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Menstrual Problems 

What is Menstrual Problems ?
Menstrual disorders include:

Heavy bleeding (menorrhagia) includes prolonged menstrual periods or excessive bleeding.

Absence of menstruation (amenorrhea). Primary amenorrhea is considered when a girl does not begin to menstruate by the age of 16. Secondary amenorrhea occurs when periods that were previously regular stop for at least 3 months.

Light or infrequent menstruation (oligomenorrhea) refers to menstrual periods that occur more than 35 days apart. It usually is not a cause for concern, except if periods occur more than 3 months apart.

A normal period is a blood loss between 30 and 40 ml per month. Bleeding can last up to eight days but bleeding for five days is average.

A heavy period  is a blood loss of 80 ml or more. However, it is difficult to measure the amount of blood that you lose during a period. For practical purposes, a period is probably heavy if it causes one or more of the following:

 Flooding through to clothes or bedding.

 You need frequent changes of sanitary towels.

 You pass large blood clots.

Menorrhagia  means heavy periods that recur each month. Also, that the blood loss interferes with your quality of life. For example, if it stops you doing normal activities such as going out, working or shopping. Menorrhagia can occur alone or in combination with other symptoms.

Tests advices are:

An ultrasound scan of your uterus : This is a painless test which uses sound waves to create images of structures inside your body. The probe of the scanner may be placed on your tummy (abdomen) to scan the uterus. A small probe is also often placed inside the vagina to scan the uterus from this angle. An ultrasound scan can usually detect any fibroids, polyps, or other changes in the structure of your uterus.

 Internal swabs: This may be done if an infection is the suspected cause of the heavy bleeding. A swab is a small ball of cotton wool on the end of a thin stick. It can be gently rubbed in various places to obtain a sample of mucus, discharge, or some cells. A swab is usually taken from the top of your vagina and also from your cervix. The samples are then sent away to the laboratory for testing

 Endometrial sampling: This is a procedure in which a thin tube is passed into the uterus. Gentle suction is used to obtain small samples (biopsies) of the uterine lining (endometrium). This is usually done without an anaesthetic. This is more likely to be done if you are aged over 45 years, have persistent bleeding or have tried treatment without it helping. The samples are looked at under the microscope for abnormalities.

 A hysteroscopy: This is a procedure in which a doctor can look inside the uterus. A thin telescope is passed into your uterus through your cervix via the vagina. This too can often be done without an anaesthetic. Small samples can also be taken during this test.

Blood tests: To check anaemia and also to look for an underactive thyroid gland or a bleeding disorder is suspected.

Blood tests: These may be take if, for example, an underactive thyroid gland or a bleeding disorder is suspected.

Treatment

⇒ Tranexamic acid tablet

Treatment with tranexamic acid can reduce the heaviness of bleeding by almost half in most cases. However, the number of days of bleeding during a period is not reduced and neither is period pain. You need to take a tablet 3-4 times a day, for 3-5 days during each period. Tranexamic acid works by reducing the breakdown of blood clots in the uterus. In effect, it strengthens the blood clots in the lining of the uterus, which leads to less bleeding. If side-effects occur they are usually minor but may include an upset stomach.

⇒ Anti-inflammatory painkillers

There are various types and brands common are mefenamic acid or naproxen. These medicines reduce the blood loss by about a quarter in most cases. They also ease period pain. You need to take the tablets for a few days during each period. They work by reducing the high level of prostaglandin in the lining of the uterus. This is a chemical which seems to contribute to heavy periods and period pain. However, they do not reduce the number of days the period lasts.
Side-effects occur in some people and may include an upset stomach. If you have a history of a duodenal or stomach ulcer, or asthma, you should tell us. 
Many women take both anti-inflammatory painkillers and tranexamic acid tablets for a few days over each period, as they work in different ways. This combination of tablets can be really effective for many women with heavy periods.

⇒ The combined oral contraceptive pill (COCP)

This reduces bleeding by at least a third in most women. It often helps with period pain too. It is a popular treatment with women who also want contraception but who do not want to use the LNG-IUS. If required, you can take this in addition to anti-inflammatory painkillers (described above), particularly if period pain is a problem. 

⇒ Norethisterone 

Norethisterone is a hormone (progestogen) medicine. It is not commonly used to treat heavy periods. It is sometimes considered if other treatments have not worked, are unsuitable or are not wanted. Norethisterone is given to take on days 5-26 of your menstrual cycle (day 1 is the first day of your period). Taking norethisterone in this way does not act as a contraceptive.
The reason why norethisterone is not commonly used as a regular treatment is because it is less effective than the other options. Also many women develop side-effects. However, norethisterone may be used as a temporary measure to stop very heavy menstrual bleeding (see ‘Emergency treatment to rapidly stop heavy bleeding’ below).

⇒ Other medicines 

Other hormonal treatments, such as gonadotrophin-releasing hormone (GnRH) analogues, are occasionally used by specialists in hospital. However, they are not routine treatments, due to various side-effects that commonly occur

⇒ Levonorgestrel intrauterine system (LNG-IUS)

This treatment usually works very well. The LNG-IUS is similar to an IUCD, or coil. It is inserted into the womb (uterus) and slowly releases a small amount of a progestogen hormone called levonorgestrel. The amount of hormone released each day is tiny but sufficient to work inside the uterus. In most women, bleeding becomes either very light or stops altogether within 3-6 months of starting this treatment. Period pain is usually reduced too. The LNG-IUS works mainly by making the lining of the uterus very thin.
The LNG-IUS is a long-acting treatment. Each device lasts for five years, although it can be taken out at any time. It is particularly useful for women who require long-term contraception, as it is also a reliable form of contraception.

Surgical treatment

Having surgery is not a first-line treatment. It is an option if the above treatments do not help or are unsuitable:

⇒ Removing or destroying the lining of the uterus is an option is an option. This is called endometrial ablation or resection. An instrument is passed into the uterus via the vagina. The aim is to remove as much of the lining of the uterus as possible. This can be done in various ways such as by using heat, microwaves, and freezing treatment (cryotherapy). This treatment prevents women from having children in the future. However, there have been some pregnancies in otherwise fertile women, so it cannot be used as contraception. Usually this is very successful but sometimes it needs to be repeated as it is not permanent. 

⇒ Hysterectomy is the traditional operation where the uterus is totally removed. However, hysterectomy is done much less commonly these days since endometrial ablation became available in the 1990s. It is a more major operation, with more possible problems and a longer recovery time. It may be considered if all other treatment options have not worked for you.