Heavy menstrual bleeding: baseline U.S. tests and care pathways

I didn’t plan to learn this much about periods, but a few cycles ago I caught myself packing extra clothes in my work tote “just in case.” That was my cue that what I was calling “a heavy month” had crossed into something that deserved real attention. I’m writing this as a personal field guide—part diary, part careful notes—on how heavy menstrual bleeding is approached in the U.S., what baseline tests clinicians usually order, and the practical care paths that tend to follow. I’m keeping the tone honest and the claims grounded, because nobody needs hype when they’re already worried.

Why “heavy” needed better words for me

At first, I kept using fuzzy language—“a lot,” “flooding,” “worse than usual.” What made things click was learning how clinicians describe heaviness in plain, observable terms. Clarity is power in those first conversations:

• Bleeding lasting more than seven days, especially if it’s consistently that long.
• Soaking through a pad or tampon every hour for several hours in a row, or needing to double up.
• Passing clots the size of a quarter or larger, or waking at night to change protection.

I started tracking these details in my notes app (time of each change, any clots, dizziness, cramps, and whether I felt washed out or short of breath). It wasn’t glamorous, but it transformed a vague complaint into a clear story I could bring to my clinician.

• ACOG patient FAQ on heavy menstrual bleeding

The baseline U.S. workup most people are offered

There’s variation by clinic and history, but across primary care, gynecology, and urgent care, I kept seeing a common “first pass” to sort causes and protect health in the near term. None of these tests are exotic; most are straightforward and covered in standard labs and imaging:

• Pregnancy test (urine or serum). Even if pregnancy isn’t expected, it’s the first fork in the pathway because it completely changes next steps.
• Complete blood count (CBC) to check for anemia, and often a ferritin level to see iron stores. Low hemoglobin or ferritin supports treating iron deficiency alongside any period-focused therapy.
• Thyroid-stimulating hormone (TSH) if symptoms or history suggest thyroid issues; thyroid disruption can alter cycles.
• Coagulation screens (like PT/aPTT) or von Willebrand testing if a bleeding disorder is suspected (e.g., easy bruising, prolonged nosebleeds, heavy bleeding after dental work, or a strong family history). This is more common than I realized.
• Pelvic examination (as appropriate) and, when indicated, transvaginal ultrasound to look for structural causes like fibroids or polyps.

Two important clarifications helped me breathe:

• Imaging is about structure—it answers “Is there a polyp, fibroid, or thickened lining?”
• Bloodwork is about function—it asks “Is there a systemic reason I’m losing or not replenishing blood?”

• CDC overview for heavy menstrual bleeding & bleeding disorders

Endometrial biopsy thresholds that kept coming up

I kept stumbling over the “do I need a biopsy?” question. Here’s how clinicians explained it to me in simple terms: an endometrial biopsy samples the uterine lining to check for hyperplasia or cancer. It’s recommended up front for many people at higher baseline risk and selectively for others.

• Age 45+ with abnormal uterine bleeding: biopsy is typically a first-line test.
• Under 45 with persistent bleeding, failed medical management, or risk factors for unopposed estrogen (e.g., obesity, PCOS), a biopsy is considered even earlier.

That framing helped me understand that the biopsy is not a “last resort” test; it’s a safety net to avoid missing serious pathology while the more common causes (like fibroids, anovulation, or a benign polyp) are addressed.

• AAFP summary on endometrial biopsy indications

The PALM–COEIN lens that made the chaos sortable

My brain loves checklists. The PALM–COEIN system is a tidy way to think about causes of abnormal bleeding:

• PALM (structural): Polyp, Adenomyosis, Leiomyoma (fibroids), Malignancy/Hyperplasia
• COEIN (nonstructural): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic (medication-related), Not otherwise classified

When my clinician and I walked through each bucket, I felt less lost. It guided which tests were essential now, which could wait, and how treatment choices fit the likely cause (or causes—plural, sometimes!).

• ACOG guidance on acute abnormal uterine bleeding

Care pathways I found useful to print and bring

I’m a visual map person, so I sketched this text-based flow many times—useful for a primary care or gyne visit:

• Step 1. Rule out pregnancy. If positive, follow pregnancy-specific care.
• Step 2. Baseline labs. CBC ± ferritin; TSH if symptoms/history; consider coagulation panel or von Willebrand workup if bleeding disorder is plausible; add STI testing if cervicitis symptoms.
• Step 3. Pelvic exam and ultrasound as indicated. If exam is abnormal, bleeding is severe, or structural causes are likely, imaging helps early.
• Step 4. Biopsy triggers. Age 45+ with any abnormal bleeding, or younger with risk factors, failed meds, or persistent symptoms.
• Step 5. Start symptom management while the workup proceeds (see options below), plus iron repletion if anemic or iron-depleted.
• Step 6. Reassess in 1–3 cycles. If bleeding improves, continue/adjust; if not, escalate to targeted procedures (polyp removal, fibroid treatment), or consider ablation or hysterectomy in appropriate cases after family planning is complete.

Treatment options explained the way I wish I’d heard them

Different people value different outcomes (lighter flow, better cramps, reliable contraception, preserving fertility, fewest side effects). Here’s a plain-English tour I wish I had from the start:

• Nonhormonal
  • NSAIDs (like ibuprofen, naproxen) during menses can reduce menstrual blood loss and cramping for some people.
  • Tranexamic acid is used during bleeding days to stabilize clots and reduce flow; it’s nonhormonal and often compatible with trying to conceive.
• Hormonal
  • Combined oral contraceptives (the pill), patches, or rings can lighten and regulate periods; extended or continuous regimens can mean fewer periods per year.
  • Levonorgestrel intrauterine system (LNG-IUS) is a strong option for heavy bleeding reduction and long-acting contraception—reversible, but not ideal if you want to avoid any hormones.
  • Progestin-only methods (pills, injections, implants) suit people who cannot take estrogen; bleeding patterns can vary from spotting to very light over time.
• Procedures
  • Polyp removal or myomectomy if a specific structural cause is driving the bleeding.
  • Uterine artery embolization for certain fibroids to reduce size and bleeding (fertility considerations are important here).
  • Endometrial ablation can reduce bleeding substantially but is not for those planning future pregnancy.
  • Hysterectomy is definitive and reserved for select cases when other options fail or are unsuitable.
• Iron repletion
  • Oral iron can correct deficiency over weeks to months; IV iron is considered if oral forms are not tolerated or levels are very low. Pairing iron with vitamin C may improve absorption; taking it away from calcium helps too.

• CDC on treatment options (tranexamic acid, desmopressin for certain disorders)
• NIH ODS iron fact sheet for consumers

What severe days look like in urgent care

Reading this calmed me: in acute heavy bleeding, teams focus on stabilizing you today and preventing short-term harm, then pivot to long-term control. If you’re soaking through protection hourly for several hours, feel faint, have chest pain or shortness of breath, or notice a fast heartbeat with pallor, those are “go now” signals. In clinic or the ER, possible immediate steps include high-dose hormonal regimens, tranexamic acid, and, if unstable, uterine tamponade or procedures to quickly reduce bleeding. These are individualized based on the cause and medical history; the goal is safety first, personalization second.

• ACOG acute AUB management overview

Small habits that made appointments more productive

I started treating my symptoms like a project I care about. Not a forever project—just organized enough to get answers faster:

• Bring a one-page summary of cycle dates, pad/tampon counts on the heaviest days, any clots, and symptoms like fatigue or dizziness.
• List medicines and supplements, including dose and timing (some, like anticoagulants, can contribute to bleeding).
• Flag preferences—for example, “I prefer a nonhormonal option if possible,” or “I want less bleeding and reliable contraception.”
• Ask how we’ll measure success: pad counts, hemoglobin/ferritin changes, or fewer missed days of work/school.

Signals that told me to slow down and double-check

• Red flags: soaking through protection hourly for >2 hours, feeling faint, chest pain, shortness of breath, or positive pregnancy test with heavy bleeding.
• Age and risk: if 45+ with new bleeding changes, or any age with obesity, PCOS, or prolonged unopposed estrogen exposure—ask about earlier biopsy.
• Family bleeding history: frequent nosebleeds, large bruises, or heavy post-procedure bleeding in relatives can hint at an underlying bleeding disorder worth testing.

What helped my mindset

What steadied me most was understanding that heavy menstrual bleeding is a pattern with many possible causes, not a moral failing or something to “tough out.” The U.S. care pathway is purpose-built: rule out pregnancy; check blood count and iron; look for systemic and structural reasons; sample the lining if risk suggests; and start treatments that fit your values. Two or three cycles of careful follow-up can make a surprising difference, especially if iron deficiency is corrected along the way.

FAQ

1) How do I know if my period is officially “heavy”?
Answer: Clinicians use practical signs: bleeding >7 days, soaking through protection hourly for several hours, needing double protection, or passing quarter-sized clots. Track these details and bring them to your visit. A helpful primer is the ACOG patient page on heavy menstrual bleeding.

2) Which tests are usually done first in the U.S.?
Answer: A pregnancy test, CBC (often ferritin), and targeted labs like TSH are common; coagulation studies or von Willebrand testing are considered if a bleeding disorder seems likely. Pelvic exam and ultrasound are added when structural causes are suspected.

3) When is an endometrial biopsy recommended?
Answer: It’s typically first-line for people 45+ with abnormal bleeding, and considered earlier for younger patients with risk factors, persistent symptoms, or failed medical therapy.

4) Can I treat heavy bleeding without hormones?
Answer: Yes. NSAIDs during menses and tranexamic acid on bleeding days are nonhormonal options. If iron stores are low, iron repletion is part of the plan. Your clinician can help decide what fits your health history and goals.

5) What if I have a bleeding disorder?
Answer: Heavy periods are common in conditions like von Willebrand disease. Management can include antifibrinolytics (e.g., tranexamic acid) or, in specific cases, desmopressin. A bleeding history and targeted labs help confirm the diagnosis so treatment can be tailored.

Sources & References

• ACOG — Heavy Menstrual Bleeding (Patient FAQ)
• ACOG — Acute Abnormal Uterine Bleeding (Committee Opinion)
• AAFP — Endometrial Biopsy Indications (2020)
• CDC — About Heavy Menstrual Bleeding (2024)
• MedlinePlus — Abnormal Uterine Bleeding (2024)

This blog is a personal journal and for general information only. It is not a substitute for professional medical advice, diagnosis, or treatment, and it does not create a doctor–patient relationship. Always seek the advice of a licensed clinician for questions about your health. If you may be experiencing an emergency, call your local emergency number immediately (e.g., 911 [US], 119).