In this two-part series, Cecilia Bottomley discusses patients with gynaecological presentations. This piece covers changes or abnormalities in menstrual flow
First, rule out the following
If the woman is premenopausal
Could she be pregnant?
• Has she missed a period?
• Has she had a light or abnormal last period?
• Is she using contraception?
If pregnancy is a possibility, ask her to take a home urinary pregnancy test. If positive, assess the need for urgent early pregnancy unit referral if there is pain or bleeding as it could be an ectopic pregnancy or miscarriage
If the woman is postmenopausal
• Is there postmenopausal bleeding?
If so, refer on the cancer pathway
If the woman has acute abdominal pain
If symptoms suggest adnexal torsion, she needs same-day emergency assessment
Once these causes have been excluded, explore the presenting problem in more detail
Menorrhagia or heavy menstrual bleeding (HMB)
Women’s perceptions of heavy bleeding vary from individual to individual, which can make it difficult to assess how much investigation or management is required. To ascertain the degree of menorrhagia, ask:
• How many days does bleeding continue?
• What size tampon (regular, super, superplus) or pad do they use (panty liner, regular, ‘night-time’), or how often do they need to empty their menstrual cup?
• Do they need to wear double protection – tampon and pad together?
• At maximum flow, how often do they need to change their protection? Every hour, every three hours, every five hours?
• Do they need to get up at night to change protection?
Double protection, changing more than every two hours and getting up at night are all signs of very heavy loss. In this case, the woman needs investigation for anaemia as well as first-line management:
Other factors to consider include medication, for example if the woman is taking oral anticoagulation, which increases bleeding, or if she is on thyroxine and needs a change to her dose.
The haemoglobin levelis important – does she need iron supplementation? It is not unusual for women to be referred to secondary care when their haemoglobin is already very low (as low as 40g/l) from menorrhagia. It is better to pick this up early when possible.
NICE guidelines on HMB suggest that testing for coagulation disorders (for example, von Willebrand disease) should be considered only for women who have had HMB since their periods started and have a personal or family history suggesting a coagulation disorder.
NICE does not recommend routine tests for ferritin, thyroid function or female hormone profile.
Pelvic ultrasound scan is recommended where the bleeding is very significant to rule out conditions that might require specialist treatment, typically:
• Fibroids (especially if submucosal).
• Polyps (which can be associated with heavy bleeding if large).
• Suspected endometrial hyperplasia (higher risk if the woman is overweight, has PCO, or is older).
Any woman reporting regular heavy bleeding can immediately, after remote consultation, be started on treatment, regardless of whether a face-to-face examination or ultrasound scan is required. Treatment should be started as soon as menstrual bleeding or pain start, rather than when they are at their height, and should be stopped once the pain and bleeding are tailing off.
• Tranexamic acid 1g three times daily if there is no personal history of thrombosis or convulsions. This may reduce flow by up to 50%.
• Mefenamic acid 500mg three times daily if the woman has no sensitivity to NSAIDs and no previous GI bleeding. This reduces pain and flow.
These drugs are effective when used together where symptoms are severe, especially if pain is a component. If symptoms are less severe, it is reasonable to start with tranexamic acid and add mefenamic acid if relief is insufficient. I reassure women that while the medications have similar names, they are completely different drugs and can be taken simultaneously for maximum benefit, and also that this is ‘non-hormonal’ treatment, which will not alter their fertility chances, weight or mood.
Further assessment may be required if the patient has significant pain with her heavy bleeding or if she reports pressure symptoms – as large fibroids or ovarian cysts may be the cause. Direct ultrasound would usually be required in these scenarios, so a face-to-face physical examination may not be mandatory. Speculum examination is not usually necessary for menorrhagia unless there is intermenstrual or postcoital bleeding or discharge, which could suggest infection, or cervical pathology.
Provided it is not contraindicated, the COC usually makes periods lighter and shorter. The chance of cycle irregularity is much less with the COC (especially if started on day one to two) than with the POP. However, the POP is likely to be more suitable if the woman is older, overweight or a smoker. Before starting the COC the woman should have a blood pressure check, which can be carried out remotely. She should be counselled about potential risks (such as VTE) and what to do if a pill is missed.
Contraindications to the COC can be found in the UK Medical Eligibility Criteria (UK MEC).
If the patient has an ultrasound scan that suggests a normal cavity and no endometrial pathology, discuss a levonorgestrel-releasing IUD (LNG-IUS), and counsel her:
• About anticipated changes in bleeding pattern, particularly in the first few cycles, and maybe lasting longer than six months.
• That it is advisable to wait for at least six cycles to see the benefits of the treatment.
While the woman would have to attend for the coil to be fitted, the discussion can be done remotely, which allows her to consider the option while trialling the first-line nonhormonal methods.
Altered flow or cycle length
A change in pattern of bleeding often causes concern to women, especially if they have previously had very predictable cycles. However, an altered cycle or flow is often not a pathological process and reassurance can usually be given. Any consultation should acknowledge that a woman may have underlying concerns, such as a family member who had a gynaecological cancer or a worry about fertility, so this can be explored during the remote consultation. Look out for the following.
Longer or shorter cycle length
Cycle lengths from 24 to 35 days are very common and these women are usually still ovulating and should not be concerned. Reassurance can be given by remote consultation and no further investigations are needed.
Where cycle lengths are more than 35 days it is more likely this is due to PCO. Ask during the remote consultation about weight increase, excessive hair growth and acne.
If there are features of possible hyperandrogenism or the woman is concerned about her symptoms, blood tests will be needed for PCO and also other rarer causes of oligomenorrhoea or amenorrhoea: These include:
• LH and FSH. The LH:FSH ratio will normally be raised with PCO. FSH and LH will be low with hypothalamic causes.
• Testosterone to rule out hyperandrogenism.
• Thyroid function.
Secondary amenorrhoea is common. Generally the cause is either hypothalamic, such as over-exercise, stress or anorexia, or PCO, where weight gain may be a symptom of PCO. Often this picture may be mixed. Ask about weight loss and stress (such as university exams, job and relationship problems, bereavement). Also ask about exercise.
In my practice I spend much time explaining to women in their 20s and 30s that it is not ‘normal’ to run 10km several times per week and that a healthy diet should include adequate carbohydrates and fats rather than predominantly fruit and vegetables. Increasing veganism and gluten avoidance seem also to be contributing to women developing habits of inadequate dietary input, which can lead to the cessation of periods. In such cases I explain the hypothalamic stress response, which leads to low oestrogen and a reduction in bone density and indicates that the body is not coping.
Delayed or missed period
A delayed period that is very heavy and prolonged is typically caused by an anovulatory cycle, especially in women in their 40s and early 50s, although a pregnancy test should be done to rule out a miscarriage. This is usually self-resolving but if it lasts more than 10 days it can be treated after remote consultation, with norethisterone 5mg three times daily for 10 days. Bleeding usually stops within 48 hours. The patient should be advised that withdrawal bleeding resembling true menstruation occurs a few days after the end of treatment.
If the problem persists despite this or is recurrent, referral for ultrasound is needed. If ultrasound is unremarkable, hormonal treatment options can be offered, which can be done remotely, to regulate the cycle – such as the COC or POP, or further courses of cyclical norethisterone. An LNG-releasing IUD is another option but obviously requires an in-person appointment.
‘Menstrual chaos’ is a term I use when women report such continuous or irregular bleeding that there is no recognisable cycle. This should raise concern especially if there are symptoms of anaemia. A woman in this situation needs referral and the possible differential diagnoses include endometrial hyperplasia or malignancy, large submucosal or even prolapsed fibroids, large cervical polyp or frank malignancy of the endometrium or cervix. A face-to-face GP consultation for examination could be useful in guiding the urgency of referral. FBC and an ultrasound scan would also be helpful.
Women may be concerned that their periods are light but generally this does not reflect a problem and has no impact of fertility, which is a common concern. An exception, where referral is needed, is a woman who has had a recent evacuation for miscarriage or intrauterine procedure where adhesions may have developed.
Miss Cecilia Bottomley is a consultant gynaecologist and clinical lead for gynaecology governance at University College London Hospitals
These features will necessitate same-day emergency hospital assessment or referral on the local gynaecology suspected cancer pathway
Postmenopausal bleeding Urgent referral on the suspected cancer pathway. Face-to-face assesment not needed.
Advise patient that you need to rule out cancer but the cause is more likely to be a polyp or atrophic vaginitis
Possible pregnancy Consider if the patient has missed a period, has unusual light or irregular bleeding, especially
if there is pain, which raises the likelihood of ectopic pregnancy. Patient should do pregnancy test. Refer to early pregnancy unit if this is positive
Weight loss, bloating, lower abdominal discomfort Consider either urgent referral on suspected cancer pathway for ovarian malignancy or arrange CA 125 and urgent ultrasound
Abnormal discharge, bleeding and pelvic pain in young woman Arrange an urgent sexual health screen for possible pelvic inflammatory disease. Consider FBC, CRP and pelvic ultrasound. If the woman is pyrexial and unwell (for example, she is vomiting) refer for same-day hospital assessment
Persistent intermenstrual bleeding for more than three cycles or persistent postcoital bleeding Face-to-face assessment is needed for a sexual health screen, and a speculum examination to rule out cervical malignancy and to assess for cervical polyp
Acute onset of very severe abdominal pain Consider ovarian torsion and refer for emergency hospital assessment, especially if the patient is vomiting
FSRH Clinical Guideline: Problematic Bleeding with Hormonal Contraception. July 2015 tinyurl.com/fsrh-hormonal
FSRH UK Medical Eligibility Criteria for Contraceptive Use (UK MEC). 2016 fsrh.org/ukmec/
NICE. Heavy menstrual bleeding: assessment and management. NG88. Updated 2021
NICE. Endometriosis: diagnosis and management. NG73. 2017