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Menstruation: Heavy Bleeding (Menorrhagia)


An in-depth report on the causes and treatment of heavy periods.

Alternative Names

Bleeding: menstrual; Menstrual Disorders

Lifestyle Changes

Making dietary adjustments starting about 14 days before a period may help some women with premenstrual syndrome and certain mild menstrual disorders, such as cramping, which commonly accompanies heavy bleeding. The general guidelines for a healthy diet apply to everyone:

  • Eat plenty of whole grains, fresh fruits and vegetables.
  • Avoid saturated fats and commercial junk foods.

Maintaining Healthy Iron Stores and Preventing Anemia

Forms of Iron. Iron found in foods is either in the form of heme or non-heme iron. Heme iron is the better absorbed than non-heme iron

  • Foods containing heme iron are the best for increasing or maintaining healthy iron levels. Such foods include (in order of iron-richness) clams, oysters, organ meats, beef, pork, poultry, and fish.
  • Non-heme iron is less well absorbed. About 60% of iron in meat in non-heme (although meat itself helps absorb non-heme iron). Eggs, dairy products, and iron-containing vegetables only have the non-heme form. Such vegetable products include dried beans and peas, iron-fortified cereals, bread, and pasta products, dark green leafy vegetables (chard, spinach, mustard greens, kale), dried fruits, nuts, and seeds.

The absorption of non-heme iron often depends on the food balances in meals. The following are foods that enhance absorption of non-heme iron.

  • Meat and fish not only contain heme iron--the best form for maintaining stores, but they also help absorb non-heme iron.
  • Increasing intake of vitamin-C rich foods can enhance absorption of non-heme iron during a single meal. In any case, vitamin-C rich foods are healthful and include broccoli, cabbage, citrus fruits, melon, tomatoes, and strawberries. One orange or six ounces of orange juice can double the amount of iron your body absorbs from plant foods. (Taking vitamin C supplements does not appear to have any significant effect on iron stores.)
  • Foods containing riboflavin (vitamin B2) may help enhance the response of hemoglobin to iron. Sources include liver, dried fortified cereals, and yogurt.

Certain nutrients impede the body's absorption of dietary iron. They include the following:

  • Polyphenols (found in tea, coffee, red wine, berries, apples).
  • Phytates (found in foods such as seeds, dried beans, soy, and bran). Such foods are typically high in fiber. It is commonly believed that fiber impedes iron absorption, but researchers report that it most likely has no effect.
  • Calcium. Calcium impairs the absorption of heme and non-heme iron. However, calcium intake needs to be fairly high to cause any significant problems. For example, a 2002 study reported that cheese had no effect on iron absorption from meals rich in heme and non-heme iron.

Cooking methods can enhance iron stores. Cooking in cast iron pans and skillets is well known to increase iron content of food. According to one study, however, boiling, steaming, or stir-frying in utensils composed of any material significantly increased the release of non-heme iron stored in vegetables.

Sources of Vitamins B12 and Folate. Vitamins B12 and folate are important for prevention of megaloblastic anemia and good health in general.

  • The only natural dietary sources of B12 are animal products, such as meats, dairy products, eggs, and fish (clams and oily fish are very high in B12); like other B vitamins, however, B12 is added to commercial dried cereals. The RDA is 2.4 mcg a day. Deficiencies are rare in young people, although the elderly may have trouble absorbing natural vitamin B12 and require synthetic forms from supplements and fortified foods.
  • Folate is best found in avocado, bananas, orange juice, cold cereal, asparagus, fruits, green, leafy vegetables, dried beans and peas, and yeast. The synthetic form, folic acid, is now added to commercial grain products. Vitamins are usually made from folic acid, which is about twice as potent as folate. Many experts now recommend that adults have 400 mcg of folic acid daily, which is considerably higher than standard recommendations of 400 mcg of folate, which does not take into consideration the possible benefits of folate on the heart. Women who are trying to conceive, who are pregnant, and who are breastfeeding should take 400 mcg of folic acid.

Iron Supplements. Iron supplements are the most effect agents for restoring iron levels but they should be used only when dietary measures have failed. Women should always discuss such supplements with their physician.

Dietary Factors Affecting Other Menstrual Symptoms

Making dietary adjustments starting about 14 days before a period may help some women with certain mild menstrual disorders, such as cramping. The general guidelines for a healthy diet apply to everyone; they include eating plenty of whole grains, fresh fruits and vegetables, and avoiding saturated fats and commercial junk foods.

Low-Fat, High-Fish Diets. A 2000 study reported that women who followed a low-fat vegetarian diet for two menstrual cycles experienced less pain and bloating and a shorter duration of premenstrual symptoms than those who ate meat. Women who are losing too much blood, however, may need meat to help maintain iron levels. Choosing more fish and eggs may be a helpful alternative. More than one study has reported less menstrual pain with a higher intake of omega 3 fatty acids (fat compounds found in oily fish, such as salmon and tuna). In another, supplements of fish oil appeared to reduce heavy bleeding in adolescent girls.

Salt Restriction. Limiting salt may help bloating. One study found that restricting salt does not alleviate bloating or other symptoms, but salt reduction in the study was modest and may have been too small to effect improvement.

Reducing Caffeine, Sugar, and Alcohol. Reducing caffeine, sugar, and alcohol intake may be beneficial. The effects of alcohol are mixed. One study found that women who drank less wine had less menstrual pain than those who drank more wine. Another reported that regular consumption of alcohol lowered the risk for developing cramps, but it actually increased the length of cramping time in certain women. Alcohol is certainly not recommended in any case for relieving menstrual disorders.

Menstrual Hygiene

Tampons should be changed every four to six hours. Scented pads and tampons should be avoided; feminine deodorants can irritate the genital area. Women should not douche during or between periods. Women who douche on a weekly basis are more likely to contract cervical cancer than those who don't. Douching may destroy the natural anti-viral and anti-bacterial agents normally present in the vagina. Bathing regularly is sufficient.

Alternative Treatments

Acupuncture. Some women report relief from pelvic pain and heaviness after acupuncture.

Yoga. Yoga exercises help some women relieve sensations of heaviness and pressure.

Iron Supplements

Iron supplements are the most effect agents for restoring iron levels, but they should be used only when dietary measures have failed. No one should take iron supplements if they have a healthy diet and no indications of iron deficiency anemia. One study reported that physicians prescribed iron pills for 64% of patients with anemia without performing tests to confirm whether iron deficiency was actually the cause. The study suggested that iron replacement was appropriate in less than half of these patients. Iron replacement therapy can cause gastrointestinal problems, sometimes severe ones. Excess iron may also contribute to heart disease, diabetes, and certain cancers.

Supplement Forms. To replace iron, the preferred forms of iron tablets are ferrous salts, usually ferrous sulfate (Feosol, Fer-In-Sol, Mol-Iron). Other forms include ferrous fumarate (Femiron, FerroSequels, Feostat, Fumerin, Hemocyte, Ircon), ferrous gluconate (Fergon, Ferralet, Simron), polysaccharide-iron complex (Niferex, Nu-Iron), and carbonyl iron (Elemental Iron, Feosol Caplet, Ferra-Cap). Specific brands and forms may have certain advantages. The following are some examples:

  • Prolonged-release ferrous sulfate (Slow Fe) may enhance iron absorption with fewer side effects than standard ferrous sulfate pills.
  • FerroSequels contains a stool softener, which helps prevent constipation.
  • Polysaccharide-iron complex has fewer side effects and equal absorption rates compared to ferrous salts. It is very expensive, however.
  • Carbonyl iron is composed of very fine tiny uniform spheres of iron powder and may prove to be less toxic than ferrous iron.
  • Coated or combination pills do not appear to offer any additional advantages and may hinder absorption of the iron.

Regimen. The general guidelines for iron replacement are as follows:

  • For adults, physicians usually advise one ferrous sulfate tablet (300 mg) three times a day.
  • Iron replacement doses for children with deficiencies are significantly lower. They are given as drops or syrup administered three times a day. A single-dose daily regimen is showing promise. IMPORTANT: As few as three adult iron tablets can poison children, even fatally. This includes any form of iron pill.
  • No one, even adults, should take a double dose of iron if one is missed.

Other tips for taking iron are as follows:

  • For best absorption, iron should be taken between meals. (Iron may cause stomach and intestinal disturbances, however, and some experts believe that low doses of ferrous sulfate can be taken with food and absorbed without side effects.)
  • One should always drink a full eight ounces of fluid with an iron pill.
  • Tablets should be kept in a cool place. (Bathroom medicine cabinets may be too warm and humid, which may cause the pills to disintegrate.)
  • One study suggested that iron supplements impeded the absorption of non-heme iron (found in legumes and other vegetables) but not heme iron (contained in meat).

Full recovery takes six to eight weeks. (Recovery will take longer in people with internal bleeding that is not under control.) Iron replacement therapy must continue for about six months, even if anemia has been reversed. Treatment must be continued indefinitely for people with chronic bleeding; in such cases, iron levels should be closely monitored.

Side Effects. Common side effects of iron supplements include the following:

  • Constipation and diarrhea are very common. They are rarely severe, although iron tablets can aggravate existing gastrointestinal problems such as ulcers and ulcerative colitis.
  • Nausea and vomiting may occur with high doses, but can be controlled by taking smaller amounts. Switching to ferrous gluconate may help some people with severe gastrointestinal problems.
  • Black stools are normal when taking iron tablets. In fact, if they do not turn black, the tablets may not be working effectively. This tends to be a more common problem with coated or long-acting iron tablets.
  • If the stools are tarry looking as well as black, if they have red streaks, or if cramps, sharp pains, or soreness in the stomach occur, gastrointestinal bleeding may be causing the iron deficiency and the patient should call the physician promptly.
  • Acute iron poisoning is rare in adults but can be fatal in children who take adult-strength tablets.

Interactions with Other Drugs. Certain medications, including antacids, can reduce iron absorption. Iron tablets may also reduce the effectiveness of other drugs, including the antibiotics tetracycline, penicillamine, and ciprofloxacin and the anti-Parkinson's Disease drugs methyldopa, levodopa, and carbidopa. At least two hours should elapse between doses of these drugs and iron supplements.

Supplementary Agents. The following agents may improve iron absorption:

  • Adding either ascorbic acid (vitamin C) or succinic acid to ferrous sulfate therapy will improve absorption of iron stores. Ascorbic acid added to iron therapy, however, may exacerbate some of the side effects. Succinic acid added to ferrous sulfate does not appear to increase side effects.
  • Some studies have found that the addition of zinc to iron supplements increases hemoglobin levels more than iron alone. (Some evidence for this suggests that zinc affects a hormone called insulin-like growth factor-I (IGF-I), which plays a role in the regulation of red blood cell production.)

A study of young Asian women found that the addition of vitamin A to iron and folate supplements increased the absorption of iron and folate. It should be noted that vitamin A is toxic in high levels and can be particularly dangerous during pregnancy. No one should take vitamin A supplements without guidance from a physician.


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