Heavy bleeding in perimenopause: when is it really too much?

'I bleed a lot' is too vague to be taken seriously, so let's get specific. Bleeding counts as heavy the moment it interferes with your physical, social or emotional quality of life, not from a set volume ^[1]. In other words, if your period runs your days, it counts.

You're probably bleeding too much if you recognise yourself here:

• You soak through a pad or tampon in an hour or less.
• You have to double up (pad plus tampon) to feel safe.
• You pass clots bigger than a 2-euro coin.
• You wake in the night to change, or wake to leaks.
• You plan outings, clothes and meetings around your flow.

For context, a normal period sheds 30 to 40 ml across the whole cycle, versus over 80 ml when it's objectively heavy ^[9]. Up to 1 in 4 women bleed this much in perimenopause, and around 9 in 10 notice a change in their pattern ^[1][6]. You're not the only one. Doubling up helps in the moment but hides how much you're really losing: it's a sign you need real treatment, not bigger products ^[5].

If your periods used to be regular and turned erratic, there's a biological reason, and it's not your fault. Picture your womb lining as a wall that builds each month, then sheds. After ovulation, your body makes progesterone, the hormone that acts as a brake and triggers a clean shed ^[1].

As menopause approaches, your ovaries stop releasing an egg every month: these are anovulatory cycles ^[7]. No ovulation means no progesterone, but estrogen keeps thickening the lining. The brake is gone, the wall builds too high. When it finally sheds, it comes away as a heavy, unpredictable bleed ^[7].

This is why 'it's your age, put up with it' is the wrong answer. The change is common, but flooding and soaking through hourly are never something to simply endure ^[1]. A bleed that clearly worsens deserves a scan (an ultrasound image of your womb) to rule out a structural cause like a fibroid or polyp ^[5].

Exhausted, breathless on the stairs, losing your words, foggy-headed, more hair falling out? Before blaming stress or age, think about iron. Every heavy period drains iron, the raw material for the red blood cells that carry oxygen around your body ^[8].

Here's the trap. Think of ferritin (your iron stores, measured with a blood test) as a savings account: it empties first, often before a standard blood count looks abnormal ^[8]. So you can be running dry and exhausted while a basic test still reads 'normal'.

That's why it's worth asking specifically for a ferritin test, not just a standard count. If it's low, iron supplements often fix it, something to discuss with your doctor ^[8]. But treating the deficiency without turning the flow down is like emptying a bath with the tap still open: the two go together.

Good news: this is one of the most treatable problems in menopause. Two medicines work only on your heaviest days, without touching your cycle.

• Tranexamic acid (Exacyl): it stops your protective clots dissolving too fast and cuts blood loss by 40 to 50% ^[2]. No hormones, taken only on heavy days.
• Anti-inflammatories (ibuprofen, mefenamic acid): they lower prostaglandins, reduce flow by 20 to 40% and ease cramps at the same time ^[4].

These anti-inflammatories need care if you have certain stomach, kidney or cardiovascular problems: your doctor confirms whether they fit you ^[4].

For the long game, the levonorgestrel coil (Mirena) releases a small dose of hormone straight into the womb and keeps the lining very thin. Less lining means far less blood: flow can drop by up to 95% over a year ^[1][3]. It's a first-line treatment for heavy bleeding, not just contraception ^[1][3].

If your family is complete and medicines aren't enough, endometrial ablation (removing the lining in a minimally invasive procedure) greatly reduces bleeding ^[1]. About half of women who bleed heavily delay care or aren't offered these treatments ^[10]: arriving with these names changes the conversation.