Heavy periods in your 40s: causes and options before surgery

Key takeaways

• Heavy bleeding is defined by its impact on your life, not by an exact amount of blood.
• In perimenopause, the most common reason is ovulatory dysfunction: cycles where you do not ovulate, so the lining builds up and sheds heavily.
• Every woman with heavy periods should have a blood count checked. Anaemia is very common in Indian women and worsens with heavy bleeding.
• NICE recommends the hormonal coil (levonorgestrel intrauterine system) as a first option for many women, with tablet treatments as alternatives.
• Bleeding between periods, after intercourse, or after menopause needs prompt assessment.

How do you know your periods are "heavy"?

So many Indian women have been told that heavy periods are normal and simply something to bear, "at this age". By their mothers, by their aunts, sometimes even by doctors. I don't accept that. NICE is clear that heavy menstrual bleeding is about its major impact on your quality of life, and treatment should aim to improve that.

The NHS describes signs of heavy periods as: - Changing pads every hour or two, or using two pads at once - Periods lasting longer than 7 days - Passing clots bigger than about 2.5 cm (roughly a ₹2 coin) - Leaking onto clothes or bedding, especially at night - Avoiding work, travel, temple visits or family functions because of your period - Often feeling tired or short of breath

My simple test: if you are planning your life around your period, it is heavy enough to be checked.

Why do periods get heavier in your 40s?

Cycles without ovulation. In perimenopause, some cycles do not release an egg. Without ovulation, the ovary makes little progesterone, so estrogen keeps building up the lining with nothing to balance it. I explain it like a wall where someone keeps adding plaster, layer after layer, and nobody tells them to stop. When it finally comes down, it comes down heavily. A review for gynaecology specialists describes ovulatory dysfunction as the most common cause of abnormal bleeding in perimenopause.

Structural causes. I also look for: - Fibroids, very common non-cancerous growths of the womb muscle. See Fibroids: your options before a hysterectomy - Polyps, small growths of the lining - Adenomyosis, where lining tissue grows into the womb muscle, often causing painful, heavy periods and a bulky womb

A thickened lining (endometrial hyperplasia). This becomes more of a concern with prolonged heavy bleeding, and with risk factors such as obesity, high blood pressure, diabetes, never having been pregnant, or estrogen exposure without a progestogen.

Other causes. Bleeding disorders, thyroid problems, some medicines such as blood thinners, and rarely womb cancer.

What tests are actually needed?

NICE advises against routinely testing female hormones for heavy bleeding, and against D&C alone as a test or treatment.

Why does anaemia matter so much?

The National Family Health Survey 5 found anaemia in about 57% of Indian women, up from 53% in the previous survey. Heavy periods make it worse month after month, like a slow leak in a tank that never gets fully refilled. Low haemoglobin and iron cause fatigue, breathlessness on the stairs, hair fall, poor concentration and palpitations, and all of these are easily mistaken for perimenopause itself.

Treating anaemia, with iron tablets or sometimes an iron infusion, often makes a clear difference to energy. Iron-rich Indian foods help too: green leafy vegetables, rajma, chana, til, jaggery in moderation, and eggs or meat if you eat them, with a source of vitamin C such as amla, lemon or guava to improve absorption.

What are the options before surgery?

NICE recommends the following, depending on your situation:

1. Hormonal coil (levonorgestrel intrauterine system). A small device placed in the womb that releases a progestogen locally. NICE suggests it as a first option for women with no structural cause, small fibroids under 3 cm that do not distort the cavity, or suspected adenomyosis. Bleeding may be irregular at first, and the benefit can take at least six cycles. It also provides contraception, and later can serve as the progestogen part of hormone therapy.

2. Non-hormonal tablets. Tranexamic acid, taken only on heavy days, reduces bleeding. Anti-inflammatory painkillers such as mefenamic acid also reduce flow and pain.

3. Hormonal tablets. Combined hormonal contraception or cyclical progestogen tablets can regulate and lighten periods, and help control irregular bleeding in perimenopause. These are prescription decisions after assessing your clot and other risks.

4. Endometrial ablation. A day procedure that destroys the womb lining to reduce or stop bleeding. It is suitable for women who have completed their family. Pregnancy afterwards is unlikely but not impossible, so contraception is still needed.

5. Treatment for fibroids or polyps. Polyps and some fibroids inside the cavity can be removed by hysteroscopy, often as a day procedure. Larger fibroids have their own options.

When is a hysterectomy considered?

Hysterectomy is a definitive answer and the right choice for some women. NICE advises that it should be discussed after other options, with a full conversation about effects on intimate and bladder function, recovery and alternatives. Removing healthy ovaries at the same time should only be done if you clearly wish it and give informed consent, because it causes immediate menopause.

There is also a time factor in your 40s. Periods will stop at menopause, which in Indian women comes at about 46 on average. The point is, for some women a treatment that controls bleeding for the remaining few years is all that is needed.

When should you seek help promptly?

• Bleeding between periods or after intercourse
• Bleeding after menopause, even a spot
• Soaking a pad in an hour for several hours, or feeling faint or breathless
• Heavy bleeding with new pelvic pain or pressure

How I approach this at Dr Tvacha

At Cocoon × Dr Tvacha in Thane West, I start with a long history, a blood count and, where indicated, a sonography, then explain every option from tablets to procedures before anything is decided. You get a written plan with fees and a review date. Read more about the Right Stop Programme on our women's health page, and see Perimenopause vs menopause.

Written by

Dr Anagha KarkhanisGynaecologist and Fertility Specialist · Reg. No. 2006/02/1187

Leads midlife women's health at Cocoon × Dr Tvacha, Thane.