Heavy Menstrual Bleeding (HMB)

This is the most common gynaecological symptom, making up 12% of all referrals to gynaecological services. Heavy bleeding can also be complicated by flooding and blood clots, which have a significant impact on daily activities and your general health.

HMB can have a cause; like a polyp, fibroid or adenomyosis, but the most of the time the reason is functional – which means that there will be no obvious cause to explain it. You will be referred for an ultrasound scan to rule out a cause and a blood test to make sure you’re not anaemic from the excessive blood loss.

Treatment of Heavy Menstrual Bleeding

Most cases of HMB can be managed through medicines to reduce bleeding such as mefenamic and tranexamic acid. Hormonal treatments such as the combined or progesterone-only contraceptive pill can also be used.

The progesterone intrauterine device (coil) such as the Mirena or Levosert are extremely effective in managing HMB – with over 90% of ladies reporting a reduction in the amount of bleeding. This can be fitted without anaesthesia and can continue to reduce menstrual bleeding for up to 5 years.

Surgical treatment can be through a procedure called endometrial ablation, where heat is applied to the lining of the womb to make it non-functioning and in turn reduce the amount of menstrual bleeding. This can be performed under local or general anaesthetic. If these treatments are ineffective or unsuitable, then a hysterectomy (removal of the womb) will be offered.

Absent or Delayed Periods

Delayed periods in the absence of pregnancy may be due to several causes, mostly hormonal. Most common causes are:

• Polycystic Ovarian Syndrome (PCOS)
• Thyroid abnormalities (overactive or underactive)
• Hormonal imbalance (such as raised Prolactin)
• Increased or decreased body mass index (BMI)
• Adhesions within the uterus or cervix

In rare circumstances, this can be a symptom of premature menopause. Your gynaecologist will refer you for an ultrasound and a blood test for hormone profile. Treatment will depend on the cause – but in most cases will be medical.

Polycystic Ovarian Syndrome (PCOS)

PCOS is a very common hormonal condition which is diagnosed with the presence of at least 2 of the following:

• Infrequent or delayed periods
• Raised testosterone or symptoms like male-pattern hair growth
• Polycystic ovarian appearance on ultrasound scan

A common misconception is that there are actual cysts on the ovaries that need treatment or removal. The “polycystic” appearance of the ovaries is nothing more than “eggs” that have not ovulated – not cysts that need removal. In some cases, PCOS is associated with obesity and insulin resistance, which can increase the risk of diabetes. Infrequent periods can also predispose to thickening of the womb lining, which in a few cases can lead to increased risk of cancer.

Management of PCOS depends on whether you are trying for a baby or not. If not, then management will focus on weight control and ensuring that you have at least 3-4 periods every year to maintain regular shedding of the womb lining. This might be achieved with the contraceptive pill or regular progesterone withdrawal bleeds. You might also opt for a progesterone intrauterine device like the Mirena or Levosert (see above). Your gynaecologist will discuss a suitable management plan with you in clinic.

If you are trying to get pregnant, then you might need to be started on Clomiphene or Letrozole (please refer to the Fertility section of this website). This might be complemented by an anti-diabetic drug called Metformin to counteract insulin resistance, which can help ovulation. In some cases, your gynaecologist might suggest a laparoscopic (key-hole) surgical procedure called “Ovarian Drilling” which might help encourage ovulation in PCOS.

Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)

PMS refers to when a group of symptoms start or get worse in the second half of the cycle (usually the two weeks before the onset of the period). These symptoms might be anything – for example; pain, cramping, bloating and breast tenderness. Or they might be unrelated to the reproductive system such as worsening asthma or skin rash.

When these symptoms are purely mental health or mood-related, it is called PMDD. PMS and PMDD are usually caused by the body and/or the brain reacting the hormone progesterone.

Your will be asked to keep a diary to diagnose PMS or PMDD. This might be a standardised paper diary such as the Daily Record of Severity of Problems – DRSP (see below) or a smartphone app such as Prementrics.

PMS and PMDD can be treated using different methods in order to reduce the progesterone effect. This can range from specific contraceptive pills such as Yasmin to drugs that induce temporary menopause such as Prostap and Zoladex (with or without hormone replacement therapy). In some cases, a hysterectomy with removal of both ovaries followed by oestrogen hormone replacement might be offered, especially when medical treatments become less effective.