Fibroids & Heavy Bleeding: Understanding Your Options

Heavy periods are among the most common reasons women come to see me, and yet so many have been enduring them for years — sometimes decades — before seeking help. I hear it in clinic regularly: “I thought it was just part of being a woman.” It is not. Periods that disrupt your work, your social life, your sleep, your relationships, and your sense of self are not something you should simply accept. They are a medical symptom, and they deserve thorough investigation and proper treatment.

In my practice, I see women who have been flooding through clothing in important meetings, cancelling plans because of unpredictable heavy days, and quietly managing anaemia for years. All of this is addressable. The first step is understanding what is causing it.

What constitutes heavy menstrual bleeding?

Clinically, heavy menstrual bleeding (HMB) is defined as blood loss exceeding 80ml per cycle. In practice, most women cannot measure this precisely, and NICE guidelines recognise that the definition should be patient-centred: if your periods are heavy enough to interfere with your physical, social, emotional, or material quality of life, they warrant assessment.

Practically, I ask about: flooding through pads or tampons, the need to use double protection (pad and tampon simultaneously), passing clots larger than a 50-pence piece, periods lasting more than seven days, and symptoms of iron deficiency anaemia — the profound tiredness, pallor, and breathlessness that chronic blood loss produces. These functional impacts matter as much as any number.

Causes beyond fibroids

Fibroids are the most common structural cause of heavy periods, but they are far from the only one. A thorough investigation must consider the full range of possibilities:

• Adenomyosis: The presence of endometrial-like tissue within the muscular wall of the uterus, which causes the uterus to become enlarged and boggy, producing both heavy and painful periods. Adenomyosis and fibroids frequently coexist
• Endometrial polyps: Benign growths within the uterine cavity that can cause heavy or irregular bleeding and are readily diagnosed on ultrasound
• Hormonal imbalance: Anovulatory cycles (cycles in which ovulation does not occur) result in unopposed oestrogen stimulation of the endometrium, leading to heavy, irregular, or prolonged bleeding. This is common in perimenopause and in PCOS
• Thyroid disorders: Both hypothyroidism and, less commonly, hyperthyroidism can disrupt menstrual regularity and flow; thyroid function is part of my standard investigation panel
• Clotting disorders: Von Willebrand disease is present in approximately 1% of women and is significantly under-diagnosed; it is particularly worth considering in women with heavy periods since adolescence
• Endometrial pathology: In women over 40, or those with risk factors, endometrial biopsy may be indicated to exclude hyperplasia or, rarely, malignancy

What are uterine fibroids?

Uterine fibroids (also called leiomyomas or myomas) are benign — non-cancerous — tumours arising from the smooth muscle of the uterine wall. They are extraordinarily common: by the age of 50, around 70% of women will have at least one fibroid. The majority are completely asymptomatic and require no treatment whatsoever. However, when fibroids do cause symptoms, they can be profoundly disruptive.

Fibroids are classified by their location within or around the uterus:

• Submucosal: Growing into the uterine cavity; even a small submucosal fibroid can cause heavy bleeding and has the greatest impact on fertility. These are the most clinically significant for bleeding symptoms
• Intramural: Located within the muscular wall of the uterus; the most common type. Large intramural fibroids can cause heaviness, pelvic pressure, and bulk symptoms
• Subserosal: Growing outward from the outer surface of the uterus; these tend to cause bulk symptoms — pressure, urinary frequency, constipation — rather than heavy bleeding
• Pedunculated: Attached to the uterus by a stalk, either into the cavity (submucosal pedunculated) or outside (subserosal pedunculated)

It is important to note that fibroids are significantly more common in Black women, who are also more likely to develop them at a younger age and to have larger or more numerous fibroids. This disparity is under-researched and under-acknowledged, and I am mindful of it in my practice.

Symptoms fibroids can cause

When fibroids are symptomatic, the most common presentations I see include:

• Heavy and prolonged menstrual bleeding, often with clots
• Pelvic pain or pressure, particularly with larger fibroids
• Urinary frequency or urgency, caused by fibroids pressing on the bladder
• Constipation or a sensation of rectal pressure from posterior fibroids
• A feeling of pelvic fullness or a visibly enlarged abdomen
• Impact on fertility: submucosal fibroids in particular can interfere with implantation and increase miscarriage risk
• Iron deficiency anaemia, with its associated fatigue, breathlessness, and reduced concentration

How I investigate heavy bleeding

A thorough investigation is the foundation of good management. In my practice, I approach this systematically:

• Blood tests: Full blood count (FBC) to assess for anaemia, ferritin to evaluate iron stores, thyroid function, clotting screen if indicated, and hormonal profile where relevant
• Pelvic ultrasound: The primary imaging investigation for assessing uterine size, fibroid number, size and location, endometrial thickness, and ovarian appearance. I perform transvaginal ultrasound in clinic, which provides the best resolution for uterine and endometrial assessment
• Endometrial biopsy: Recommended for women over 45 with heavy bleeding, or younger women with risk factors for endometrial hyperplasia, to exclude endometrial pathology
• Sonohysterography (SIS): Saline infusion sonohysterography, in which a small amount of saline is introduced into the uterine cavity during ultrasound, provides excellent visualisation of the cavity and can identify submucosal fibroids or polyps that may not be clearly seen on standard ultrasound

Medical management

Many women with heavy bleeding and even significant fibroids can be very well managed with medical treatment, avoiding or deferring surgery entirely.

• Tranexamic acid: An antifibrinolytic agent taken during menstruation only, which reduces blood loss by up to 50% in most women. It has no hormonal activity and is suitable for those who cannot or do not wish to use hormones
• NSAIDs (mefenamic acid, ibuprofen): Reduce both pain and blood loss; useful alongside other treatments
• Combined oral contraceptive pill: Regulates the cycle, reduces bleeding, and can be taken continuously to suppress periods altogether
• Progestogen-only treatments: Including oral norethisterone for acute or heavy breakthrough bleeding
• Mirena IUS (levonorgestrel intrauterine system): This is often my preferred first-line hormonal treatment for heavy bleeding — it reduces menstrual blood loss by up to 90% in most women, and many experience very light periods or none at all. It is licensed by NICE specifically for heavy menstrual bleeding and is highly effective even in the presence of small-to-moderate fibroids
• GnRH analogues (e.g. leuprorelin, goserelin): These medications temporarily suppress oestrogen production, shrinking fibroids and stopping periods. They are generally used short-term — for three to six months — as a bridge to surgery or to improve anaemia before an operation, as prolonged use causes bone density loss

Surgical options (referral)

When medical management is insufficient, or when the anatomy or clinical picture makes surgical treatment the better option, I will refer you to an appropriate surgical colleague with a full discussion of what each procedure involves:

• Endometrial ablation: A procedure to destroy the lining of the uterus, significantly reducing or stopping periods. Suitable for women who do not wish to conceive. Very effective for heavy bleeding without large fibroids
• Hysteroscopic fibroid resection: Minimally invasive removal of submucosal fibroids from within the uterine cavity using a hysteroscope. Excellent for targeted treatment of fibroids causing heavy bleeding, with rapid recovery
• Myomectomy: Surgical removal of fibroids while preserving the uterus; can be performed laparoscopically, hysteroscopically, or by open surgery depending on the number, size, and location of fibroids. The preferred option for women wishing to retain fertility
• Uterine artery embolisation (UAE): A radiological procedure in which the blood supply to fibroids is blocked, causing them to shrink. Performed by an interventional radiologist; suitable for women who wish to avoid surgery and do not plan to conceive
• Hysterectomy: Removal of the uterus; the only definitive cure for both fibroids and heavy menstrual bleeding. Modern laparoscopic techniques have transformed recovery. This remains an important and life-changing option for women who have completed their families and whose symptoms are severely affecting quality of life

When to seek specialist input

1. Your periods have become progressively heavier over recent cycles
2. You are regularly passing clots or flooding through protection
3. You are experiencing symptoms of anaemia: persistent tiredness, breathlessness, pallor, or difficulty concentrating
4. Your periods are affecting your ability to work, socialise, or exercise
5. You have been told you have fibroids and are unsure whether they require treatment
6. You are trying to conceive and have been told you have fibroids
7. You have irregular or unpredictable bleeding in addition to heavy flow
8. You have tried over-the-counter treatments without adequate relief

Heavy periods are not a sentence. There is a great deal that can be done, and the right starting point is a thorough specialist assessment. I am here to help you understand what is happening in your body, to investigate it properly, and to find an approach that works for your life.