Your heavy menstrual bleeding deserves attention.

You may have normalized it. Your doctor might have normalized it. The people in your life might have normalized it. But it's not normal to miss out on school, work, play, and life because of your heavy menstrual bleeding. It's not normal to have to carry an outfit change for your heavy bleeding. It's not normal to wear a tampon + pad + period underwear + towel around your waist to bed for your heavy menstrual bleeding.

Common Causes

There are a variety of different reasons you can have heavy menstrual bleeding. And ultrasound and bloodwork can go a LONG way here. Here are a variety of causes of heavy menstrual bleeding:

• Endometriosis
• Adenomyosis
• Underlying inflammatory conditions
• Low progesterone
• Anovulatory cycles (like in athletes, adolescence, around perimenopause, with high prolactin levels, and in PCOS)
• Fibroids
• Polyps
• Iron deficiency (not just iron deficiency anaemia but also low-end iron levels)
• Fatty liver
• Thyroid disorders
• Clotting disorders (uncommon but can be a factor for some)

When we're younger, heavy menstrual bleeding is typically not due to structural issues, but due to anovulatory cycles when we don't have progesterone to help with tempering our endometrial lining in the second half of the cycle. As we get into our 30s, structural issues like fibroids, polyps, and adenomyosis can be part of the picture.

Your treatment plan will depend upon what's driving your heavy bleeding. Regardless, you should be presented with options to choose from in regards to how you want to manage your healthcare. Ultimately, you have to pick whatever is best for you and your life: medication, herbs and supplements, food and nutrition support, acupuncture, hormone therapy, surgery, wait and see, or a combination approach.

Communicating with Your Healthcare Provider

The unfortunate truth about heavy menstrual bleeding is that sometimes symptoms reported by patients aren't trusted. In fact, there are research papers that state that patients' recall about their bleeding is unreliable. When combined with the general narrative about periods being painful and disruptive, this sometimes means that practitioners can be dismissive. Here are some tips to communicate with your doctor:

• Measure your blood loss. This is easier if you use a cup versus other period products. If you use other products, then note down how many products you go through in a day including the size of the product (an overnight pad can absorb much more blood than a regular sized one). Share this blood loss with your doc
• Note down the number of days you bleed
• Note down any clots you might be passing
• Convey if there's any soiling of clothes or bed sheets
• Let your doctor know how this impacts your (quality of) life: missing school, events, work, playing with children, hanging out with family and friends etc.
• If there's a change in bleeding from before, relay the change in blood loss
• Convey any other symptoms you experience with your flow as well
• Ask for a referral to a specialist if your family doctor will not provide the care you deserve and need

Heavy menstrual bleeding is defined as >80mL of blood loss technically, but you could also have a heavier menstrual bleed compared to before i.e. a significant change from your usual flow. For example, if you were losing 30mL of blood before and now are losing 60mL, that deserves an investigation as well.