“Heavy” is an adjective, and adjectives do not get written down. The same thing said as a count — a pad an hour, clots bigger than a coin, two days of work gone every cycle — is a finding, and findings get acted on.

Your words, and the same thing in counts

Answer for your worst two days rather than for an average. Every answer becomes a row: what you would have said, the counted form, and the line that decides whether it is outside what an ordinary period does. Nothing is saved and nothing leaves the page.

Why years go by while everybody is being reasonable

• The comparison class is wrong from the start. Nobody sees anybody else's periods. The only benchmark most people have is their mother's or a friend's account, and both of those may be describing the same undiagnosed thing. “Everybody gets this” is a genuinely held belief built on a sample of one or two.
• Adjectives get sympathy; counts get tests. A clinician who hears “heavy” has no way to know whether that means five pads a day or a pad an hour. The word cannot go in a record in a form the next person can use, so what gets written is a sentence about the conversation rather than about the bleeding.
• The first treatment is often given without the picture being written down. Hormonal treatment frequently helps, and starting it is reasonable. What goes wrong is when it is the only thing that happens: nothing is recorded, nothing is measured, and if it does not work there is no baseline to compare against two years later.
• Pain is discounted by everybody including the person having it. People who have never had a pain-free period have no idea what an ordinary one feels like, and they systematically under-report. The measure that survives that is not how bad it feels but what it stops: days lost, plans cancelled, painkillers taken at full dose without effect.
• The tiredness gets its own separate, useless answer. Exhaustion mentioned in a different sentence from bleeding is attributed to work, stress, sleep or age. Said in the same sentence, it produces a blood test.
• A normal scan closes the file. An ultrasound is good at fibroids and cysts and can be entirely normal in endometriosis. “Your scan was normal” answers a question that was never the whole of yours, and it is the commonest place the process stops.

What counts as heavy, in the numbers that are actually used

• Soaking through a pad or a tampon every one to two hours, for several hours, is the clinical description of heavy menstrual bleeding. Not one bad hour: a run of them.
• Bleeding through onto clothes or the bed, or waking at night to change, counts — and it is the detail most often left out because it is embarrassing rather than because it is unimportant.
• Clots bigger than about two and a half centimetres, which is roughly a two-euro coin. Small clots are ordinary and mentioning them adds nothing.
• Bleeding lasting more than eight days, or a cycle shorter than three weeks from the start of one period to the start of the next.
• Needing to plan life around it — a change of clothes carried, dark trousers only, no swimming, not leaving the house on day two. That is impact, and impact is a recordable measure in its own right.
• Any of that plus breathlessness, dizziness or new exhaustion is not a diary question but a blood test: a full blood count and a ferritin, asked for by name.

The pain that is not what an ordinary period does

• Pain that full-dose painkillers do not touch. Ordinary period pain usually responds at least partly to anti-inflammatory painkillers taken properly — at the dose on the packet, started as the pain starts rather than hours into it. Pain that ignores them is worth reporting as exactly that.
• Pain on days without bleeding. This is the single most useful thing to notice, because an ordinary period does not do it. Note which days and where.
• Deep pain during or after sex, as distinct from pain at the entrance. It is specifically asked about when endometriosis is being considered and it is very rarely volunteered.
• Pain opening the bowels or passing urine that follows the cycle. The timing is the informative part: pain that arrives with the period and goes with it points somewhere specific.
• Pain that has changed. A new pattern in somebody in their thirties is not the same as a pattern that has been there since school, and both are worth reporting — but for different reasons.
• Pain plus difficulty conceiving. Say both parts in the same appointment even though they feel like separate subjects. Together they change the order in which things get looked at.

The blood test that gets left off

• Ask for a full blood count and a ferritin. Two names, one sentence. The full blood count shows anaemia; the ferritin shows whether the iron stores behind it are empty, which happens first and is missed by the first test alone.
• Ask for the numbers, not the word “normal”. The bottom of a laboratory range is not the same as enough, and a ferritin at the very bottom with heavy periods and exhaustion is a different situation from a ferritin in the middle.
• If iron is low, ask what is being done about the bleeding too. Replacing iron while the cause continues is a repair that has to be redone every year, and it is a common way for the underlying question to be postponed indefinitely.
• Iron tablets are worth taking properly if they are prescribed. Every other day is often as good as daily and easier to tolerate, taking them with vitamin C helps and with tea or coffee does not, and it takes months rather than weeks to refill stores — so stopping when the blood count normalises leaves the job half done. Ask when to be retested.
• Do not start iron on your own to see whether it helps. Not because it is dangerous, but because taking it before the test blurs the result that would have told everybody what was going on.

What can usually be offered, in general shape

Names, availability and who prescribes what differ by country, and the specifics belong to somebody who knows your case. The shape does not differ, and knowing the shape is what lets you ask a useful question.

• Things for the bleeding that are not hormonal exist, including a medicine taken only on the heavy days that reduces blood loss substantially. It is often not mentioned to somebody who says she does not want hormones, and it is worth asking about by that description.
• Anti-inflammatory painkillers taken properly reduce both pain and blood loss, which surprises people. Started early, at the dose on the packet, on a schedule rather than when the pain wins.
• Hormonal options range from tablets to a hormone-releasing device fitted in the womb, which is one of the most effective treatments for heavy bleeding and is often thought of only as contraception. Ask what each one is expected to do to the bleeding, to the pain, and to fertility later.
• Procedures exist for specific findings — removing a polyp or a fibroid, treating the lining — and they are the right answer for some people and not for others. Ask what it is expected to change and what happens if it does not.
• Referral is what happens when the first two or three things do not work, and asking “at what point would this be referred?” early gives you a marker rather than an argument later.
• Nothing here is a recommendation. Every one of these has trade-offs that depend on your history, your plans and what is causing the bleeding, and this page has no way to know any of that.

What is not a diary question

• Sudden severe pelvic pain when a pregnancy is possible. Assessed the same day: an ectopic pregnancy is time-critical, and a negative pregnancy test early on does not settle it. Ring the emergency number or the out-of-hours service.
• Bleeding so heavy that you feel faint, cold, shaky or breathless while it is happening. That is now, not next week.
• Bleeding that starts more than a year after your periods stopped. Always looked at, whatever it feels like, and the phrase that routes it is “bleeding after the menopause”.
• Bleeding between periods or after sex that is new. It has its own checks, and it does not become less relevant because the periods are heavy too.
• A period that becomes very different very suddenly, particularly with pain that is new or one-sided, is worth a call rather than a wait-and-see.
• Feeling that you cannot go on with it. Chronic pain grinds people down and that is not a separate subject from the pain. If you are having thoughts of ending your life, that is worth saying out loud to somebody today — there are lines for it in every country, and the emergency number in Europe is 112.

What people believe, and what is so

The drill: 16 conversations

Sixteen ordinary appointments and kitchen-table conversations — the normal scan, the mother who says everybody gets this, the pill offered with nothing written down, the exhaustion nobody connects. Most have a patient, reasonable answer that costs another year. Pick your move; every answer explains why.

The card

Print it, count for two cycles, and take it in. The counts are the whole of it.

🖨️ Print the card