apigenin in fruit such as cherries, apples, grapes, herbs (endive), vegetables (beans, broccoli, celery, onions, barley, tomatoes), and drinks (tea, wine).
Luteolin found in celery, parsley, broccoli, onion leaves, carrots, peppers, cabbages, and apple skins
Naringenin in grapefruit, bergamot, sour orange, tart cherries, tomatoes, cocoa, oregano, water mint, and beans.
These phytonutrients can also be supplemented.
4. Support progesterone around the menstrual cycle
These supplements have been found to support the luteal phase when they are taken during the entire menstrual cycle.
Vitamin B6 has been used clinically to treat luteal phase defect, including PMS and PMDD. It modulates expression of receptors to hormones and progesterone, especially when given in it's activated form.
Melatonin (1.5-3 mg at bedtime) is a powerful anti-oxidant and increases progesterone production in the luteal phase (Melatonin: shedding light on infertility, 2014). Sleep has an important association with menstrual health, with shift workers who have circadian rhythm disruption experience higher rates of irregular periods.
5. Suppoting Progesterone in the Luteal phase
You can use either of these in the luteal phase only to increase progesterone:
Phyto-gestins
Vitex agnus-castus can reduce period pain and flow intensity in women (Phyto-progestins for the treatment of abnormal uterine bleeding, 2023) and boosts progesterone production in animal studies (Gynecological efficacy of Vitex agnus-castus, 2008).
Vitex agnus-castus can also be used through the whole the cycle.
Cyclical Natural Progesterone
Body identical progesterone supplementation will increase progesterone levels, improve blood flow to the corpus luteum and promote changes in the endometrium that support lighter periods. It is also used to support fertility.
The dose can range from 200-300mg at night and can be given orally or vaginally.
Cyclical progesterone is a good option if dietary and lifestyle and herbal options have not reduced heavy bleeding.
It can also be a great option for PCOS alongside testosterone and insulin lowering strategies.
This can be used alongside continuous natural estradiol if you are having other significant perimenopause symptms.
6. Managing Stress
High levels of stress can disrupt the HPA axis (Hypothalamic-pituitary-adrenal axis), which controls the stress response. This can interfere with the HPO axis, (hypothalamic-pituitary-ovarian axis) contributing to anovulation, irregular periods or luteal phase deficiency. and can lead to dysregulated hormone levels.
Stress is linked increased severity of pre-menstrual symptoms, indicating it impacts the luteal phase of the cycle (Impact of stress on menstrual cycle, 2015).
It has also been connected with irregular cycles, indicating a disruption of the cycle that impacts ovuation (Effect of Perceived Stress on Menstrual Function, 2015).
There are many ways to manage stress so find the ones that work best for you.
Deep breathing can reduce cortisol and prolactin levels and help us feel more relaxed.
Gentle restorative yoga, walks in nature or along the beach can also help lessen our stress hormones.
Journalling,
Mindfulness, meditation
Gardening, fishing
Disconnecting from social media
Related: Take a deep dive into the 5 Pillars of Perimenopause Health and Wellbeing.
7. Restorative Sleep
Getting a good night's sleep is also paramount for healthy hormone balance, as sleep deprivation can lead to increased cortisol levels which can disrupt other hormones in the body. It also disrupts melatonin and circadian rythm of the body and this impacts the menstrual cycle.
Try to aim for 7-9 hours of sleep per night and establish a bedtime routine to help you relax and wind down before bed.
Meditation and mindfulness practices have also been shown to reduce stress levels and improve overall well-being.
8. Building red cells, a new endometrial lining and hormones
It is essential to eat adequate protein for building blood cells that are lost, rebuilding the endometrial lining and hormones required to maintain the menstrual cycle. Protein should be consumed with each meal and for active menstruating women is 1.2-1.6mg/kg per day.
Protein dense animal foods include:
Lean meats such as beef, chicken, turkey,
Fish and seafood
Dairy products such as milk, yogurt, cheese and cottage cheese
Eggs
Protein dense plant foods include:
pumpkin seeds, hemp seeds, chia seeds,
flaxseeds
peanut butter and other nut butters
almond, walnuts, pistachios
chickepeas
lentils
beans
tofu
tempeh
9. Maintaining Iron Stores
Iron is also an important nutrient for maintaining healthy blood levels. It is found in both animal and plant sources, with heme iron (found in animal sources) being more easily absorbed by the body. Plant-based sources of iron include:
dark leafy greens (spinach, kale, swiss chard)
dried fruits (raisins, apricots, dates)
legumes (lentils, chickpeas, kidney beans)
tofu
fortified cereals and breads
Always pair iron-rich foods with sources of vitamin C (such as citrus fruits or tomatoes) to enhance absorption.
Additionally, avoiding caffeine, tannins and calcium -rich foods (such as dairy) during meals can also help with iron absorption.
If you are experiencing heavy menstrual bleeding, you may also need iron and vitamin C supplementation to replace lost iron.
Related: Learn more about how to support your hormones if you have PCOS: A Complete PCOS Guide
The Takeaways: Treating Hormonal Heavy Periods
There are many causes of heavy periods in perimenopause, but often there is a hormonal influence.
You should seek medical advice if you are having heavy periods to determine the cause and the best treatment.
You can make lifestyle changes to both support your hormones in their healthy cycle and so you can feel and function better.
DIM and phytoestrogens from plant foods can lower your estrogen levels if high estrogen/progesterone ratio is contributing to your heavy periods.
Phytogestins from plant foods, herbs or natural progesterone can support higher progesterone in your luteal phase.
Support your iron intake with iron-rich foods eaten alongside vitamin C containing foods.
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References
Ibrahim NA, Shalaby AS, Farag RS, et al. Gynecological efficacy and chemical investigation of Vitex agnus-castus L. fruits growing in Egypt. Nat Prod Res. 2008 Apr 15;22(6):537-46.
Fernando S, Rombauts L. Melatonin: shedding light on infertility?--A review of the recent literature. J Ovarian Res. 2014 Oct 21;7:98.
Thomson CA, Ho E, Strom MB. Chemopreventive properties of 3,3'-diindolylmethane in breast cancer: evidence from experimental and human studies. Nutr Rev. 2016 Jul;74(7):432-43.