What are the treatment options for heavy periods?

Hormonal contraceptives like birth control pills or hormonal coils (IUDs) affect the menstrual cycle and lessen the amount of bleeding. If one of these doesn't help, it is usually possible to try out another one that is used in a different way or has a different active ingredient in it. Sometimes surgery can help.

The treatment options will also depend on whether you would like to have children in the future. The most effective treatments all limit a woman's ability to get pregnant – either temporarily, like the pill and hormonal coil, or permanently, like surgery to remove the womb (hysterectomy).

As long as heavy periods aren’t causing anemia, they don’t necessarily have to be treated. Over time, women often find ways to be as prepared as possible for “heavier” days. Some manage well that way. But it’s still a good idea to see a doctor and try to find out why your periods are so heavy.

Painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs), like ibuprofen and diclofenac, are often used for the relief of period pain and cramps, and also for heavy periods. They not only reduce the pain, but can also lessen the bleeding somewhat. Acetylsalicylic acid (ASA, the drug in medicines like Aspirin) is not suitable for heavy periods because it reduces blood clotting so it can make you bleed more during your period.

The most common side effects of NSAIDs are stomach problems and nausea. In studies on women with heavy periods, those who took NSAIDs didn't experience many more side effects than those who took a placebo (fake medicine) instead.

Another medication that can help in the treatment of heavy periods is tranexamic acid. This medication affects blood clotting, reducing the tendency to bleed. You take it three times a day during your period, in the form of a tablet – but only for four days at the most. Tranexamic acid may cause headaches, tiredness and muscle cramps. It also increases the risk of thrombosis, especially if you're on the birth control pill too.

If you have heavy periods and feel very tired, you might have iron deficiency anemia. This is normally treated by taking iron tablets. Iron supplements may have side effects such as stomach ache and constipation, and can cause your stool to turn black.

The menstrual cycle is influenced by various hormones: The female sex hormone estrogen causes an egg to mature in the ovaries each month. The hormone progesterone helps the lining of the womb to prepare for a possible pregnancy. Hormonal contraceptives interfere with these processes and can reduce menstrual bleeding that way.

Heavy periods can be treated with tablets that contain progesterone. This hormone inhibits the growth of the lining of the womb before your period starts, which lessens the bleeding during your period.

Progesterone tablets are taken on 14 to 25 days per menstrual cycle. Research has shown that they are most effective if you take them on more days per month (20 to 25 days). You get your period during the monthly pill break. Possible side effects include weight gain, nausea, headaches and a lack of sexual desire.

Birth control pills ("the pill") contain either a combination of estrogen and progestin (combination pill), or only progestin (mini-pill). Progestin is a synthetic version of progesterone. Birth control pills are typically used as contraceptives. In Germany, public (statutory) health insurers then only cover the costs of the pill for women under the age of 22.

Many women who have heavy periods decide to use the mini-pill. This low-dose progestin pill is taken on every day of the month without any breaks. As a result, your periods usually become irregular or you might even stop getting them altogether.

Most combination pills are taken once a day on 21 days of the month. This is followed by a 7-day break, when you usually get a period. It is also possible to take the pill continuously on every day of the month, without a break. Then you usually stop getting your period completely after a while, and only have light spotting at the most. But most combination pills haven't yet been approved for continuous use in Germany. Your doctor must tell you about that, including the possible consequences and risks of using the pill in this way.

Side effects of the pill may include headaches, nausea, breast tenderness and mood swings. There is also an increased risk of blood clots (thrombosis), especially when taking the combination pill. Because of this, women who have a greater risk of thrombosis (for example, smokers) are advised not to take it.

The hormonal coil is placed inside the womb and can be left there for 3 to 8 years, depending on the specific type. It prevents pregnancy by releasing a continuous amount of a progestin called levonorgestrel. Research has shown that progestin-releasing coils can reduce blood loss and related problems during menstruation.

The most common side effects of hormonal coils are acne, headaches, spotting (especially at first), mood swings and breast tenderness. But these side effects are more likely to occur when using the mini-pill. Hormonal coils may also cause benign cysts to grow on the ovaries. These usually go away on their own within one year, though. In about 5 out of 100 women who get the coil fitted, it moves out of place or comes out. Then they need to see the doctor again.

Having the coil fitted can be painful, but you can take painkillers beforehand. The doctor also uses a local anesthetic to numb the area during the procedure.

If the coil has been prescribed to treat heavy periods rather than for use as a contraceptive, public health insurers usually cover the costs in Germany.

According to scientific research comparing the various medications and hormonal treatments, hormonal coils are the most effective at reducing bleeding and the related problems. The second most effective of these treatments is tranexamic acid.

Progesterone tablets and NSAID painkillers can also lessen menstrual bleeding somewhat, but they're less effective than the hormonal coil or tranexamic acid. Progesterone tablets work a little better than NSAIDs do.

There is no good research on the effect of the birth control pill on heavy periods, so it's not clear how well the pill works here.

Surgery may be necessary if benign growths in or on the wall of the womb (fibroids or polyps) are causing heavy periods. Doctors can remove fibroids through the vagina or a cut in the abdominal wall. This operation is called myomectomy or fibroidectomy. The womb is not removed during this procedure, so you can usually still get pregnant afterwards.

The exact surgery approach will depend on the number, location and size of the fibroids. Sometimes you can go home on the day of the surgery, but you might need to stay in the hospital for one to three days.

Most women who have had fibroid-related problems for a long time notice a major improvement after surgery, or no longer have any symptoms at all. Research shows that about 90 out of 100 women are still satisfied with the surgery results one to two years later. In up to 25 out of 100 women, though, fibroids grow again within the first few years after the procedure.

Surgery to remove fibroids can lead to various complications: In about 5 out of 100 women, nearby organs or blood vessels in the abdomen are damaged, or a further operation is needed. The wall of the womb might be injured too. Temporary problems like a fever or infected wound are possible. In the long term, scarring and adhesions (where tissue sticks together) can lead to things like bowel problems or pain in your lower belly. In very rare cases, the procedure causes bleeding that can't be stopped and then the womb has to be removed (hysterectomy).

If the heavy periods aren't caused by fibroids or polyps in the womb, there are two other surgical options:

One possible treatment for heavy periods involves removing the lining of the womb (the endometrium). Here the tissue is either removed using surgical instruments (endometrial resection) or destroyed, for instance using things like extreme cold, heat or other kinds of energy (endometrial ablation). Both of these are done through the vagina. There may be period-like bleeding and pain for one to two weeks after this procedure. After that, the woman often stops having periods, or her periods are much lighter. You are unlikely to become pregnant if you have this procedure. If you do get pregnant, there is a high risk of miscarriage or preterm birth.

According to research, 89 out of 100 women who have surgery to remove or destroy the lining of their womb say that their periods are lighter afterwards. But the lining of the womb can grow back. If heavy periods start again as a result, the procedure can be repeated. About 20 out of 100 women have this kind of surgery again within two years.

Endometrial ablation or resection treatment is generally done as an outpatient procedure (you can go home on the same day). You then recover quite quickly afterwards. The procedure is associated with the usual surgery-related risks, such as infections or wound-healing problems. The wall of the womb might be injured, too.

If your periods are very heavy and distressing, and previous treatments weren't successful, your doctor may suggest a hysterectomy (surgery to remove your womb). This can either be done through your vagina or through a cut in your abdominal wall. You will usually have to stay overnight in the hospital for a short time afterwards.

Women who have a hysterectomy no longer have periods or the related problems. They can no longer get pregnant, either. But the balance of hormones in their body doesn't change because their ovaries are nearly always left intact.

Removing the womb is quite a major operation. In about 5 out of 100 women, nearby organs or blood vessels are injured during the procedure. It is also associated with the usual surgery-related risks, such as infections or wound-healing problems. As well as physical effects like pain during sex, it can have emotional repercussions too: Some women feel that by losing their womb they have also lost an important part of being a woman.

A comparison of these two options shows that removing the womb completely (hysterectomy) is the more effective treatment for heavy periods. But it is also a more major operation, and is more likely to lead to complications than endometrial ablation or resection are. What's more, many women feel strongly about wanting to keep their womb. Research found that surgery led to an infection or a fever, or the need for a blood transfusion, in

• 32 out of 100 women who had a hysterectomy, and
• 6 out of 100 women who had surgery to remove the lining of their womb.

Most of these complications were temporary, though, and didn't have any long-lasting effects.

The research also showed that women who had a hysterectomy often felt that their health had improved more over the long term and also experienced less pain than women who had surgery to remove the lining of their womb. But women who had a hysterectomy also had more emotional problems afterwards. Regardless of which type of surgery they had, most women were satisfied with the outcome.