Jennifer Johnson, ND, LAc

“Mia” is a 32-year-old female who came to me with a 20-year history of heavy and painful periods. For 18 of those 20 years, her concerns were treated dismissively. Having had no relief and disruptive side effects from hormonal contraceptive pills, her medical doctors offered no additional treatments. Mia eventually established with a naturopathic doctor, who was the first provider to investigate her symptoms. Labs revealed severe anemia necessitating a blood transfusion, and imaging found adenomyosis and a large endometrioma on her ovary. She began regular acupuncture, Chinese herbs, and supportive supplements, and with these interventions, her periods improved. When her provider moved, she established with me.

For Mia, whose periods had always been disruptive and whose experience was minimized by medical providers, her symptomatic improvement was significant. However, I discovered she was still bleeding excessively, emptying a menstrual cup (equivalent to three super tampons) 12 times per day for 3-5 days per cycle. Ultimately, I referred Mia to a gynecologist who performed surgery to remove the endometriosis and placed a levonorgestrel-releasing intrauterine device (IUD), while I provided supportive care around surgical recovery and prevention of future endometriosis lesions.

Mia’s case illustrates how common menstrual concerns can go inadequately investigated and treated. Heavy menstrual bleeding (HMB) affects 10-30% of menstruating individuals.¹ Technically it is defined as more than 80 mL of blood loss per cycle for the majority of the past 6 months. Practically speaking, we use tools like the Pictorial Blood Assessment Chart (PBAC) and surrogate markers of heavy flow (clots bigger than 1 inch, needing to change menstrual products during the night, use of double protection like a pad plus tampon, and bleeding through clothes) to determine if someone is experiencing HMB.² It is also vital to consider the impact on quality-of-life; if the amount of flow is distressing, it is worth treating.

In Mia’s case, doctors assumed her heavy flow and cramping were minor functional complaints, and it was only when a holistic provider dug deeper that a serious and treatable underlying cause was found. Extreme or persistent symptoms warrant further investigation. In my practice, extreme is saturating a super tampon (or its equivalent) hourly or more, and persistent is continued heavy flow after 3 cycles despite treatment. According to the International Federation of Gynecology and Obstetrics, HMB can be caused by abnormal structures (polyps, fibroids, adenomyosis, hyperplasia, cancer) or a variety of nonstructural issues (bleeding disorders, ovulation dysfunction, medication reactions).³ These conditions can be identified with thorough questioning, targeted physical examination and labs, and—if needed—imaging.

Knowing the underlying cause of HMB allows us to provide targeted interventions. Mia’s treatment plan focused on staunching bleeding, encouraging antioxidant and anti-inflammatory effects, and increasing progesterone levels to balance the effects of estrogen on endometriosis.

“Sarah,” a 36-year-old female with frequent, heavy, and prolonged menstrual flow, had HMB due to polycystic ovary syndrome (PCOS). Her plan focused on slowing flow, reducing the effect of testosterone in her body, and encouraging regular ovulation to trigger cyclic progesterone surges. Overgrowth of the uterine lining (endometrial hyperplasia) caused by infrequent ovulation was also found and treated surgically.

“Amy,” a 29-year-old with infrequent but heavy flow was diagnosed with hypothalamic oligomenorrhea (infrequent periods due to malnourishment), complicated by hypermobile Ehlers-Danlos syndrome (hEDS) and mast cell activation syndrome (MCAS), which made her blood vessels particularly fragile and prone to bleeding. Her treatment plan focused on healing disordered eating to encourage regular ovulation and providing support for connective tissue and mast cell stabilization.

These three cases highlight how treatment for HMB can and should be individualized.

Evaluation

Good work-up starts with a thorough history. The menstrual cycle itself should be discussed in detail: cycle length and variability, flow volume and duration, presence of clots or intermenstrual bleeding, cramping, premenstrual symptoms, and breast-related symptoms (tenderness, nipple discharge). In addition, a thorough review of systems can help narrow potential underlying causes of HMB. Systems of interest include endocrine (fatigue, weight gain/loss, temperature intolerance, hot flashes, night sweats), integumentary (acne, dry skin, hives, hair loss, hirsutism), hematologic (easy bruising, easy bleeding), and gastrointestinal (constipation, diarrhea, symptoms suggesting nutrient malabsorption).

Medications should be reviewed in detail, as many common prescriptions can cause or contribute to HMB, including hormonal contraceptives, hormone therapy, tamoxifen, spironolactone, copper IUD, blood thinners, corticosteroids, chemotherapeutic drugs, antipsychotics, and selective serotonin reuptake inhibitors (SSRIs).² Social history should give particular attention to diet, exercise, and smoking status; and family history should be assessed for potential bleeding disorders.

A complete blood count to rule out anemia and ferritin to assess iron storage are appropriate for anyone with heavy flow (low ferritin is another surrogate marker of HMB). Depending on age and clinical picture, other helpful blood tests include thyroid stimulating hormone (TSH), free and total testosterone, dehydroepiandrosterone (DHEA) sulfate, 17-hydroxyprogesterone, prolactin, and follicle stimulating hormone (FSH). When fertility is a concern, I will check basal (day 3) estradiol and FSH, as well as mid-luteal phase progesterone (drawn 7 days before predicted onset of next period).

When the clinical picture is complicated, more expansive panels may be needed; for example, if there is suspicion for a bleeding disorder, multiple tests are needed to accurately diagnose the condition. There are a variety of specialty labs offering salivary sex hormone testing or urinary hormone metabolite testing. There are various opinions on whether and which specialty tests are useful; personally, I do not find them necessary to treat HMB in general.

Pelvic and transvaginal ultrasound is useful for visualizing most structural causes of HMB, though some additional assessment may be needed for confirmation. It can also identify polycystic ovaries. Magnetic resonance imaging (MRI) provides more detail when ultrasound is equivocal. An endometrial biopsy can check for endometrial hyperplasia and cancer in the event of an ultrasound showing thickened lining. A saline infusion sonography (SIS) is ideal for diagnosing endometrial polyps. Rarely, high grade precancerous or cancerous changes to the cervix can cause HMB (pelvic pain and intermenstrual bleeding are more common), so it is important that cervical cancer screening is up to date.

Management: General Support

Regardless of cause, most HMB benefits from interventions that are astringent, anti-inflammatory, capillary-strengthening, and/or tonifying to the uterus. Traditional astringent herbs used as needed for heavy flow include cinnamon (Cinnamomum verum), shepherd’s purse (Capsella bursa-pastoris), cranesbill (Geranium maculatum), lady’s mantle (Alchemilla xanthochlora), yarrow (Achillea millefolium), and greater periwinkle (Vinca major).

Anti-inflammatory treatments include dried ginger (Zingiber officinale) and citrus bioflavonoids. Citrus bioflavonoids and vitamin C strengthen capillaries.

Traditional uterine tonics include dong quai (Angelica sinensis), raspberry (Rubus idaeus), partridge berry (Mitchella repens), black cohosh (Actaea racemosa), and false unicorn root (Chamaelirium luteum).

Most herbal interventions combine herbs from multiple categories for synergistic effects. Here are a few researched options that can be used individually or in combination:

• Dried ginger 250 mg capsules: take 1 capsule 3 times daily starting the day before onset of flow through day 3 of cycle.⁴
• Cinnamon and Erigeron essential oil: 1-5 drops every 3 hours as needed for HMB.⁵
• Chaste tree berry (Vitex agnus-castus): 20-40 mg daily.⁶ Most encapsulated forms will have a higher dosage, which is acceptable.
• Vitamin C (ascorbic acid): 750 mg daily.⁷ Higher doses may be used if support is needed for iron absorption.
• Citrus bioflavonoids: 1,000-2,000 mg daily.⁸
• Vitamin A: 60,000 IU daily.⁹ Note: vitamin A doses above 10,000 IU daily are teratogenic and should be avoided in women actively seeking pregnancy.

A holistic plan for menstrual dysfunction may also involve supporting hormone metabolism and detoxification pathways to avoid an imbalance of estrogen and progesterone (colloquially known as “estrogen dominance”). Many endocrine-disrupting chemicals in the environment exert a pro-estrogen influence in the body,¹⁰ so limiting exposure to these chemicals where possible is helpful for hormone balance. Metabolism of hormones via phase 1 and phase 2 detoxification in the liver is encouraged by diindolylmethane (DIM), sulforaphane, and calcium-D-glucarate. Traditionally, castor oil packs over the liver also aid this process. Adequate dietary fiber ensures metabolized hormones are successfully eliminated from the body.

From a simplified Traditional Chinese Medicine perspective, HMB can be caused by deficiency (qi, blood, or yang) or excess (heat or blood stagnation). This system of medicine is highly individualized and dependent upon multiple signs and symptoms, but in general if the underlying cause is deficiency, the individual will feel depleted, whereas if the underlying cause is excess, disruptive pain is likely present. Xiao Yao San is a formula that builds up qi and blood to help the body hold onto both better and would be useful for most deficient women with HMB.¹¹ For those with excess, the herb San Qi (Panax notoginseng) slows bleeding and alleviates pain.¹²

Pharmaceutical interventions for HMB are primarily hormonal: combined hormonal contraceptive pills (which can also be long cycled to reduce menstrual frequency), progestin-only contraceptive pill (norethindrone), cyclic progestins (micronized progesterone, medroxyprogesterone, norethindrone), depot medroxyprogesterone, and levonorgestrel-releasing IUD.¹³ Progestins act by decreasing endometrial growth and reducing inflammation. Combined hormonal contraceptives can also treat other hormone-related conditions, including acne and premenstrual syndrome (PMS).

In women who are not good candidates for hormonal treatments (such as those actively seeking pregnancy) or who don’t tolerate them, there are two additional medication options. Tranexamic acid is an antifibrinolytic medication, meaning it slows flow by discouraging breakdown of the fibrin clots that halt bleeding.¹³ Non-steroidal anti-inflammatory drugs (NSAIDs) reduce bleeding by lowering prostaglandin levels, thereby reducing inflammatory damage to the endometrial lining.

In terms of surgery, hysterectomy is curative for HMB, although it is an invasive procedure typically reserved for individuals not desiring fertility and for whom other treatment methods were ineffective. Endometrial ablation is a lower risk option that is about as effective as a levonorgestrel-releasing IUD, however it is not recommended for women hoping to get pregnant¹.

Management: Targeted Support

Below are specific interventions for some common causes of HMB.

Fibroids. Research-supported natural interventions for fibroids are unfortunately limited. Green tea extract (45% EGCG) at a dose of 800 mg per day for 4 months was found to reduce fibroid volume and improve fibroid symptoms.¹⁴ I typically combine this with acupuncture and a Chinese herbal formula containing the robust blood-moving herbs San Leng (Rhizoma sparganii) and E Zhu (Curcuma longa).

Fibroids are estrogen-dependent benign tumors,¹⁵ so if a person is taking unopposed estrogen or imbalanced estrogen/progesterone hormone therapy, it can fuel fibroid development and growth; in these cases, the prescriptions should be modified to correct the imbalance. If there is suspicion for an endogenous imbalance of estrogen and progesterone, the hormone detoxification support described above may be useful. Beyond the general pharmaceutical options for HMB, medications that impact GnRH (both agonists and antagonists) can be used to treat fibroids; but the cost, limited efficacy, side effects, and long-term sequelae usually outweigh the benefits.

Surgical intervention may be needed for large growths or more severe symptoms (severe HMB, constipation, bladder dysfunction). Myomectomy is particularly effective for larger fibroids, while uterine artery embolization is a less invasive option available for smaller growths. When a uterus has numerous large fibroids, hysterectomy may be appropriate. In my experience, people who undergo surgical intervention for fibroids benefit from post-surgical pelvic floor myofascial release treatment.

Polycystic ovary syndrome. PCOS is a multifaceted condition with many potential targets for treatment. The following are some natural options to encourage ovulation, improve menstrual cycle regularity, and increase luteal phase progesterone:

• Maitake capsules (18 mg MSX extract plus 250 mg of dried herb powder): 3 capsules 3 times daily on days 5-9 of cycle.¹⁶
• Cinnamon (Cinnamomum cassia): 1.5 grams daily.¹⁷ Note: this herb also improves metabolic metrics.
• Berberine: 400 mg 3 times daily.¹⁸
• Myo-inositol: 4,000 mg daily.¹⁹
• Ground flaxseeds (Linum usitatissimum): 2 tablespoons daily.²⁰

Medication therapy includes an anti-androgenic combined hormonal contraceptive pill, spironolactone, and/or metformin. Of the pharmaceutical options, the combined hormonal contraceptive pill is the one to directly address HMB.

Surgery is not typically needed for PCOS, except to treat one of its sequela: endometrial hyperplasia. For Sarah, chronic infrequent ovulation combined with increased aromatizing adipose tissue led to overgrowth and cellular changes to the endometrium. This was successfully treated with dilation and curettage. When an individual has recurrent endometrial hyperplasia, endometrial ablation may be appropriate.

Perimenopause. As ovarian function declines, women may ovulate inconsistently, and high FSH levels can initially encourage high estrogen levels. These factors set the stage for irregular and heavy flow and may also encourage the growth of fibroids. Supporting progesterone directly is highly effective, in addition to helping with other common perimenopausal symptoms like anxiety and insomnia. Micronized progesterone capsules taken before bed in a cyclic fashion (details of which will be dependent on the individual’s menstrual pattern or lack thereof) are most effective in my experience, although for some women a transdermal cream is better tolerated. The levonorgestrel-releasing IUD is also helpful in this population and provides contraception, an important consideration with irregular ovulation and high miscarriage rates in this age group.

Conclusion

Heavy menstrual bleeding is one of the most common concerns I see in practice, affecting women from adolescence through perimenopause. Properly diagnosing and successfully treating this complaint has a tremendous impact on health and quality of life. The interventions described here span simple dietary measures through surgical intervention. By understanding the scale and impact of the symptom on the individual, a strong integrative treatment plan can be developed.

References

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Published April 22, 2023

About the Author

Jennifer Johnson, ND, LAc, is a naturopathic doctor and acupuncturist specializing in primary care, women’s health, and mental health. Her approach blends evidence-based functional medicine with traditional Chinese medicine to support optimal wellness.

Dr. Johnson earned her degrees from Bastyr University in Seattle, Washington, and completed a competitive two-year women’s health residency in Portland, Oregon. She has done additional training in genomic medicine, craniosacral therapy, biofeedback, and pelvic floor myofascial work. Her passion for learning means she keeps current on the latest medical science and is forever exploring new ways to support healing. Her website is https://www.drjenjohnson.com/.