Menstrual Disorders
Evaluation and management of painful, irregular, unusually heavy or absent periods
What is menstrual disorders?
A cycle is being described as abnormal when it has changed from what is normal for you: heavier, longer, more often, or arriving when it is not expected. The reference point is your own pattern, and a change in it is the thing worth reporting.
The causes fall into two groups, and separating them is the whole point of the workup. Structural causes are things a scan or a camera can see in the uterus itself. Non-structural causes are hormonal, involve clotting, or come from medication, and the uterus looks entirely normal in them.
The two groups look identical from the outside and are treated completely differently, so no experienced doctor will commit to a treatment before knowing which one they are dealing with.
What you might notice
- Periods that are heavy or long
- Bleeding between periods or after intercourse
- Bleeding after menopause
How it is diagnosed
The first three tests are a pregnancy test, a blood count and a transvaginal ultrasound. Pregnancy has to be excluded whatever the age, the blood count says how much has actually been lost, and the scan looks at the wall of the uterus and the thickness of the lining.
Thyroid function and clotting studies are added where the pattern suggests them, particularly in a younger woman who has bled heavily since her very first cycle. A hormone profile is worth taking where cycles have become irregular and unpredictable.
Sampling the lining is the step that changes with age. After forty-five, and earlier where there are risk factors such as a high body weight or long stretches without a cycle, the lining is sampled to be certain of what it is made of before any treatment is chosen.
Recovery
Medical treatment is the starting point for most women and takes three months to be judged fairly. A hormonal approach often makes the first two cycles unpredictable before it settles, and stopping at six weeks is the commonest reason a treatment that would have worked is written off.
Where something is done through the cervix, recovery is a matter of days: cramping and spotting for under a week, and normal activity almost immediately.
Correcting the anaemia takes longer than stopping the bleeding. Iron replacement runs for three months after the count has come back to normal in order to refill the stores, and the tiredness lifts weeks after the loss itself is under control.
If it is left untreated
Irregular cycles that are not troubling you and are not making you anaemic can reasonably be watched, particularly in the first years after periods start and in the years approaching the menopause, when the cycle is expected to be unsettled.
Where the loss is heavy, the cost of waiting is iron. Stores are drained faster than food replaces them, and the tiredness and breathlessness that follow build so slowly that most women adjust to them without noticing, so a blood count is often the first thing that shows how long it has been going on.
The reason not to simply manage it indefinitely is that a structural or a cellular cause goes unnamed while it is being managed. Abnormal cells of the lining are treatable when they are found early, and the bleeding is the only warning they give. Any bleeding after the menopause is investigated to a conclusion, and soaking through protection every hour, or feeling faint with it, needs seeing the same day.
Questions about menstrual disorders
How heavy is too heavy?
The definitions in the textbooks are in millilitres and nobody measures that, so the practical tests are better. Soaking through a pad or tampon every hour or two, needing double protection, passing clots larger than a rupee coin, bleeding for more than seven days, or getting up at night to change are all markers of loss that is more than it should be. The simplest test is whether it dictates what you can do on those days. Tiredness and breathlessness on the stairs suggest the loss has already made you anaemic, and a blood count settles that in a day.
Do I have to have a hysterectomy?
Almost certainly not, and it is now the last option instead of an early one. Most women are controlled with medical treatment, and a hormone-releasing coil in particular reduces loss substantially for the majority who try it while leaving the uterus in place. Where a structural cause is found, correcting that one thing often solves the problem. Endometrial ablation is a further option for a woman whose family is complete. Removing the uterus is reserved for bleeding that has not responded to any of these, for a uterus badly distorted by fibroids, or where abnormal cells have been found in the lining.
Why does the lining need to be sampled?
Because a scan can measure the thickness of the lining and cannot say what it is made of, and the whole point is to be certain there are no abnormal cells before treatment is chosen. It is standard from about forty-five onwards, and earlier where there are risk factors such as a high body weight, polycystic ovaries or long gaps between cycles, and it is done for any bleeding at all after the menopause. The sample is taken with a fine tube through the cervix in the clinic in a couple of minutes, or during a hysteroscopy where the cavity needs looking at as well, and the result takes about a week.
Other obstetrics & gynaecology treatments
Delivery of a baby through surgery when vaginal delivery is not advisable or safe
InpatientManagement of non-cancerous growths in the uterus, based on symptoms, size, location and reproductive plans
Day CareTalk to a care coordinator about menstrual disorders
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one