Heavy Periods: When normal isn’t actually normal

by rootin Menstrual Healthon Posted on

Heavy menstrual bleeding (HMB) is defined as excessive blood loss during menstruation that negatively impacts a woman’s  physical, emotional, social, or quality-of-life parameters. HMB may include:  passing large clots, needing to change sanitary protection every hour or two, or flooding through to clothing or bedding1. Because much of what counts as “heavy” remains subjective, many women do not realise that their bleeding is abnormal or are told it’s just part of the cycle. This is often dismissed as “normal” or simply part of being a woman, but for many, it is far more than an inconvenience. HMB affects a significant proportion of women: studies show prevalence estimates ranging from about 24% to as high as 48.6%, depending on measurement methods and populations. In England and Wales alone, 1 in 4 women in reproductive age is estimated to experience HMB2. 

The Social Challenge: Normalisation & Dismissal

A pervasive barrier in addressing HMB is the tendency to normalise or minimise menstrual suffering. Many women are told, “that’s just how periods are,” or “you’ll get used to it,” even when bleeding severely disrupts daily life. Such dismissal, whether implicit or explicit, can delay diagnosis, reduce self-advocacy, and allow the condition to worsen.

This form of medical minimisation imposes a substantial emotional burden3. Women may internalise the belief that their symptoms are exaggerated or unimportant, making them less likely to seek specialist care or advocate for further investigation. Over time, the cumulative physical, psychological, and social effects can lead to isolation, chronic fatigue, anxiety, and frustration.

Because menstruation is widely framed as a routine physiological process, menstrual disorders are often categorised as “normal discomfort” rather than evaluated as potential pathology. This cultural framing has consequences beyond individual encounters. Despite heavy menstrual bleeding affecting up to 30% of menstruating individuals during their reproductive years4, menstrual health research receives disproportionately limited funding compared to conditions of similar prevalence and burden. Analyses of national research portfolios have consistently shown that gynaecological conditions receive a small fraction of total biomedical research investment, with funding per affected individual substantially lower than for many non-sex-specific chronic diseases.

This imbalance perpetuates diagnostic delays, limits innovation in diagnostics and therapeutics, and reinforces the perception that menstrual health is a lower clinical priority.

The Scientific Challenge: Causes & Consequences

HMB is rarely a standalone condition and frequently reflects underlying structural, hormonal, or haemostatic abnormalities. Recognised causes include uterine fibroids, adenomyosis, endometrial polyps, ovulatory dysfunction, thyroid disease, and inherited bleeding disorders5. Notably, bleeding disorders such as von Willebrand disease may be present in up to 20% of individuals presenting with HMB, particularly among those with symptoms from menarche or a family history of abnormal bleeding6. These data underscore that HMB is often a clinical signal of systemic pathology rather than a benign variation of menstruation.

Irrespective of cause, excessive menstrual blood loss carries significant biological consequences. One of the most immediate and well-characterised is iron deficiency and iron-deficiency anaemia, which can manifest as fatigue, dizziness, dyspnoea, and impaired cognitive and physical performance8. Over time, chronic iron depletion may affect educational attainment, occupational functioning, and overall health.

Beyond measurable laboratory parameters, the lived impact of HMB is substantial. Symptom severity correlates strongly with reduced quality of life, yet these effects often remain invisible. Many individuals continue to meet academic, professional, and social expectations by adapting their routines around bleeding, pain, and exhaustion, often at considerable personal cost. Disruption to work or study, social participation, intimate relationships, mental wellbeing, and physical performance (including in sport) may therefore be profound but under-recognised by clinicians, educators, and employers.

Despite these wide-ranging consequences, diagnostic pathways remain inconsistent. Many individuals are managed symptomatically, through hormonal suppression or iron supplementation, without systematic evaluation of underlying causes. This approach reflects a broader scientific gap: although HMB is highly prevalent and imposes a significant burden, its underlying pathophysiology remains comparatively under-investigated, with research often prioritising treatment efficacy over mechanistic understanding, biomarker development, and long-term outcomes7.

Emerging reviews call for more robust mechanistic research, improved phenotyping, and integrated care models that connect gynaecology, haematology, and primary care. Strengthening this scientific foundation is essential, not only to improve symptom control, but to reduce delayed diagnosis, prevent avoidable morbidity, and enable more precise, patient-centred interventions9.

The Way Forward: Solutions

Progress requires action on three fronts: science, medicine, and societal empowerment.

  • Society & patient advocacy: Women should be empowered to seek appropriate evaluation; including imaging, hormonal assessment, and clotting investigations, and to request second opinions where symptoms persist. Public awareness campaigns can help shift cultural narratives that frame heavy bleeding as something to investigate rather than to endure, encouraging earlier help-seeking and reducing stigma.

    Empowerment must also extend to the workplace. Heavy menstrual bleeding can lead to recurrent absences, reduced productivity, or the need for flexible working arrangements, yet menstrual health conditions are often poorly reflected in organisational policies. Greater workplace education, clear HR guidance, and medically informed policies are essential to ensure individuals are treated with dignity and appropriate support. Recent policy developments in countries such as Spain, which has introduced menstrual leave, reflect growing recognition that menstrual health is a legitimate occupational health issue rather than a minor inconvenience.
  • Medical care: Clinical encounters benefit from acknowledging patients’ reports of excessive bleeding, undertaking appropriate diagnostic evaluation, and discussing management options in a collaborative manner, rather than defaulting to watchful waiting. Management strategies may include a range of clinically prescribed and supervised interventions, spanning medical and procedural options such as hormonal therapies, tranexamic acid, intrauterine systems, minimally invasive surgical techniques, or definitive procedures where clinically indicated. All treatments should be initiated and monitored in consultation with a GP or specialist to ensure safety, appropriateness, and ongoing review.  
  • Science & innovation:  The first priority is the development and implementation of clear, standardised diagnostic pathways to identify heavy menstrual bleeding as a clinical condition, followed by tools that support systematic evaluation of its underlying drivers. These may include structural abnormalities, ovulatory dysfunction, or haemostatic disorders. Improved diagnostics should enable accurate phenotyping, allowing treatments to be tailored to the dominant mechanism in a given individual, rather than relying on trial-and-error approaches. Over time, advances in biomarkers, imaging, and stratified care models may support more precise and less invasive management. 

Call To Action

To change how HMB is understood and addressed, we need collective commitment. Stakeholders – from funders and clinicians to patient groups and policy makers – must:

  1. Elevate lived experience, by sharing patient stories, amplifying real-world impact, and involving those affected in the design of services and educational materials.
  2. Strengthen clinical pathways, so that individuals with persistent or high-impact bleeding are appropriately assessed, investigated, and supported within existing healthcare systems.
  3. Reframe HMB as a significant health concern, rather than a benign or inevitable experience, to shift clinical, institutional, and public perceptions.
  4. Invest in research and innovation, including improved diagnostic tools, stratified care approaches, and targeted therapies that address underlying mechanisms.

Only by combining data, science, and social advocacy we will move toward a future where women no longer suffer silently through bleeding that undermines their health, dignity, and lives.

References

  1. Davies, J., & Kadir, R. A. (2017). Heavy menstrual bleeding: An update on management. Thrombosis Research, 151, S70–S77. https://doi.org/10.1016/s0049-3848(17)30072-5 
  2. Kiran, A., Geary, R. S., Gurol-Urganci, I., Cromwell, D. A., Bansi-Matharu, L., Shakespeare, J., Mahmood, T., & van der Meulen, J. (2018). Sociodemographic differences in symptom severity and duration among women referred to secondary care for menorrhagia in England and Wales: a cohort study from the National Heavy Menstrual Bleeding Audit. BMJ Open, 8(2), e018444. https://doi.org/10.1136/bmjopen-2017-018444
  3. The Painful Effects Of Heavy Periods | Fibroid Fighters. (2025, November 20). Fibroid Fighters. https://www.fibroidfighters.org/news/5862/
  4. Munro, C. B., Flanagan, M., Moussaoui, D., Kite, L., & Grover, S. R. (2024). Missing and dismissing the impact of periods. Outcomes of focus groups of teens with period concerns. Women’s Health, 20. https://doi.org/10.1177/17455057241303003
  5. Hapangama, D. K., & Bulmer, J. N. (2016). Pathophysiology of Heavy Menstrual Bleeding. Women’s Health, 12(1), 3–13. https://doi.org/10.2217/whe.15.81
  6. CDC. (2024, February 14). About von Willebrand Disease. Von Willebrand Disease (VWD). https://www.cdc.gov/von-willebrand/about/index.html
  7. Critchley, H. O. D., Babayev, E., Bulun, S. E., Clark, S., Garcia-Grau, I., Gregersen, P. K., Kilcoyne, A., Kim, J.-Y. J., Lavender, M., Marsh, E. E., Matteson, K. A., Maybin, J. A., Metz, C. N., Moreno, I., Silk, K., Sommer, M., Simon, C., Tariyal, R., Taylor, H. S., & Wagner, G. P. (2020). Menstruation: Science and society. American Journal of Obstetrics and Gynecology, 223(5), 624–664. https://doi.org/10.1016/j.ajog.2020.06.004
  8.  Akpan, I. J., Narang, M., Edio Zampaglione, Marshall, S., & Stefanik, D. (2025). Iron deficiency anemia in patients with heavy menstrual bleeding: The patients’ perspective from diagnosis to treatment. Women S Health, 21. https://doi.org/10.1177/17455057251321221
  9. Wattar, A., Ewelina Rogozińska, Nicholson, L., Fisher, D. J., Ekaterina Bordea, Niccola Hutchinson-Pascal, Moss, N., Hunter, R. M., Khan, K. S., Jurkovic, D., Tierney, J. F., & Vale, C. L. (2025). Treatment options for women with heavy menstrual bleeding: a protocol for comprehensive systematic review, network meta-analyses and health economic assessment. BMJ Open, 15(4), e085292–e085292. https://doi.org/10.1136/bmjopen-2024-085292

Post author

Written by