Menstrual Problems

About Menstrual problems

Normal cycle

Normally a period (bleed from the uterus/ womb) occurs approximately every 28 days, and is a normal part of the monthly menstrual cycle. Periods usually start from the age of 12yrs (sometimes earlier), and continue until the menopause at approximately 45-55yrs.

Heavy bleeding (known as menorrhagia)

This can occur with or without other symptoms including menstrual pain (dysmenorrhoea). It is a common problem which can lead to anaemia and can cause a lack of confidence, affecting overall quality of life.

What causes abnormal, heavy and/or painful periods?

There maybe many causes including problems within the uterus, ovaries or hormone production.

Problems in the uterus:

Polyps. Disorders of the lining of the uterus such as polyps, or a thickened lining, can contribute to heavy bleeding and cramps. It can also indicate something more serious and should always be investigated especially:

if greater than 35 years of age
where periods have been irregular
past history of PCOS
use of hormones

Enlargement of the uterus. This can occur naturally as the uterus is made up of muscle which is constantly contracting.
Fibroids. These are small or large benign (non-cancerous) growths usually in the muscle of the uterus. Fibroid polyps can project into the uterus preventing proper closure of the uterus and can cause pain, discomfort and heavy bleeding.
Myosis. Fragments of the endometrium which is the bleeding layer of the uterus, break away.
Endometriosis. The womb lining attaches to other organs including the pelvis, stomach and bowel.
Polycystic ovaries are sometimes associated with increased blood loss.
Cancer of the womb (a very rare condition)

Other causes

Following insertion of coil blood loss may increase by approximately 50% following coil insertion.
Hypothyroidism An under-active thyroid gland is sometimes linked to heavy periods.
Liver or renal disease

How is it diagnosed?

A medical history will be taken in order to identify the possible causes of heavy bleeding. Details relating to length of period, how regular they are, whether there is any bleeding between periods and/or after sexual intercourse, and whether there is a family history of any diseases which may affect blood clotting, will be discussed.

Examination

Some of these tests may be required depending on your symptoms.

Pelvic examination will indicate whether there are any abnormalities.
Biopsy of the uterus This is done if periods are irregular or the lining is thickened.
Ultrasound scan Usually an internal scan (transvaginal) which will be able to detect the presence of polyps and fibroids.
Blood test Tumour Marker CA125
Hysteroscopy
Laparoscopy

What is the Treatment?

This can be medical or hormonal treatment and/or surgical treatment.

Non-surgical Treatments

Levonorgestrel-releasing intrauterine system (LNG-IUS) - This is a small plastic device placed in your womb which slowly releases the hormone progestogen, and prevents the lining of the womb thickening. It is also a form of contraception.
Tranexamic acid tablets which help the blood to clot in the womb, and can reduce blood loss by up to 50%.
Non-steroidal anti-inflammatory drugs (NSAIDs) tablets which reduce your production of prostaglandin (which is linked to heavy periods).
Combined Oral contraceptive pill which regulates the menstrual cycle and reduces menstrual pain.

Surgical Treatments

Endometrial Ablation

Laparoscopy. This procedure is used to examine the reproductive organs lying within the abdomen, and is performed under a general anaesthetic. It takes approximately 20 minutes. The instrument is passed through a small cut in the abdomen and a second cut is sometimes made so that a probe can be inserted to manipulate the organs. Carbon dioxide gas is then pumped into the abdomen to separate the tissues so that the organs can be seen more clearly. Note: It is important that you do not have unprotected intercourse during the cycle leading up to your laparoscopy. If any abnormality is found at the time of laparoscopy 'keyhole surgery' may be performed. This requires a small incision and therefore has better cosmetic results than conventional surgery.

Myomectomy. This involves the removal of uterine fibroids. The uterus, cervix, fallopian tubes, ovaries and vagina all remain intact. The operation is performed under a general anaesthetic and the time taken will depend on the number and size of the fibroids to be removed but is usually 1-2 hours. There is a small chance that a hysterectomy may be needed if any bleeding cannot be stopped.

Hysterectomy. This procedure completely removes the uterus and is a cure for excessive bleeding. It is major surgery which is performed under general anaesthesia. Several days in hospital and up to six weeks recovery are most common.

Hysterectomy and removal of ovaries (oophorectomy). Hysterectomy may involve removal of either or both ovaries. This is likely to be the case if there is a problem with the ovaries, or if the woman is approaching the menopause or has already been through the menopause. For women who have not reached menopausal age, it is more usual to leave the ovaries in place, if they are healthy. If the ovaries are suddenly removed from a woman who has not reached the menopause, she is likely to start to experience menopausal symptoms unless the hormones are replaced artificially, i.e. by hormone replacement therapy (HRT) or an alternative therapy.

Other Treatments

Fibroid Embolisation
This procedure is non-surgical and is the closing off of blood vessels supplying uterine fibroids. The fibroid is deprived of blood and then dies and shrinks.