Heavy periods (“menorrhagia,” “hypermenorrhea”) and lengthy periods may reflect an underlying mechanical abnormality inside the uterus (fibroids, polyps), may be a cause of iron-deficiency anemia, may contribute to uncomfortable menstrual cramps.

If the examination, Pap smear, and pregnancy test are normal, then the chance of malignancy is very low and need not be further considered in those under age 40 unless symptoms persist. Those over 40 should have an endometrial biopsy. A transvaginal ultrasound scan, if available, can identify abnormalities within the uterus, including fibroids, adenomyosis, and polyps.

One good therapeutic approach is to give birth control pills to women with these heavy periods. The effect of the BCPs is to reduce the heaviness and duration of flow. If they are anemic, oral iron preparations will usually return their iron stores to normal. If the BCPs (standard, low dose, monophasic pill such as Ortho Novum 1+35, LoOvral or LoEstrin 1.5/30) fail to reduce the flow appreciably, they can be taken continuously, without the usual “week off.” This will postpone their menstrual period indefinitely.

Alternatively, you could start the patient on DMPA (depot medroxyprogesterone acetate) 150 mg IM Q 3 months. This will usually disrupt the normal period and she probably won’t continue to have heavy periods. There are some significant drawbacks to this approach, however. Light spotting or bleeding are common among women taking DMPA, so you will be substituting one nuisance for another nuisance.

If sonohysterography demonstrates an endometrial polyp, removal of the polyp will often restore a normal menstrual flow. OCPs will sometimes reduce the flow due to fibroids enough to allow the patient to tolerate these flows for extended lengths of time.