Got heavy bleeding or irregular periods? Gynaecologist Gabrielle Downey addresses the most common menstrual problems and what to do about them
Almost all women have problems with their period from time to time. Whether it be heavy bleeding, irregular bleeding or no bleeding at all, experiencing issues every once in awhile is pretty common. However, sometimes these problems are more serious than they appear to be.
First things first: what exactly is a period? In case your primary school didn’t properly educate you on the subject, a period is the lining of the womb falling away when there is no pregnancy. A “normal” period comes every 21-35 days and typically lasts for five days. The flow is light for the first day or two, heavier for two to three days and then tails off over a day or two (about 5 to 8 teaspoons per month.) Most women have fairly tolerant periods, give or take a few cramps, but it’s important to know when problems can become more serious, what you – and your doctor – can do about them.
The most common complaint is of regular, heavy bleeding. This is called menorrhagia or “dysfunctional uterine bleeding.” It is heavy bleeding that occurs during your period, not at other times. There is often a physical cause such as an enlarged womb due to childbirth (adenomyosis), infection, fibroids (benign lumps of gristle on the muscle of the womb) and polyps. If your periods become heavy, for example, you are flooding through your pad/tampons/clothes and/or passing clots or you need “double protection,” then you should seek help.
Heavy periods due to dysfunctional uterine bleeding seem to be more common in the first few years after starting periods. This is also the case in the months running up to the menopause. If you are a teenager and have heavy periods, you have a good chance that they will settle down over a few years. If you are in the perimenopausal phase (about four to ten years before the menopause), they will eventually stop, but you may not want to wait until then.
For regular, heavy periods you do not need an internal examination, but they should examine your abdomen for fibroids.
Your GP should take a history detailing the length of your cycle, how long you bleed for, what contraception you use, if any, your fertility wishes and smear history. For regular, heavy periods you do not need an internal examination, but they should examine your abdomen for fibroids. If they can feel your womb, then a scan is useful to determine the size and location of the fibroids. In general, blood tests are not required except a full blood count to see if you are anaemic. If you do not have fibroids, then you should be referred to a specialist.
The GP should offer you medical treatment in the form of tablets, such as Mefenamic acid or Tranexamic acid, for your heavy bleeding. If the tablets don’t work after six months, you should be referred to a specialist. Their medication choice depends on your fertility wishes. If you want to become pregnant or do not want to take hormones, then the options are:
Mefenamic Acid – reduces pain and blood loss – take up to 4 times a day during bleeding.
Tranexamic Acid – reduces blood loss – take up to 4 times a day for a maximum of 3 days.
If you do not wish to become pregnant, then you could have:
The “combined” or progesterone-only pill
Hormone injection (lasts 3 months) or implant – lasts three years
Intrauterine hormonal contraception
Irregular bleeding, that is no pattern to your loss and varying amounts is less frequent, but it is more important as there can be a sinister cause. If you have an irregular cycle or experience bleeding in between periods or after intercourse, then an internal examination with a speculum (the instrument used to do a smear test) and a bimanual (internal examination using the fingers) is mandatory. If the GP thinks the cervix is abnormal, you should be sent to see a specialist on what is termed a “two-week wait” as it may be a sign of cancer (don’t panic—only one in 100 of women sent up for this reason actually have cancer.) If you’re under 40 years old, they should take three swabs: two of the cervix and one of the vagina as infection is a common cause of the symptoms, particularly bleeding in between periods and after intercourse. A smear is not required as this is used as a screening test in women with no symptoms and is often difficult to interpret or falsely reassuring.
If you have an irregular cycle or experience bleeding in between periods or after intercourse, an internal examination with a speculum is mandatory
If the examination is normal, then a trial of progesterone (hormone) pills should be given for two cycles. A good response is reassuring and means you can continue. If the abnormal bleeding persists, then a referral to a specialist is required. The main causes of irregular bleeding are polyps (benign overgrowths of the womb lining that are removed surgically), infection, a hormonal imbalance and (very rarely) a cancer.
If the GP thinks the cervix is abnormal, you should be sent to see a specialist on what is termed a “two-week wait” as it may be a sign of cancer
Occasionally, further tests are required such as an ultrasound scan. This looks for fibroids and polyps. It is not a substitute for a clinical examination as it misses the vulva, vagina and cervix where problems like those I have mentioned above can manifest. It should only be used if clinically indicated. For example, an enlarged uterus or failure to respond to treatment. If you have symptoms suggestive of an underactive thyroid problem, then a blood test will be required to check how it is working.
No period at all
A lack of periods is also common. This is when your cycle is longerthan 35 days. Apart from pregnancy (always check!) the main cause is a condition called ‘polycystic ovaries’ which is where your ovaries do not produce eggs regularly, thus no periods. Other common causes are excessive weight loss/gain, exercise and stress. The GP should do blood tests for oestrogen, FSH (follicular stimulating hormone that stimulates your ovaries), testosterone, sex hormone binding globulin and prolactin levels. They should also organise an ultrasound scan. The cornerstone of polycystic ovary management is weight loss if you are overweight (BMI > 30). Other treatment options depend on your fertility wishes, if you would like to have regular periods and whether or not you would like contraception.
The important aspect of your care is to a) to find the cause and b) ensure the lining of the womb is protected either with a special coil called an IUS or making you bleed at least three times a year by giving you a short course of drugs every three to four months.
Dr. Gabrielle Downey is a Birmingham-based consultant gynaecologist. She has been a consultant gynaecologist at the Birmingham City Hospital for over 15 years. Dr. Downey publishes regularly in renowned journals and writes for medical textbooks, was a co-author to the current NHS cervical smear program, and has specialist expertise in problems such as abnormal smears among many other conditions.
Click here to read more about Downey.