For many women, perimenopause can feel a lot like being back in junior high: acne, mood swings, body odor concerns, and … ugh … unpredictable and heavy periods.

Occasional heavy periods (called “menorrhagia”) are common to both puberty and perimenopause, but women in perimenopause generally experience the heaviest flows. One study reported that nearly 78 percent of its 1,300 middle-aged female participants had “three days or more of heavy flow.” Because they’re so common, heavy periods are our symptom of the month.

So, what does “normal” heavy flow look like? How much is too much; how long is too long? Heavy periods are, at best, inconvenient, and at worst, dangerous to your health. So let’s talk about what’s happening, why it’s happening, when you might need to involve a doctor, and what you can do about it.*

What causes heavy flow periods in perimenopause?

Here’s how it works:

In a period, the level of hormone FSH (follicle stimulating hormone) rises, causing eggs to mature in the ovaries. These follicles produce estrogen, and the estrogen in turn causes the lining of the uterus (the endometrium) to thicken, to prepare to receive a fertilized egg. Ovulation (the release of the mature egg) creates progesterone, and when the progesterone goes away because the egg isn’t fertilized, the endometrium is sloughed off, during what we know as our period.

However, during perimenopause periods, there aren’t as many follicles to stimulate, so the body bumps up the FSH, resulting in more estrogen being created. More estrogen means the uterine lining becomes even thicker – causing heavier bleeding and perimenopause periods lasting longer. This whole process can take longer, too, resulting in the longer gaps between periods.  Finally, it’s more common not to ovulate in perimenopause, so in some cycles, the endometrium continues to thicken until it has to be shed – resulting in a very heavy flow.

What does “normal” menstrual flow look like?

Like everything in perimenopause and menopause, “normal” can cover a startlingly wide range of experiences. Some women notice a slight increase in flow or duration of their period; others are unwilling to leave their homes for fear of leaking.

“Normal” menstrual flow – for premenopausal women – is about 2-3 tablespoons over 3-5 days, though even that is just an average, and many women have higher or lower flows for shorter or longer times. Any amount of blood between 25-80 mls is within “normal” range, though that can be hard to measure unless you use a menstrual cup that has measurements on it.

The usual way to measure flow is how often you need to change your protection. During a normal period, you shouldn’t have to change your tampon or pad more than every 4-5 hours. Remember, however, that this can vary from woman to woman, so if your experience is different, that’s probably just fine.

You may see blood clots, especially in the heaviest part of your cycle; as long as the clots are smaller than a quarter, no worries.

What does heavy menstrual flow look like?

Heavy flow is defined as anything over 80ml per period, and it usually means you’re changing your protection every hour or two. As a reference, twelve to sixteen or more soaked sanitary products during a period means you’re experiencing heavy flow. You may also see more or larger clots. In menopause and perimenopause, pink spotting is common during times of heavy flow.

What are the impacts of having heavy periods?

While the occasional heavier period is completely normal during perimenopause, there are health ramifications to be aware of.

  1. Blood volume. If you feel dizzy or your heart pounds or your head swims when you get up from lying or sitting, the amount of blood in your system is too low. Replace it with salty fluids like tomato juice, broths, etc. You’ll need to bump up your fluid intake by as much as 4-6 cups.
  2. Iron deficiency. Anemia is pretty common, especially if you’ve had a few heavy cycles in a row. You can take an iron supplement every day and increase the iron-rich foods in your diet: liver, egg yolks, dark leafy greens, and dried fruits.
  3. Increased stress. Many women would probably say having their period adds a layer of stress to their lives, but concern over leaking or excessive bleeding can really impact a woman’s life.

What else can cause heavy bleeding besides perimenopause?

Though heavier flow and periods lasting longer during perimenopause are relatively normal, there are other causes for menorrhagia– some much more serious than a hormonal imbalance. According to Everyday Health, other reasons for heavy bleeding include uterine fibroids, endometrial polyps, infections, weight changes, stress, bleeding disorders, conditions related to pregnancy, and uterine cancer. Mayo Clinic says heavy bleeding can also result from using an IUD or certain medications like anti-inflammatories, hormones, and anticoagulants. Hypothyroidism may also be responsible for heavy bleeding. There are many menstrual irregularities in menopause, and a wide range of causes.

When do I need to talk to a doctor?*

As always, you know your body best, and you should never hesitate to get professional help if you think you need it. If you experience heavy bleeding, you should probably consult your ob/gyn to rule out other causes. Here are some things to look out for:

  1. Bleeding so heavy it soaks a pad or tampon in an hour and lasts for more than two hours.
  2. Clots larger than a quarter.
  3. Dizziness, breathlessness, fatigue.
  4. How long is too long for periods during perimenopause? Bleeding that lasts more than two weeks should be addressed with a professional.
  5. Bleeding after menopause.
  6. Bleeding after sex.

If any of these sound familiar, make an appointment with your ob/gyn.

What can I do about heavy bleeding?*

If heavy bleeding is impacting your life – even if the cause isn’t dangerous – there are ways to control it. As usual, they run the gamut from lifestyle changes to surgery.

Lifestyle:

  1. Manage your weight. Fat tissue produces estrogen, which, if you remember, thickens the uterine lining, and the thicker lining results in a heavier period.
  2. Take NSAIDs. Nonsteroidal anti-inflammatories like ibuprofen (Advil, Motrin IB) or Aleve can help reduce blood loss.
  3. Check your birth control and other medications. Since these can contribute to heavy bleeding, you might want to check with your doc on finding alternatives.

Medications:

There are medications that can reduce heavy bleeding in perimenopause, including some hormones (birth control pills, progestin-releasing IUDs), and tranexamic acid (a non-hormonal drug).

Surgery:

If other methods don’t work or are otherwise ruled out, there are surgical procedures to reduce or eliminate heavy bleeding:

  1. Hysterectomy. The removal of the uterus obviously ends heavy bleeding. There are health concerns from this procedure as well, so weigh the pros and cons with your doctor and family.
  2. Endometrial ablation. This surgical destruction of the lining of the uterus can slow or stop menstrual flow. While women can still get pregnant after an ablation, it may be more difficult or riskier.
  3. Removal of polyps or fibroids. Both polyps and fibroids can trigger heavy bleeding, so surgical removal may be recommended.

Heavy bleeding is spectacularly annoying, but for most women it doesn’t happen often or long enough for concern. Weird periods are to be expected in our 40s and up.

But if heavy bleeding is disrupting your life to an extraordinary extent, or if you feel you may be experiencing something outside the (admittedly wide) range of “normal,” please see your doctor. Rule out more serious causes, get help and advice to handle what’s happening. Then share with us in the comments or on genneve’s Facebook page or in Midlife & Menopause Solutions, our closed Facebook group.

*As always, the information in this blog is for educational purposes only and is never meant to replace the advice and care of a qualified health care professional. If you think you need help, for crying out loud, go get it.

Got symptoms? Not sure if what you’re experiencing is “normal”? Check out our other “symptom of the month” posts for information on tingling fingers, frozen shoulder, painful breasts, cold flashes, and more.