Heavy Menstrual Bleeding

Heavy menstrual bleeding means bleeding that feels excessive for you—such as soaking through pads or tampons quickly, passing large clots, bleeding longer than usual, or needing to “double up” on period products. Some people also notice spotting or bleeding between periods. While many conditions can cause heavy bleeding, it’s especially important to consider adenomyosis and endometriosis when heavy bleeding occurs alongside pelvic pain, painful periods, or fertility concerns.

With [adenomyosis](/adenomyosis), the lining-like tissue grows into the muscular wall of the uterus. That can make the uterus more inflamed, thicker, and less able to contract efficiently during a period—often leading to heavy, prolonged bleeding and painful cramping. Adenomyosis is one of the most common explanations for heavy bleeding in people who also describe a “boggy,” tender uterus or a feeling of pelvic pressure.

With [endometriosis](/endometriosis), endometrial-like tissue grows outside the uterus (on the pelvic lining, ovaries, bowel, bladder, and other areas). Endometriosis is more strongly associated with pain than bleeding, but many patients still report heavy periods or intermenstrual spotting—especially when endometriosis coexists with adenomyosis, fibroids, polyps, ovarian cysts/endometriomas, or hormonal cycle disruption.

Heavy bleeding can look similar across conditions, which is why evaluation matters. For example, fibroids, uterine polyps, thyroid disorders, bleeding/clotting conditions, perimenopause, and some medications can also cause heavy or irregular bleeding. At Lotus, we focus on careful [evaluation and diagnosis](/evaluation-and-diagnosis) to clarify whether bleeding is coming from a uterine source (often adenomyosis/fibroids) and whether endometriosis is also contributing.

Beyond the physical symptoms, heavy bleeding can reshape daily life—planning around bathrooms, carrying spare clothes, missing work or school, avoiding exercise or travel, and coping with anxiety about leaks. Over time, it can also contribute to iron deficiency and anemia, worsening fatigue and brain fog—problems that are already common in pelvic pain conditions.

People often describe heavy menstrual bleeding as periods that “take over the day.” You might need to change a pad or tampon every 1–2 hours, wake up at night to prevent leaking, or feel like you can’t leave the house without knowing where the nearest bathroom is. Passing clots (sometimes large), sudden “gushes,” or bleeding through clothing or bedding are also common descriptions.

For many with adenomyosis, heavy bleeding comes with strong, deep cramping and a sense of pelvic heaviness or pressure—sometimes described as a “bowling ball” feeling in the pelvis. With endometriosis, bleeding may be less dramatic but can show up as prolonged periods, spotting before/after the main flow, or bleeding that flares with pain episodes.

Experiences vary widely. Some people have very heavy bleeding with minimal pain; others have severe pain with moderate bleeding. Symptoms can change over time—often worsening after pregnancy, with age, or during perimenopause. And if you have both endometriosis and adenomyosis, the combination can make periods feel both heavier and more painful than what you were told is “normal.”

Heavy menstrual bleeding is very common in adenomyosis—it’s one of the hallmark symptoms, along with painful periods and an enlarged/tender uterus. In clinical studies, a substantial proportion of people with adenomyosis report heavy or prolonged bleeding (menorrhagia), though the exact percentage varies depending on how adenomyosis is diagnosed (ultrasound vs MRI vs pathology).

In endometriosis, heavy bleeding can occur but is less specific—many patients have normal-flow periods while still having severe pain, bowel/bladder symptoms, or infertility. Importantly, endometriosis and adenomyosis often co-occur, and when they do, heavy bleeding becomes more likely. Bleeding symptoms do not reliably correlate with the “stage” of endometriosis; someone can have significant symptoms with minimal visible disease and vice versa.

If heavy bleeding is a prominent symptom, it can be a clue to look carefully for uterine causes (adenomyosis, fibroids, polyps) in addition to assessing for endometriosis—especially if pelvic pain, painful sex, bowel/bladder pain, or fertility struggles are also present.

In adenomyosis, endometrial-type glands within the uterine muscle trigger chronic inflammation and remodeling of the uterine wall. This can increase the surface area and fragility of bleeding tissue, disrupt normal uterine muscle contractions that help stop bleeding, and promote a more “congested” uterine blood supply. The result can be heavier flow, longer periods, and more clotting.

In endometriosis, bleeding symptoms are often indirect. Endometriosis lesions outside the uterus respond to hormonal cycles and can drive inflammation throughout the pelvis. That inflammatory environment may contribute to uterine irritability, altered prostaglandins (chemical messengers linked to cramping and bleeding), and hormonal imbalance—factors that can worsen perceived heaviness or prolong bleeding.

Several factors can intensify heavy bleeding regardless of the underlying condition: fibroids/polyps, anticoagulant medications, thyroid dysfunction, and anemia (which can create a vicious cycle of heavier bleeding and worsening fatigue). Stress and poor sleep don’t “cause” heavy bleeding, but they can lower your resilience and amplify symptoms.

While heavy bleeding is not primarily a “nerve symptom,” inflammation and high prostaglandins can increase uterine cramping and pelvic pain, and persistent pain can sensitize the nervous system over time. That’s why treatment plans often address both bleeding control and pain regulation.

Treatment depends on your goals (bleeding control, pain relief, fertility, avoiding hormones, avoiding surgery) and on whether adenomyosis, endometriosis, or another condition is driving the bleeding. A thorough workup—often including pelvic exam, labs for anemia, and targeted imaging—is a key first step in [evaluation and diagnosis](/evaluation-and-diagnosis).

Medical options may include:

• Hormonal therapy to thin the uterine lining and suppress cycle-driven inflammation (e.g., progestin-based options, combined hormonal contraception, or other suppressive approaches). Learn more about options in [Hormonal Therapy](/hormonal-therapy).
• Non-hormonal bleeding control, such as tranexamic acid (used only during menses in appropriate patients) or anti-inflammatory medications when safe.
• Iron repletion (dietary iron and/or supplements) when iron deficiency is present—this can significantly improve fatigue and exercise tolerance even before bleeding is fully controlled.

Surgical considerations depend on what’s found. If endometriosis is contributing—especially deep disease, endometriomas, bowel/bladder involvement—excision surgery is considered the gold standard approach for removing endometriosis lesions and restoring anatomy. Lotus specializes in advanced minimally invasive excision through [Surgery & Advanced Excision](/surgery-and-advanced-excision), led by [Dr. Steven Vasilev](/dr-steven-vasilev-md). For adenomyosis, treatment ranges from medical suppression to uterus-sparing procedures in select cases, and for those who are done with childbearing and have severe symptoms, hysterectomy can be definitive.

Integrative and self-care strategies can help support symptom control and recovery, especially alongside medical/surgical care:

• Anti-inflammatory nutrition and gut-supportive habits (see [Integrative Medicine & Lifestyle Care](/integrative-medicine-and-lifestyle-care))
• Heat therapy, pacing, and targeted supplements when appropriate
• Pelvic floor physical therapy when pelvic muscle guarding and pain coexist (common with endometriosis)

What to expect: many patients can reduce bleeding substantially with medical therapy, but if adenomyosis is significant or endometriosis is untreated, symptoms may recur when suppression stops. A specialist-guided plan helps you weigh short-term relief versus long-term control, especially if fertility is a priority.

Seek urgent care now if you are soaking through a pad/tampon every hour for several hours, feeling faint, having chest pain/shortness of breath, passing very large clots with dizziness, or if you might be pregnant and have heavy bleeding. These can be signs of severe blood loss or pregnancy-related emergencies.

Schedule a specialist visit if heavy bleeding is new, worsening, lasts longer than 7 days, causes fatigue/lightheadedness, or comes with pelvic pain, pain during sex, bowel/bladder symptoms, or infertility—especially if you’ve been told “everything looks normal.” Heavy bleeding deserves a clear diagnosis and a plan that matches your goals.

When you meet with your clinician, bring specifics: how often you change products, whether you pass clots, how many days you bleed, any spotting between periods, and how it affects your life. If you’re ready for a deeper evaluation for endometriosis/adenomyosis and personalized treatment options, you can [schedule a consultation](/contact) with Lotus.