'It's not just an inconvenience': We've underestimated the health impacts of heavy periods

Heavy menstrual bleeding is a serious health condition. Only now are we starting to understand what causes it – and how it can be treated.

From the age of 12-13 onwards, Michelle Alston slept off the worst days of her menstrual periods in the school nurse's office, battling severe pain as she bled through period products. "I was taught that this is just normal," she says. "This is just something that you have to learn to cope with."

She felt weak, failing to cope with her periods as well as her peers seemed to. It wasn’t until she reached her early 40s that she learned weakness had little to do with it – her periods were unusually heavy. When bleeding during periods is so extensive that it interferes with quality of life, doctors call it heavy menstrual bleeding, and it's a serious medical problem. 

Studies of populations from around the world estimate that between 10 and 30% of reproductive-aged women experience heavy menstrual bleeding like Alston's. And due to under-reporting and a general lack of understanding of how much bleeding is too much, studies suggest it may actually occur in half of all reproductive-aged women. Heavy menstrual bleeding can also signify other health problems and have serious consequences when unchecked, such as anaemia.

Yet, only recently have researchers began exploring the resulting harms from heavy menstrual bleeding in depth, pursuing better diagnostics and treatments. A search of PubMed (a database of biomedical research publications) for the term "menstrual blood" yielded just 400 publications in the last decade. Publications for "semen", for instance, number over 15,000.

"Women are probably owed years, if not decades, of research," says Jackie Maybin, a gynaecologist at the University of Edinburgh in Scotland and programme director of The Missed Vital Sign, a research initiative for heavy menstrual bleeding. "And I think the time is now."

How much blood is too much?

For researchers, heavy menstrual bleeding is blood loss of over 80ml per cycle, blood clots exceeding the size of a US quarter, or periods lasting beyond seven days. But for those of us who menstruate, there's no standardised or metric conversion for the practical ways of measuring bleeding: the number of bathroom visits, pads or tampons changed, or bloodstained pairs of underwear.

Some clinicians try to meet patients halfway, asking them to judge their blood loss using charts featuring progressively bloodier pads and tampons. But that too is imprecise, as all period products aren't created equal and often vary widely in absorption.

As a result, determining how much blood is too much during a period isn't straightforward, and often clinicians have to determine heavy menstrual bleeding by whether it interferes with quality of life.

"The patient sometimes doesn't realise that the amount of bleeding they're having is not normal, and that actually, something can be done about it," says Adwoa Christy, a clinical professor in the department of gynaecology, obstetrics, and reproductive sciences at the University of California, San Francisco.

Alston routinely bled through her sheets and clothes, and once, onto an unforgivingly white chair at a cell phone store. She just thought she was doing something wrong, and maybe that she needed different period products to contain the flow.     

She was told to accept that experiencing painful cramps and embarrassing bloodstains while on your period is normal. In other regions of the world, period taboos and stigma run deeper.

"I think there are a lot of people in my part of the world who may not complain about it, and who, maybe because of normalisation [of pain] and stigma, don't actually come to a doctor," says Hemantha Senanayake, emeritus professor of obstetrics and gynaecology at the University of Colombo in Sri Lanka and head of the Asian Society of Endometriosis and Adenomyosis (both conditions that can cause heavy menstrual bleeding).    

And while gynaecologists may know to ask detailed questions to detect heavy menstrual bleeding, clinicians outside the field may overlook the signs. Alston waited nearly 30 years before someone identified her heavy menstrual bleeding, and she's far from alone.

Heavy menstrual bleeding is not just a symptom

While a problem in its own right, heavy menstrual bleeding is primarily a symptom of a larger issue. It arises from a variety of conditions, including polyps, fibroids, cancer, blood disorders, ovulatory issues, and endometrial disorders, such as endometriosis. It is also common – though still something to address – when someone first starts having periods and during the transition to menopause, when the body’s hormonal choreography is in a period of transition.    

Treating these conditions can lessen the heavy bleeding, but scientists still don't know how these conditions interfere with the quantity of blood loss, exactly. "There's been a........

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