В previous article, we delved into how heavy periods are defined, as well as how various diet and lifestyle issues, as well as some drugs and contraceptive medications and devices, can contribute to heavy menstrual bleeding (HMB). However, many cases of HMB are linked to underlying uterine or systemic conditions. In this article, we will discuss the diagnosis and treatment of the underlying medical conditions that often cause HMB.
Improving diagnosis of HMB
To improve the diagnosis of HMB, in 2011, the International Federation of Gynecology and Obstetrics (FIGO) created a standardized classification system for abnormal uterine bleeding (AUB). FIGO System 1 describes bleeding patterns using four primary descriptors: frequency, duration, regularity, and flow volume. FIGO System 2 classifies possible causes of AUB using the acronym PALM-COEIN [1].
- PALM: structural causes (Polyp, Adenomyosis, Leiomyoma, Malignancy)
- COEI: nonstructural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic)
- N: not yet classified
Structural causes of HMB (PALM)
- Polyp (P): Small overgrowths of endometrial tissue. While often asymptomatic, they can cause irregular or heavy bleeding, particularly in women over 40. A 1988 study found that 28% of women with abnormal uterine bleeding had endometrial polyps, most commonly between ages 40 and 50 [2].
- Adenomyosis (A): Endometrial tissue invading the muscular wall of the uterus. HMB is the most common symptom of adenomyosis, although roughly one-third of women with the condition may have no symptoms. The exact mechanism behind adenomyosis isn’t fully understood, but impaired uterine contractility is thought to play a role [2].
- Leiomyoma (L) / Fibroids: Non-cancerous tumors that grow in the muscular wall of the uterus. A 2016 study found that 46% of women with fibroids experienced excessive bleeding, compared to 28% of those without. Fibroids are especially common in black women, and all women in their 40s and perimenopausal years, when progesterone levels drop and estrogen dominates [2].
- Malignancy and hyperplasia (M): Although less common, cancers of the uterus или шейка матки can cause abnormal or heavy bleeding [2].
Non-structural causes of HMB (COEIN)
- Coagulopathy (C): Blood clotting issues, such as von Willebrand disease, can prevent the body from properly stopping menstrual bleeding. Some estimates suggest that up to 13% of women with menorrhagia have an undiagnosed bleeding disorder [3].
- Ovulatory dysfunction (O): Common in conditions like синдром поликистозных яичников (PCOS), where infrequent ovulation leads to prolonged estrogen exposure without progesterone. This causes excessive endometrial buildup and heavier bleeding. Elevated androgens in some types of PCOS are converted into estrone, a potent form of estrogen that further thickens the lining [2].
- Endometrial (E): Inflammation or infection of the uterine lining (endometritis) can cause irregular, prolonged, or heavy bleeding [2].
- Iatrogenic (I): Certain medications—such as blood thinners, tamoxifen, and some forms of hormonal contraception—can trigger or worsen heavy bleeding.
- Not otherwise classified (N): Includes causes still being researched, such as the interplay between gut microbiome health and abnormal bleeding patterns.
How are heavy periods diagnosed and treated?
Treatment of HMB varies depending on the cause. Working with a doctor trained in Восстановительная репродуктивная медицина (RRM) can help ensure root-cause treatment for your heavy periods. This may include lifestyle and nutrition changes to support hormone balance, targeted hormonal therapies like bioidentical progesterone, surgical interventions such as fibroid removal or polyp excision, and microbiome and liver support to optimize estrogen metabolism.
Treatment of HMB varies depending on the cause. Working with a doctor trained in Restorative Reproductive Medicine (RRM) can help ensure root-cause treatment for your heavy periods. This may include lifestyle and nutrition changes to support hormone balance, targeted hormonal therapies like bioidentical progesterone, surgical interventions such as fibroid removal or polyp excision, and microbiome and liver support to optimize estrogen metabolism.
The best first step in diagnosis is using a Метод информирования о бесплодии (FAM), which helps detect cycle patterns and can speed the journey to diagnosis through hormone testing (estrogen, progesterone, thyroid, insulin), pelvic ultrasound (to evaluate fibroids, polyps, or adenomyosis), endometrial biopsy (to assess for abnormal or precancerous cells), and blood work (to check for anemia, infection, or clotting issues).
What we still don’t know about heavy menstrual bleeding
Despite progress, many questions remain—such as the exact trigger for endometrial shedding, why similar hormone profiles can yield vastly different symptoms, and how gut health, immunity, and environmental exposures interact to drive abnormal bleeding. More research is needed into treatments that address root hormonal imbalances rather than simply suppressing symptoms.
Resources to help you on the path towards healing from heavy periods
If you’re struggling with heavy menstrual bleeding and are looking for answers, Natural Womanhood has a variety of free resources to help you start on the path towards healing today.
- Consider booking a free 20-minute phone call with one of Natural Womanhood’s experienced fertility awareness instructors.
- Fill our our Контрольный список симптомов цикла to bring to your doctor to help get to the root cause of your heavy periods.
- If you’re new to the world of fertility awareness and want to harness the power of your “fifth vital sign” in addressing the root cause of heavy periods and other cycle-related issues, use this guide to choose a FAM and start learning today.
- Looking for a doctor who can utilize your menstrual cycle charts in diagnosing and treating your heavy periods (without birth control?). Нажмите здесь.
The bottom line on heavy menstrual bleeding
Considering that a woman will have, on average, 400 repetitive cycles of menstrual bleeding during her lifetime, heavy bleeding can be a real disturbance to her well-being throughout her reproductive life. As research has developed a more robust understanding of what causes nearly 30% of women to experience heavy menstrual bleeding, it is important for women to feel equipped to not let this experience go unaddressed.
Heavy periods can come from a wide range of causes, and these can be hormonal, metabolic, or structural in nature (or some combination thereof). From estrogen dominance, stress, and insulin resistance, to uterine fibroids, PCOS, and thyroid dysfunction—and even external factors like copper IUDs and gut microbiome disruption—addressing the root cause(s) of your heavy period is critical to your overall health and well-being as a woman. Furthermore, understanding the root cause can empower you to seek treatment that supports your health and honors the natural design of your body.
