My periods are heavy, painful, or both

“Heavy” has a measure. Soaking through a pad every hour, passing clots the size of a coin, bleeding for more than a week, or bleeding so much that your haemoglobin drops: any of those counts. “Painful” has a grade too. Pain that eases with an ordinary tablet and a hot water bottle is one thing. Pain that needs an injection, or that has you lying on the bathroom floor, is another, and it is the second kind that needs looking into.

Behind heavy bleeding there is often nothing structural at all: the balance of hormones across the cycle has shifted, the lining of the uterus grows thicker than it should, and it comes away in a flood. That is common in the teens, after childbirth, and in the years before menopause. The structural causes are fibroids, which are firm lumps of muscle in the wall of the uterus; polyps, which are small soft growths on the lining; and adenomyosis, in which the lining grows into the muscle wall and makes the whole uterus tender and heavy. A thyroid that is running slow, and less often a bleeding tendency, can do it too.

Pain that has come on in your late twenties or thirties, after years of easy periods, points towards endometriosis or adenomyosis more often than not. Pain since the very first period is more often the ordinary cramping of the uterus, which is real, and treatable, and not a sign of anything wrong with you.

The story. How many pads on the worst day, whether you flood, whether there are clots, how long it lasts, and how it has changed over the years. How the pain runs: when in the cycle it starts, where it sits, whether it comes with your bowels or with intercourse. Whether you are trying for a baby, or want to keep the option open, because the treatment is chosen around that.

Then an examination, and a scan of the uterus and the ovaries. The scan is what finds a fibroid, a polyp or an adenomyotic uterus, and it takes a few minutes. A blood test for haemoglobin, always, because a low count is the part of this that affects you every day and it is the easiest part to fix. A thyroid test where the story suggests it.

You leave knowing whether there is something in the uterus, what it is, and what will be tried first.

• Iron, if you are anaemic. Tablets for a few months, or an infusion where the count is very low or the tablets do not agree with you. This is treated on the first visit, not after the bleeding is sorted, because you should not have to wait to feel well.
• A tablet that reduces bleeding, taken only on the heavy days. Tranexamic acid cuts the flow for many women and does not touch your hormones or your fertility.
• Anti-inflammatory tablets for the pain, started the day before the period rather than when the pain has taken hold. Timing is most of the trick.
• Hormonal treatment. A pill, a cyclical progesterone, or a small device placed inside the uterus that releases a low dose of hormone for five years and makes most periods light or absent. The device is one of the most effective non-surgical treatments for heavy periods, and one that many women have never been told about.
• Watching a fibroid that is small and is not the cause of the symptoms. Many are found by chance and need nothing at all.

Surgery comes into it for a polyp, which is removed through the cervix in a short procedure; for a fibroid that is large, is in the cavity of the uterus, or has not responded to medicine; and for endometriosis where the pain has not settled with hormonal treatment. The page on cysts, fibroids and endometriosis says what each operation involves.

You are bleeding through a pad an hour. Come now, or go to an emergency department if it is night and you feel faint. Bleeding at that rate needs the haemoglobin checked today and a tablet that slows it, and it usually needs a scan the same week.

You have fainted, or you are breathless on the stairs. That is anaemia until proven otherwise. Come in for a blood test this week; iron started now makes a difference within a month, and the bleeding is treated alongside.

The pain started in your thirties, after years of easy periods. Do not accept “that is just periods”. A change like that is the commonest way endometriosis and adenomyosis announce themselves, and both are easier to treat when they are found early.

• Bleeding through a pad every hour for more than two hours
• Fainting, dizziness on standing, or breathlessness
• Bleeding between periods, or after intercourse
• Any bleeding after a year without periods
• Pain that needs an injection, or that has you missing work every month
• Trying to conceive with heavy or painful periods, at any age

A polyp is removed with a hysteroscope, a thin telescope passed through the cervix, as a short procedure with no cut. A fibroid inside the cavity is removed the same way; one in the wall, when it needs removing, is taken out by laparoscopy through small cuts, with the uterus kept. Endometriosis that has not settled with medicine is treated by laparoscopy too. Removing the uterus is an answer for a few women who have finished their families and for whom nothing else has worked, and it is never the first suggestion. You are told who will do it and where, before anything is booked.