Introduction
Issues around heavy menstrual periods and irregular bleeding are common and form a large part of gynaecological problems for women.
Symptoms
Periods can be:
- Too heavy.
- Go on for too long.
- Overly painful.
- Irregular, i.e.: they fail to follow a regular cycle.
- Absent, or occur very infrequently.
Bleeding can also occur between periods, (which is called intermenstrual bleeding), or after intercourse, which is called postcoital bleeding. Both conditions are abnormal and require investigation.
Dysfunctional Uterine Bleeding
Most period issues are due to a condition called Dysfunctional Uterine Bleeding, which is diagnosed once any other structural or pathological abnormalities of the uterus and cervix have been ruled out. Dysfunctional uterine bleeding is generally due to a subtle hormone imbalance in the body, which affects the lining of the uterus and how it thickens up before the period comes, and then how it sheds once the period starts.
There can, however, be an abnormality of the cervix, uterus, or pelvis which can cause period problems or other abnormal bleeding. Some of these include:
Polpys in the uterine cavity or cervix
These are usually solid benign growths in the cavity of the uterus which can increase the level of bleeding at the period, or can cause bleeding between the periods.
Abnormalities of the lining of the uterus
Particularly relevant is a condition called endometrial hyperplasia, which occurs when there is an overgrowth of cells lining the uterus. Mostly, these cells are normal cells, and simple treatment with medication or a Mirena IUD settles everything down, but sometimes these cells can be pre-cancerous cells and a hysterectomy is required.
Uterine fibroids
These are benign muscle tumours that grow in the wall of the uterus. Sometimes these fibroids can press into the cavity of the uterus (where the lining sheds away each month during the period), causing disruption to shape of the cavity and increasing the bleeding amount at the period.
Infections
Bleeding after intercourse can be a warning sign that there may be a Chlamydia infection in the cervix which needs urgent antibiotic treatment to prevent damage to the Fallopian tubes and potential ongoing infertility.
Abnormal cells on the cervix
The presence of abnormal cells on the cervix can cause bleeding between periods, or bleeding after sexual intercourse. A special check of the cervix called a colposcopy in Dr Friebe’s rooms may be required in this situation to rule out any problems.
Absent, infrequent, or irregular periods
This can have several causes – a good history, examination and some investigations will almost always be able to determine the cause and correct management.
Some common causes of include:
- Unexpected pregnancy (more common than you’d think).
- Failure to ovulate due to Polycystic Ovarian Syndrome (PCOS).
- Failure to ovulate due to other hormonal issues impacting on the body- underactive thyroid gland, high prolactin hormone.
- An approaching menopause, especially for a woman over 50. A woman is considered post-menopausal when she has had no periods for 12 months. Leading up to this for a year or two there can be some major changes in period frequency, heaviness and duration which is all included under the label of perimenopausal bleeding changes. These changes can be a problem for a woman and can lead her seeing the doctor for advice.
- Much, much more rarely, and mainly affecting young women of teenage years, chromosome abnormalities and structural abnormalities of the uterus, cervix or vagina can lead to issues especially with periods failing to start, a condition called primary amenorrhoea.
Investigation
Initial assessment of heavy periods or issues with irregular or abnormal bleeding patterns will involve a thorough history and examination, including a Pap smear if one is due. An ultrasound is generally always necessary, and if this has not been organised by the GP prior to seeing Dr Friebe, this can be performed in his rooms during the initial consult.
Further investigation beyond this may involve a procedure called a hysteroscopy (with D+C).
Treatment
Treatment of heavy bleeding or irregular bleeding will be customised to the individual, and is an elective choice for the patient after discussion of the options with Dr Friebe.
Broadly speaking, management options fall under 3 different categories:
Medical
Using the contraceptive pill to regulate the cycle and reduce the period blood loss. Transexamic Acid taken at the time of the period to try and reduce the period blood loss.
Mirena IUD
This is a progesterone hormone secreting Intrauterine Device (IUD), which is placed into the uterus, and for up to 5 years can stabilise and suppress the uterine lining, thus often leading to suppression of periods altogether, or significant reduction in period blood loss.
Surgical
This involves either an endometrial ablation, to permanently destroy the uterine lining to try and cease periods or greatly reduce the blood loss at period time, or hysterectomy, to remove the uterus altogether. Please see lower sections for explanations on these procedures.