What are Menstrual Problems?
Each woman is different, and the amount of bleeding and pain varies widely from one person to another. You have been referred to hospital because your periods are disrupting your life. This may be due to pain, heavy bleeding or irregular bleeding.
Heavy menstrual bleeding, also known as menorrhagia, is excessive menstrual (monthly) blood loss, which is either very heavy or lasts for more than seven days.
Dysmenorrhoea is a term used to describe painful periods which can be caused by certain conditions, such as endometriosis. Irregular bleeding, when periods are not monthly but can be more or less frequent, can occur for a variety of reasons including when women are approaching the menopause, polycystic ovarian syndrome and other hormonal changes.
Please ask your nurse or doctor if you need more information about these conditions. This leaflet is designed to give you information about the range of possible non-surgical treatments that you may be offered and help you to make a decision about selecting the best option for you.
What tests (investigations) should I have?
You may not need any tests or investigations for your symptoms. However, sometimes we may arrange a scan to look at your uterus (womb) and ovaries.
Alongside this, you may be offered an internal vaginal examination to look at the cervix, some blood tests to check your blood count, or hormone levels, or possibly a biopsy of the lining of your uterus (womb) if your bleeding is heavy.
What treatments are available?
There are a number of different treatment options for menstrual problems which can be broadly divided into surgical and medical (non-surgical) treatments. You may have already heard or tried some.
Each treatment acts in a different way and not all treatments suit every problem. Some are better for irregular periods, whilst some are better for heavy or painful periods. It can be a matter of trial and error to see which medical preparation is the most suitable and works for you.
The alternatives of surgical management vary depending on your symptoms but are described in separate leaflets, and you can discuss these in further detail with your doctor.
Tranexamic acid
Tranexamic acid does not alter hormones but works to prevent heavy bleeding. For some women this can happen if there is an imbalance in the blood factors within the blood.
Tranexamic acid stops excess release of these factors. It is not contraceptive and will not affect your chances of getting pregnant.
How do I take it?
You can take 1g (two 500mg tablets) three times a day from the start of your period for up to four days. It should be stopped if symptoms don’t improve within three months.
Are there any unwanted effects? You should not take tranexamic acid if you have a history of blood clots (DVT) or stroke. Unwanted effects are rare. Some people experience diarrhoea, nausea or vomiting with this medication.
Non-steroidal anti-inflammatory drugs
These tablets (for example ibuprofen, naproxen or mefenamic acid) do not alter hormonal balance but act as a painkiller to alleviate period pain and can also make periods lighter.
They do this by reducing the body’s production of prostaglandin (a hormone-like substance linked to heavy bleeding). They are not contraceptive and will not affect your chances of getting pregnant.
How do I take it?
You can take these tablets from the start of your period (usually three or four times a day), until your heaviest or most painful days are over. It should be stopped if symptoms don’t improve within three months.
Are there any unwanted effects?
Sometimes these tablets cause heartburn or gastric discomfort. Avoid if you have a stomach ulcer.
Combined contraceptives
Combined hormonal treatments are available as pills, a patch or a ring. They contain both oestrogen and progestogen (the female hormones) and suppress the ovaries and the lining of the uterus (womb).
They tend to make periods lighter, less painful and regular, if used in a standard regime. They are a good choice for contraception and when taken correctly they are over 99% effective at preventing pregnancy. They do not have an effect on future fertility.
How do I take it?
The standard way of taking ‘the pill’ is to take one tablet every day for 21 days, then have a break for seven days. During this week you have a bleed like a period.
The pill can be taken in several different ways, for example you can take the pill every day for nine weeks (taking three packets back-to-back without any break) followed by a short break.
Your doctor or Nurse will advise you if this is recommended.
The patch (Evra) is a small sticky patch that releases hormones into your body through you skin. Each patch lasts for one week and you wear a patch (one per week) for three weeks then have a week off without a patch.
The ring (NuvaRing or Syreniring) is a small soft, plastic ring that you place inside your vagina and releases hormones that get absorbed into the blood stream. Each ring lasts for three weeks then no ring is worn for the fourth week.
You could try a combined hormone medication for six months and stop if symptoms don’t improve.
Are there any unwanted effects?
Most women manage with combined hormones well. However some common side effects include:
- Mood changes
- Nausea
- Breast tenderness
- Headaches.
There is a very low risk of a serious side-effects such as a blood clot (DVT / PE).
The combined pill is not suitable if you are over 35 and smoke, or if you have certain medical conditions (for example women who are obese, heart disease, high blood pressure or a history of blood clots or migraines with aura).
Progestogen tablets (Norethisterone or Medroxyprogesterone acetate)
This works like the natural female hormone progesterone. It is usually taken over a short time to delay or stop bleeding, for example, when you are going on holiday or with an episode of heavy, prolonged bleeding.
How do I take it?
Start as prescribed (usually two or three times a day) to stop or delay bleeding. This is primarily used short-term, prior to a more long-lasting therapy or perhaps surgery.
Are there any unwanted effects?
Some women have tender breasts, feel bloated or have
minor mood change. There is a small increased risk of blood clots taking this medication.
Levonorgestrel-releasing intrauterine system (LNG-IUS)
This is a small T-shaped plastic device that is placed in the uterus and slowly releases the hormone progestogen. The IUS (previously known as a ‘coil’) works by preventing the lining of the uterus (womb) from growing quickly. It was designed as a contraceptive, but it was noticed that many women who used it had lighter periods or no periods and is now used as a treatment for heavy and painful periods.
It can be fitted in women of any age and can still be fitted if you have not been pregnant before.
It is a very effective contraceptive which lasts for five to eight years (depending upon the type of coil used). It will not have an effect on future fertility.
How is fitted?
This is done using a speculum (similar to when you have a cervical smear taken). The doctor or nurse will insert the speculum into the vagina so that your cervix (neck of the womb) can be seen. You may be given some local anaesthetic to numb the area, and then the IUS is inserted through the cervix, usually taking less than five minutes. Most women manage the procedure well.
However, if you found this too uncomfortable, you can use entonox (‘gas and air’) or you could have the procedure under sedation or general anaesthetic.
Are there any unwanted effects?
It is common to have persistent irregular bleeding for the first six months. Some women get hormonal side effects such as breast tenderness, but this usually settles with time.
We would generally recommend you try the IUS for at least six months to allow the bleeding to settle and hormonal side effects to improve. There is a small risk of infection at the time the coil is fitted, perforation (making a small hole in the uterus) at insertion, or expulsion (where the coil falls out).
If you get very heavy bleeding, severe pain, cannot feel the IUS threads or think you might be pregnant, seek medical advice from your GP/practice nurse.
Gonadotrophin-releasing hormone (GnRH) analogues (eg Goserelin acetate ‘Zoladex’, Leuprorelin ‘Prostap’) and GnRH antagonists (Relugolic in Ryeqo and Linzagolix)
These medications are generally used as a short-term trial (usually six months) to see if your symptoms resolve if your periods are stopped. This may be considered prior to hysterectomy.
It works by causing a reversible menopause and most women will have no periods whilst they take this medication. It can also help to manage symptoms relating to fibroids and endometriosis following completion of treatment.
How do I take it?
This is an injection given once monthly or every three months, under the skin. You will usually receive your first dose in the hospital and can have the remaining doses with the GP.
There is a tablet formulation, and this is taken once a day. You can stop this treatment at any time within the six-month trial if you find it does not resolve your symptoms, or you are struggling with the side effects.
Are there any unwanted effects? As this medication causes a reversible menopause, side effects of menopause such as hot flushes, sweats and mood swings are common. These side effects can be reduced by using hormone replacement therapy (HRT) together with the GnRH analogue.
Is there an order in which I should try each treatment?
This may depend on your symptoms, if you are planning a pregnancy and if you have tried any of these.
Generally, we recommend starting with a non-hormonal option, like tranexamic acid or a non-steroidal anti-inflammatory before moving to a hormonal option, however this may not be the best option for you.
Your doctor will discuss with you these options in detail and should advise appropriate options for trialling the different types of treatment, and in what order to do so.
What shall I do if I have a question?
If you have any concerns about any of your medications, please discuss them with your pharmacist or GP.
If, however, you cannot reach your GP, staff at the Women’s Health Unit or our Gynaecology Ward may be able to offer advice over the telephone.
Ward 40
24 hours – Please note that if clinic staff are busy, they may arrange to call back later in the day
Research
At the RVI, we have a large research team and often work with Newcastle University.
All of our consultant team are actively involved in research and may discuss the possibility of you getting involved in research at any of our clinics.
Whilst we are very grateful for those who choose to participate, this is not essential and please feel free to decline. This will not affect your care.
For further information
PALS (Patient Advice and Liaison Service) for help, advice and information about NHS services.
You can contact them on freephone 0800 032 02 02, email [email protected]
Useful website
If you would like further information about health conditions and treatment options, you may wish to have a look at the NHS website at www.nhs.uk
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