Spotlight on period problems

Kathy Oxtoby looks at period problems and the support and advice practitioners can give.

By Kathy Oxtoby On 5 Nov 2024

Periods may be a normal and natural part of life. But they can come with period problems that negatively impact on lives, including debilitating pain, heavy or irregular bleeding, and endometriosis.

According to a recent survey by the charity Wellbeing of Women, many girls say their periods leave them ‘bed bound’ unable to eat or sleep, and feeling like life isn’t worth living.

When asked about specific symptoms, 97% of girls said they experience painful periods with 42% of these describing their pain as severe. Almost all girls had experienced such heavy bleeding that it impacted their daily activities, with more than a quarter reporting this happens most periods.

The charity is calling for the Government to make menstrual health a priority and invest more in education, workplace support and women’s health research. It would like to see girls and women routinely asked about their period problems when seen by healthcare professionals, for example, when they have a vaccination, are given contraceptive advice, or register with a GP.

The survey and asks are part of the ‘Just a Period’ campaign which has been “empowering women with education and resources to help them tackle normalisation and dismissal of period-related symptoms”, the charity says. The new data shows that many girls start experiencing severe period symptoms early on, which could be signs of underlying conditions requiring treatment or support.

Treatment for period problems

Alongside impacting education, physical activity, and mental health, delays in treatment can have severe consequences including iron-deficient anaemia, infertility, and the need for complex multi-system surgeries for conditions like endometriosis, which are progressive, the charity says.

“Women are too often dismissed when they seek help for their period problems, despite experiencing severe pain and heavy bleeding that disrupts their lives, relationships, education and careers. These symptoms can sometimes be a sign of an underlying issue like fibroids, adenomyosis or endometriosis,” says Janet Lindsay, chief executive of Wellbeing of Women.

“Our “Just a Period” campaign seeks to address the unacceptable normalisation of heavy and painful periods, and make sure there is good information and education available for anyone who needs it. We want to empower women to speak out for their health and for them to be listened to, and their concerns taken seriously and investigated, by their healthcare providers,” she says.

Different kinds of period problems

Irregular periods

When it comes to menstrual cycles, “every woman’s experience can be a bit different”, says Mr Hemant Vakharia, consultant gynaecologist and advanced laparoscopic surgeon at London Gynaecology.

A period is considered ‘late’ if it is more than a week late. Reasons for this could be pregnancy, Polycystic Ovary Syndrome (PCOS), hormonal imbalance – issues with thyroid or pituitary gland hormones – eating disorders, and approaching menopause, says Mr Vakharia.

Contraceptive devices like the copper IUD might cause spotting, while hormonal IUDs, injections, implants, and the mini-pill can lead to lighter periods or no periods at all, sometimes with irregular bleeding at first, he says.

For those who begin to experience irregular periods, “it is a good idea to keep a diary and note down when the period occurs”, says Mr Vakharia. “This can be conveniently done using one of the many apps available.”

‘Red flag’ symptoms include prolonged bleeding, heavier flow, bleeding between periods or after sex, he says.

GPs may refer patients to a gynaecologist if they need tests to find out what’s causing their irregular periods. If treatment is needed it will depend on the cause. For example, if a condition like polycystic ovary syndrome is causing irregular periods, the combined pill may help make periods more regular, the NHS advises. ¹

Heavy periods

Many women with extremely heavy periods “still believe their periods to be normal as they have nothing else to compare with”, says Mr Narendra Pisal, consultant gynaecologist at London Gynaecology.

“Bleeding during an average period is supposed to be around 80ml – less than half a cup – but a lot of women do have more bleeding than this,” says Mr Pisal. “You can call your periods heavy, if you are passing lots of clots or having to constantly use double protection, changing protection more frequently than every four hours or if your periods are making you anaemic. It is a subjective thing,” he says.

Heavy periods can be an indicator of underlying problems such as fibroids, endometriosis or thyroid dysfunction, he says.

Prescription medications such as tranexamic acid, which reduces the amount of bleeding, and mefenamic acid, which can relieve spasms, “can be effective”, says Mr Pisal.

“Taking the combined contraceptive pill usually has a positive effect on the menstrual cycle, often making periods lighter and less painful. Hence, the pill is often used as a therapeutic intervention for conditions such as endometriosis, heavy or painful periods,” he says.

Hormonal IUDs (Mirena or Jaydess) secrete a small amount of progesterone within the uterine cavity and will often lead to lighter and less painful periods. Sometimes the periods are completely blocked. Irregular bleeding in the first few months is also a common side effect. The injection, implant and mini-pill all contain progesterone and often lead to absence of periods. Irregular unpredictable bleeding is a known side-effect, says Mr Pisal.

If these measures are not helpful, patients can be referred to a gynaecologist for an assessment and a pelvic ultrasound scan, he says.

Painful periods (dysmenorrhoea)

Dysmenorrhoea is painful cramping, usually in the lower abdomen, which occurs shortly before or during periods, or both, says Dr Priyanka Patel, consultant gynaecologist at London Gynaecology.

Primary dysmenorrhoea “occurs in young females where no pelvic pathology is identified”, says Dr Patel. “It is thought to be caused by uterine prostaglandins produced during periods, which causes uterine contractions and pain. Secondary dysmenorrhoea is caused by an underlying condition, such as endometriosis, fibroids, pelvic inflammatory disease or copper coil.”

Diagnosis of secondary dysmenorrhea is through further investigations, such as a pelvic ultrasound scan or diagnostic laparoscopy, says Dr Patel.

Treatment to alleviate painful periods includes simple painkillers, prescription medications such as tranexamic acid and mefenamic acid, and the combined contraceptive pill, which can often make the periods lighter and less painful, says Mr Pisal.

Exercise, maintaining a healthy body mass index and nutritional changes can help. In particular, avoiding sugars and dairy will reduce period pains, he advises

There are long-term treatment options that can reduce severe period symptoms, such as using a Mirena contraceptive device, endometrial ablation, and a key-hole hysterectomy, he says.

Endometriosis

Endometriosis is defined as “the presence of endometrium-like tissue outside the uterus”, says Mr Vakharia. It is an oestrogen driven, chronic inflammatory condition that most commonly affects pelvic organs but can also in some cases can occur at different areas of the body including the bowel, diaphragm and in the chest cavity.

While pain is a major feature in endometriosis, “the impact it can have on those who suffer with it can be enormous, which is why prompt diagnosis and treatments are crucial,” says Mr Vakharia.

Dysmenorrhoea is one of the symptoms of endometriosis. The endometriotic cells are stimulated by hormones in the natural cycle, which causes inflammation and pain. “It is important to also recognise that some patients experience pain throughout their cycle and not just with their periods,” says Mr Vakharia.

“Generally, if someone comes to the practice with extreme period pain, I would ask if there is a history of endometriosis in the family,” says Helen Lewis, an advanced nurse practitioner and Queen’s Nurse, based in south Wales. Nausea, vomiting, and pain when opening bowels and during intercourse “are all ‘red flags’ for endometriosis,” she says.

Treatment options are medications, such as pain relievers, hormones, and surgery. ²

Adenomyosis

Adenomyosis is “a common but under-recognised condition characterised by an enlarged uterus due to infiltration of the uterine lining into the muscle wall”. “During menstruation, this adenomyotic tissue also swells up and bleeds within the uterine wall which can cause severe period pain, cramps and heavy periods,” says Mr Pisal.

The condition is often diagnosed on an ultrasound or MRI scan where an enlarged uterus is seen with one wall of the uterus thicker than the other, he says.

Typical symptoms are heavy and painful periods. “Sometimes the uterus is so enlarged that a lump can be felt in the lower abdomen and can also cause pressure on the bladder and bowel causing urinary frequency and constipation. Having said that, a lot of women do not have any symptoms at all,” says Mr Pisal. “Many women live with this condition without ever having a diagnosis made.”

Adenomyosis can lead to anaemia due to heavy bleeding, to extreme tiredness, and affect performance at work and sports.

Adenomyosis and endometriosis often occur together. In both cases, the pathology is similar – presence of tissue similar to uterine lining in atypical places, in endometriosis, it is outside the uterus whereas in adenomyosis, it is present in the uterine muscular wall.

“Both doctors and women are now more aware of this condition and increasing availability of ultrasound scans will lead to higher detection rate,” says Mr Pisal.

“Treatment options are still limited as adenomyosis is often embedded in the muscular wall of the uterus,” says Mr Pisal.

Treatment includes anti-inflammatory medication to help relieve mild pain, hormone therapy such as the contraceptive pill, to help control heavy or painful periods, and, in extreme cases, a hysterectomy, NHS Inform advises.³

Period problems and mental health

The menstrual cycle can have “a significant impact” on mood due to the hormonal fluctuations that occur during the different phases,” says Dr Claire Phipps, a GP and advanced menopause specialist at London Gynaecology. Not everyone will be affected in the same way, and it is thought that this is due to an individual’s sensitivity to changing hormone levels within the brain.”

Some women experience premenstrual symptoms (PMS), and some may experience a more significant change in their mood known as premenstrual dysphoric disorder (PMDD), she says.

Practitioners can advise women to keep track of their cycle to note how their mood changes and to manage symptoms, says Dr Phipps. Magnesium-rich foods such as nuts, seeds and leafy greens, and gentle exercise like yoga or swimming can be helpful, says Dr Phipps. It is important to stop smoking, “as there is some evidence that this can make PMT symptoms worse”, she says.

Premenstrual syndrome and premenstrual dysphoric disorder are two very different conditions, treated in different ways, and thereby no means a ‘one size’ fits all treatment, says Dr Phipps.

“It is well known that lifestyle and dietary changes are important for both conditions. Regular exercise, eating a healthy diet, maintaining hydration, ensuring adequate sleep, and alleviating stress can improve symptoms,” she says.

Selective serotonin reuptake inhibitors (SSRIs) can be effective in treating PMS and PMDD symptoms too. And talking therapies are “a good option for many”, says Dr Phipps.

Taking a history

GPs are often the first port of call for most women who are having problems with their menstrual cycle, says Dr Phipps. There are “many different causes of period problems and in order to clarify these we know that taking a good medical history is really important”, she says.

An initial assessment should include taking a history, she says. This will involve a detailed menstrual history (cycle regularity, duration, flow, associated symptoms), the impact on quality of life and daily activities, medical, surgical, and family history. It will also involve current medications, including over-the-counter and herbal remedies, sexual history and contraceptive use, and smear history, says Dr Phipps.

A physical examination will involve a general physical examination, and an abdominal and pelvic examination to check for masses, tenderness, or other abnormalities, she says.

Investigations might include blood tests – a complete blood count (FBC), iron levels, thyroid function tests, hormonal profile (FSH, LH, oestradiol, testosterone, prolactin), and free androgen index. Investigations might also involve a pregnancy test and a smear test if applicable, and a pelvic ultrasound to evaluate the uterus, endometrium, and ovaries, says Dr Phipps.

“If there is any diagnostic uncertainty or of course any worrying features then a referral or discussion with secondary care is an option. Treatments, of course, will depend on the cause,” she says.

When supporting patients “you’ve got to give reassurance, and patients have to have the confidence to come back to see you”, says Ms Lewis. “Don’t send them away saying it’s ‘just period’ pain. It may well be. But it could also be fibroids, endometriosis, or an ovarian problem. And if the patient is concerned, those of us working in primary care are the gatekeepers for their investigations.”

Further information/resources

Primary Care Women’s Health Forum: https://pcwhf.co.uk
Royal College of General Practitioners (RCGP): https://www.rcgp.org.uk/
Faculty of Sexual and Reproductive Healthcare (FSRH): https://www.fsrh.org/home
Endometriosis UK: https://www.endometriosis-uk.org
Verity: A self-help group for those with polycystic ovary syndrome (PCOS). https://www.verity-pcos.org.uk