Heavy periods aren't something to outlast.

Plenty of women spend years managing bleeding that shouldn't be managed alone — doubling up on protection, keeping a spare outfit in the car, declining the beach day, quietly exhausted. Heavy or unpredictable bleeding is one of the most common reasons women come to us. It's also one of the most fixable, and one of the most frequently waved off.

What counts as "too heavy"?

You don't need to measure anything. If any of these sound familiar, it's worth a visit:

• Soaking through a pad or tampon every hour for several hours in a row
• Passing clots larger than a quarter
• Bleeding longer than seven days
• Doubling up on protection, or waking at night to change
• Planning your work, travel, or wardrobe around your cycle
• Bleeding between periods, or after sex
• Fatigue, breathlessness on stairs, or pica (craving ice) alongside your periods

And the most useful signal of all: your bleeding has changed from what's normal for you. Normal varies widely between women; a change in your own pattern is the thing worth investigating.

Why it so often starts in your 40s

Perimenopause is a common explanation. As ovulation becomes less consistent, progesterone declines while estrogen still surges — and without progesterone's steadying influence, the uterine lining can build up unopposed and then shed heavily, unpredictably, or both. Cycles may shorten before they lengthen, and a period can arrive twice in a month or skip a month and return with force.

But "it's just perimenopause" should be a conclusion, not an assumption. The same symptom can come from fibroids, polyps, adenomyosis, thyroid disease, an inherited bleeding disorder (often first noticed as heavy periods in adolescence), medications including blood thinners, and — importantly — precancerous or cancerous changes of the uterine lining. Gynecologists work from a formal framework for exactly this reason, so nothing gets skipped: structural causes (polyps, adenomyosis, fibroids, malignancy or hyperplasia) and non-structural ones (bleeding disorders, ovulatory dysfunction, endometrial causes, medications).

The part nobody mentions: your iron

Heavy menstrual bleeding is one of the leading causes of iron deficiency in women — and iron can be depleted long before anemia shows up on a standard blood count. That matters because low iron produces exactly the symptoms women are most likely to blame on hormones, stress, or age: fatigue that sleep doesn't fix, breathlessness, hair shedding, cold hands, poor concentration and brain fog, restless legs.

We check ferritin, not just hemoglobin, because normal hemoglobin with a low ferritin is a common and very treatable finding. Repleting iron properly is often one of the fastest quality-of-life wins available — and it's independent of whatever we do about the bleeding itself.

How we evaluate it

An unhurried history first — your pattern, your timeline, what you've already tried — then testing matched to your situation rather than a reflex panel:

• Labs: blood count and ferritin, pregnancy testing where relevant, thyroid studies when indicated, and coagulation testing if your history suggests it
• Pelvic ultrasound to look for fibroids, polyps, adenomyosis, and to assess the lining
• Endometrial biopsy in the office when the lining or your risk profile warrants sampling
• Office hysteroscopy — a slender camera that lets us see inside the uterus directly when imaging leaves questions, without a trip to the operating room

Most of this happens in our office, and we explain each step before it happens rather than narrating it as it occurs.

Treatment: you almost always have options

The single most useful thing to know is that a hysterectomy is not the only answer, and rarely the first one. Depending on your cause, your goals, and whether you may want future pregnancy:

• The levonorgestrel IUD — highly effective at reducing menstrual blood loss, and a guideline-recognized option for heavy bleeding and lining protection, not only contraception. Many patients bleed dramatically less or not at all.
• Other hormonal options — combined hormonal contraception or cyclic progestogens, chosen against your history.
• Non-hormonal medication — tranexamic acid, taken only on bleeding days, meaningfully reduces flow for many women; NSAIDs can help modestly and also with cramping.
• Iron repletion — oral iron dosed for absorption, or IV iron when oral isn't enough or isn't tolerated.
• Hysteroscopic procedures — removing polyps or certain fibroids that sit inside the uterine cavity, often solving the problem at its source.
• Endometrial ablation — an option for women finished with childbearing whose evaluation supports it.
• Surgery — myomectomy or hysterectomy when it's genuinely the right answer, discussed honestly rather than defaulted to.

Which of these fits depends on findings we don't have yet. That's the point of the visit.

What to bring to your visit

You don't need to prepare, but these make the first visit far more productive: roughly when your pattern changed, how many days you bleed and how often, what protection you use on your heaviest day, any clotting, your medications and supplements (including anything blood-thinning), and whether heavy bleeding runs in your family. If you've had recent labs or imaging elsewhere, we'll request them.

Related: full-scope gynecology · menopause & hormone therapy · perimenopause vs. menopause · vaginal dryness · hot flashes · midlife weight · FAQ