Menstrual Disorders – Heavy and Painful Periods

Abnormal uterine bleeding

Abnormal uterine bleeding can be due to uterine abnormalities that are structural such as fibroids, polyps, adenomyosis (a thickening of the muscle of the uterus) or even cancer of the uterus.

Bleeding can be abnormal in a number of ways; too heavy, irregular rather than cyclical, at the wrong time, or too prolonged.

Bleeding can be abnormal for hormonal reasons that result in an abnormality of the lining of the uterus, due to lack of ovulation (no egg released in the cycle) or associated with egg release (ovulation). Abnormal uterine bleeding in the absence of a structural abnormality of the uterus, where we believe that the cause is hormonal either with or without ovulation is called dysfunctional uterine bleeding.
This is a diagnosis of exclusion after pathological causes of abnormal bleeding, including malignancy, have been excluded.

The most concerning types of abnormal bleeding, as they are the most likely to be associated with malignancy, are post-coital bleeding (bleeding after intercourse) or post-menopausal bleeding (bleeding after the menopause).

Evaluation of abnormal bleeding involves a full history and examination, appropriate blood tests including a full blood examination, iron levels, thyroid hormone levels, hormone testing and a pelvic ultrasound.

Intramenstrual bleeding, spotting between periods, and post-coital bleeding may be due to an abnormality of the cervix and then a colposcopy (visualisation of the cervix with a microscope) and an accurate cervical screening test is essential.

A diagnostic surgical procedure called a hysteroscopy under general anaesthetic may be required. In this procedure a telescope is inserted through the cervix and into the uterus under general anaesthetic and biopsies (curette) of the lining of the uterus is performed. Any lesions such as polyps are also removed at the same time. A hysteroscopy and curette as a diagnostic procedure is especially important in older patients (over 40 years of age) and where the bleeding is intramenstrual, post-coital or particularly irregular; situations more likely to be related to malignancy.

Dysmenorrhoea

Dysmenorrhoea is painful menstruation.
This can be primary implying it has always been present with your periods, or secondary, which means that it has developed as a new symptom whereas your periods were previously painless or nearly so.

Dysmenorrhoea of note occurs in 50 – 80% of women in the reproductive age range. It obviously varies in intensity between different women.

Women (especially those with primary dysmenorrhoea) probably have pain due to prostaglandin hormone release. All women release prostaglandins early in their period. It is thought that women with significant primary dysmenorrhoea either release more prostaglandin or are more sensitive to the amount of prostaglandin they release. Unfortunately there is no reliable blood test to tell us whether or not prostaglandin sensitivity is the cause of your dysmenorrhoea.
These symptoms are often helped by anti-prostaglandin medications (NSAIDS). These medications help by reducing prostaglandin production and are in themselves pain relieving. The earlier you start these medications in association with your menstrual cycle the more likely they are to be helpful. If you can actually start the medication 12 – 24 hours prior to your anticipated pain they are most likely to be effective.

Common causes of secondary dysmenorrhoea?

Common causes of secondary dysmenorrhoea are endometriosis, adenomyosis, pelvic inflammatory disease, adhesions or for unknown reasons.

Investigations again include a full history and examination as well as the following:

• testing for infection – blood tests, cervical swabs for chlamydia and other infections
• pelvic ultrasound

Secondary dysmenorrhoea is best managed with a laparoscopy to make a diagnosis. A laparoscopy is a procedure using a telescope under general anaesthetic inserted via a small incision in the umbilicus to visualise all of the pelvic organs. It especially looks for causes of secondary dysmenorrhoea such as endometriosis.

Treatment of abnormal uterine bleeding and/or dysmenorrhoea

The treatment of abnormal menstrual bleeding and painful periods depends on the cause. It includes:

• hormonal treatments such as oral contraceptives and progesterone hormone
• a progesterone releasing IUD
• tranxenamic acid – for reducing blood loss
• endometrial ablation (novasure, used for blood loss not for dysmenorrhoea)
• laparoscopic excision and diathermy of endometriosis

Dr Kliman has had a long career managing women with menstrual disorders and period pain and will go through the pros and cons of all management options.