Understanding Menstrual Flow: What’s Normal & When to Seek Help

Normal Menstrual Parameters

• Volume: 30–80 mL total per cycle (~2–3 tablespoons). "Heavy" = >80 mL or soaking a pad/tampon every 1–2 hours.
• Duration: 2–7 days.
• Frequency: Cycle length 21–35 days (day 1 = first day of bleeding).
• Clots: Small (<1 inch) occasionally normal; large/frequent clots suggest heavy flow.

Signs of Abnormally Heavy Bleeding (Menorrhagia)

• Soaking through ≥1 pad/tampon every 1–2 hours for several consecutive hours.
• Needing double protection (pad + tampon) or changing at night.
• Passing clots >1 inch (quarter size).
• Bleeding >7 days.
• Symptoms of anemia: fatigue, shortness of breath, pallor, dizziness.
• Disruption of daily activities (work, school, social).

When to See a Clinician

• Any of the above heavy bleeding criteria.
• Cycles <21 or >35 days consistently.
• Bleeding between periods or after sex.
• Sudden change in pattern.
• Postmenopausal bleeding (always evaluate).
• Trying to conceive with irregular cycles.

Common Causes of Heavy/Irregular Bleeding

• Anovulatory cycles (PCOS, perimenopause, thyroid)
• Uterine fibroids/polyps
• Adenomyosis
• Endometrial hyperplasia/cancer (rare but must exclude)
• Bleeding disorders (von Willebrand, platelet dysfunction)
• Medications (anticoagulants, hormonal contraceptives)
• IUD (copper IUD often increases flow)

Evaluation Typically Includes

• History, physical, CBC (anemia), TSH, pregnancy test.
• Pelvic ultrasound (transvaginal).
• Endometrial biopsy if >45 or risk factors.
• Hysteroscopy/sonohysterography for structural lesions.

Treatment Options

• NSAIDs (reduce flow 20–50%)
• Tranexamic acid (antifibrinolytic)
• Hormonal: combined OCP, progestin-only (pill, IUD, implant, injection)
• Procedural: endometrial ablation, myomectomy, hysterectomy (definitive).