Heavy Menstrual Bleeding: When to Seek Medical Advice

Soaking three super-absorbent tampons per hour is not normal and meets criteria for heavy menstrual bleeding (HMB), defined as >80 mL blood loss per cycle or bleeding that interferes with quality of life.

Red Flags for Urgent Evaluation

• Soaking ≥1 pad/tampon per hour for >2 consecutive hours.
• Passing clots >1 inch (2.5 cm).
• Bleeding >7 days.
• Symptoms of anemia: fatigue, dyspnea, pallor, tachycardia.
• Bleeding between periods or after sex.

Common Causes

• Structural: Fibroids (submucosal), polyps, adenomyosis.
• Hormonal: Anovulation (PCOS, perimenopause), thyroid dysfunction, coagulopathy (von Willebrand).
• Iatrogenic: Copper IUD, anticoagulants, hormonal therapy.
• Malignancy: Endometrial hyperplasia/cancer (rare <40y, but possible).

Workup

• CBC, ferritin, TSH, coagulation screen (if indicated).
• Pelvic ultrasound (transvaginal preferred).
• Endometrial biopsy if >45y or risk factors (obesity, unopposed estrogen).

Management

• Medical: NSAIDs, tranexamic acid, combined OCP, progesterone (cyclic or IUD-LNG).
• Surgical: Polypectomy, myomectomy, endometrial ablation, hysterectomy (definitive).

Do not self-treat with excessive tampon use—toxic shock syndrome risk. Seek care promptly.