Every woman’s menstrual cycle is unique. Not all women experience heavy flow or pain, but many do. Amongst the population of women dealing with heavy, painful bleeding, there are a lot of questions about how to know what may be normal for them, and what is not.

It is true that symptoms experienced during a menstrual cycle can vary greatly from person to person and “normal” can mean a variety of things depending on the individual. However, there are thresholds regarding the amount of flow and/or pain a woman experience before it is considered abnormal.

Here are some guidelines to follow that will help you know when to report heavy bleeding or painful periods to your healthcare provider:

  • Bleeding that is heavy enough to saturate more than 1 pad in 1-2 hours
  • Leaking through a heavy flow/ultra-tampon
  • Sleeping with extra padding/towels to protect your bedding from leaking; or using the same for the seats in your car during commutes
  • Passing blood clots
  • Feeling fatigued or weak during your heavy flow days

Heavy bleeding and painful bleeding do not always go hand in hand, but it is common that a heavy flow is also painful. While some uterine cramping, bloating or other discomforts may be considered normal, there are also guidelines one should follow to determine if the pain associated with the menstrual cycle deserves the attention of a healthcare provider:

  • Pain unrelieved by medication like Advil or Ibuprofen
  • Pain that causes you to be absent from school, work, or social activities
  • Pain that leads to nausea or vomiting, chills/shakes

What Can Cause Painful Periods?

Heavy menstrual flow or a painful menstrual flow that meets the criteria previously discussed deserves the attention of a medical professional. The cause of the heavy and/or painful bleeding should be investigated so that treatment options are discussed, and a plan put into place to provide relief of these uncomfortable symptoms. Not only is it important to feel better, but it is also important to prevent more serious complications related to these menstrual abnormalities.

There are some common conditions that can be the cause of heavy bleeding that are worth understanding as you prepare to discuss this with your doctor.

Uterine fibroids

A fibroid is a tumor that can grow inside the uterine cavity, or within the uterine muscle. The tumor is most always benign but can apply pressure to the pelvis, increasing blood flow and menstrual pain. Sometimes fibroid tumors can begin to shed or slough which can increase menstrual flow and/or cause clots to pass.

Uncomfortable symptoms caused by fibroid tumors range from mild to severe depending on the size and number of the tumors. Fibroids are detected by ultrasound, which a gynecologist can perform. There are procedures and medications that can remove fibroid tumors or decrease their size. Fibroids can interfere with the ability to carry a healthy pregnancy and the associated heavy bleeding can cause anemia or low iron levels and for these reasons, it is important to assess for fibroids and treat accordingly.


Endometriosis is a condition that is classified as the growth of tissue similar to the lining of the uterus outside of the uterus. It can be found on or around the bowels, bladder, ovaries, and other internal organs.

The presence of this tissue leads to very painful menstrual cycles with or without heavy flow. The gold standard for diagnosing endometriosis involves a minor surgical procedure and the same procedure will allow for endometriosis to be removed. Other medical therapies should be utilized after a diagnosis is obtained to limit the effects of endometriosis on the reproductive system, especially if fertility preservation is desired.

Hormonal imbalances

Estrogen instabilities or severe fluctuations in estrogen levels can cause the uterine lining to grow in excess. Conditions like PCOS (polycystic ovarian syndrome) and perimenopause are common causes of the uterine lining becoming more thick, or not shedding monthly and when bleeding does occur, it can be very heavy, include large clots or last much longer than a normal 5-7 day menstrual period. These types of conditions can be diagnosed with lab tests and pelvic ultrasounds. When the uterine lining does not shed regularly and begins to grow abnormally thick, risk of uterine cancer is increased. Prolonged, heavy bleeding poses a risk for severe anemia (low iron) leading to severe fatigue and risk of requiring a blood transfusion.

Treatment of Heavy Bleeding and Painful Periods

When monthly menstrual cycles are heavy and painful, the muscles and nerves of the pelvis are also impacted and can become tense and inflamed. This often leads to pelvic pain becoming chronic or constant, even when it’s not time for a period.

If you’ve been diagnosed with a condition that causes heavy, painful menstrual bleeding, the providers at Pelvic Rehabilitation Medicine can assess and treat the subsequent pelvic pain you’re experiencing. A problematic period should never be deemed “normal”, it is in fact a quality-of-life issue that deserves attention and solutions.

Image of what to expect after 3 months of treatment.