For many women, periods are sufficiently regular, light and pain-free not to interfere with life. However, a substantial proportion are bothered by heavy or irregular bleeding and will present with this problem to their GP.
Diagnosis
The NICE heavy menstrual bleeding guidance, published in January 2007, defined heavy bleeding not in terms of absolute blood loss, but by its impact on quality of life.
The skill in taking a history is to understand not only the nature but also the impact of the complaint. Features to understand include regularity and length of bleeding, how many days are heavy and light, intermenstrual bleeding, pain, and other features of the cycle, such as cyclical mood change or breast tenderness.
You may find that the patient is not presenting with anything unusual, and reassurance may be enough. Be alert, however, for a hidden agenda, as complaints of period problems may be a way of asking for contraception, or there may be issues that the patient finds difficult to discuss such as vaginismus or other sexual difficulties.
Having established that there is a menstrual problem, possible causes should be considered and necessary examination, investigation and treatment planned.
Disturbance of frequency and regularity points to an endocrine aetiology, while problems with the amount and character of bleeding and pain suggest a pelvic origin.
Heavy bleeding
Moderately heavy but regular bleeding with no other concerns can be treated with mefenamic acid or tranexamic acid. Women wanting contraception who meet the UK medical eligibility criteria, can be given combined hormonal contraception in either patch or oral form.
This offers the potential advantages of cycle regulation, reduction in bleeding and pain, and prevention of luteal-phase symptoms such as breast tenderness. Attention must be given to factors such as smoking that render synthetic oestrogen an unacceptable risk.
NICE guidelines recommend a levonorgestrel-releasing intrauterine system as a cost-effective option for women with heavy bleeding who will accept contraception and are seeking a longer-term solution.
Marked uterine enlargement of the cavity indicates a need for ultrasound as first-line investigation for structural anomaly. In the absence of structural problems women may consider an endometrial ablation if they have completed their family.
Ultrasound can identify endometrial polyps. These should be referred onward for hysteroscopy and removal.
Large fibroids may be treated by myomectomy or uterine artery embolisation. This may allow retention of fertility. Hysterectomy is not a first-line option due to its risk profile.
Intermenstrual bleeding
Intermenstrual bleeding is a red-flag symptom that should always lead to examination with further investigation based on findings.
Chlamydia, cervical lesions and polyps are all common and can be easily excluded.
It is worth considering endometrial biopsy to achieve a histological diagnosis in women over 45 years who have failed simple medical treatment.
Irregular periods
The hypothalamo-pituitary-ovarian axis is responsible for cycle regulation. Very irregular periods in the absence of hormonal contraception result from disruption of this axis.
The most common problem is polycystic ovarian syndrome. In primary care the combination of infrequent periods and a raised free androgen index are sufficient to make this diagnosis.
Weight loss to a BMI below 18kg/m2 or high levels of anxiety can inhibit ovulation through hypothalamic mechanisms and it is important to ask about this.
Irregular bleeding with progestogen-only methods of contraception is an entirely separate issue that is not fully understood.
Endometriosis
Endometriosis results from ectopic deposits of endometrium that undergo cyclical change. The key feature of this problem is pain.
Definitive diagnosis requires MRI or laparoscopy. Treatment can include surgery to remove endometriotic lesions.
Alternatives to surgery include combined hormonal contraception, high-dose progestogens or gonadotrophin-releasing hormone analogues. These are limited to six months' use in the absence of add-back HRT because they produce a hypo-eostrogenic state. Danazol is rarely used because of its high side-effect profile.
Dr Gray is a GP in Truro, Cornwall, and a medical adviser at Women's Health Concern
REFERENCES
- NICE. Heavy Menstrual Bleeding (Guideline 44) 2007. http://guidance.nice.org.uk/CG44
- Faculty of Sexual and Reproductive Healthcare.UK Medical Eligibility Criteria for Contraceptive Use. 2006. www.ffprhc.org.uk/admin/uploads/298_UKMEC_200506.pdf.
