Women’s Health: Period Problems

SOMETIMES it’s hard to be a woman.

And we’re not talking about relationship troubles. Normally from puberty, right up until menopause, the average woman will spend approximately 3,500 days menstruating.

Of these women, 20 per cent will experience period problems according to Dr Luciano Nardo - consultant in gynaecology, reproductive medicine and surgery and director of North West Fertility and GyneHealth.

He said: “It’s such a common problem and one of the main areas of gynaecological interest.”

“I had a patient who had a period once every four months and thought that was normal. There are a lot of misconceptions.”

From a lack of periods to heavy periods the irregular and darn right painful – when not caused by pregnancy, menstrual irregularities may be a sign of a gynaecological condition or problem. It is common for women at the beginning and end of their reproductive lives to miss or have irregular periods, however there are many conditions that can cause menstrual irregularities.

Dr NardoDr Nardo said: “It’s a big area and there are many different types of problems within it. Firstly, it’s important to identify the age range of the woman. A period problem in a woman who is 28 is completely different to a woman of 50. The investigations we carry out therefore are also different. We have to individualise the management of period problems.”

Please note, we’ve intentionally not covered PMS/PMT within this article as it’s a different area (a large area at that) which often requires a multi-disciplinary approach. This topic will be covered in a separate article next month.

What is the normal cycle?

Dr Nardo said: “I had a patient who had a period once every four months and thought that was normal. There are a lot of misconceptions. Some women also believe they have to have pain to have periods and if they don’t have pain, it’s not a period. That of course isn’t the case either.

“A normal period should be anything from 28 to 35 days. Normal flow should last for about four days and in 60-70 per cent of cases, a period shouldn’t last for more than five days. If it does last more than five days or if there are blood clots, then that is then classed as abnormal heavy bleeding (menorrhagia).”

Reasons to see a doctor

- If you haven’t had a period by the age of 16.

- If your periods are irregular.

- If you bleed between periods.

- If your flow lasts longer than seven days each month.

- If you experience heavy bleeding that requires changing pads or tampons more than every one or two hours.

- If you experience severe pain or cramps during menstruation.

Painful Periods

Painful periods are the most common reason for women being seen by a gynaecologist or GP, among women complaining of period problems.

Doctors and gynaecologists use visual scales with patients to assess the pain being experienced. Dr Nardo asks patients to say on a scale of 1-10 how bad the pain is. He has found that the majority of women will say 7, 8 or 9 therefore making it very difficult to measure the pain threshold.

Doctors will then go on to ask how debilitating the pain is (time off work etc), find out how the patient manages the pain (pain killers etc), how long the pain lasts and whether the pain is triggered by anything else or is associated with other symptoms (e.g. heavy and painful periods). Painful periods are often associated with anatomical causes and it’s important to bear in mind that period pains are rarely a sign of disease, especially in younger women.

Possible causes:

- Endometriosis: The abnormal growth of cells similar to those that form the inside of the uterus, but in a location outside of the uterus. These patches behave like the normal womb lining (shed on a monthly basis), but cause pain, subfertility and inflammation.

- Adenomyosis: known as ‘endometriosis of the uterus’, it’s the presence of fibroid type tissue inside the uterus. The tissue makes the uterus contract causing pain.

- Non-specific: some women can have pain symptoms that aren’t related to anything specific. Some of these women may benefit from seeing an acupuncturist or hypnotherapist.

Painful Periods

Heavy Periods

Menorrhagia is the medical name for heavy periods and this is the second most common period problem. Heavy menstrual bleeding is considered to be 60-80ml or more in each cycle. The average amount of blood that is lost during a period is 30-40ml. Heavy bleeding does not necessarily mean there is anything seriously wrong, but it can affect a woman physically, emotionally and socially, and can cause disruption to everyday life. 

Possible causes:

- Anatomical causes: Heavy periods are often associated with anatomical causes such as fibroids or polyps (both benign lumps within the uterus). Hormonal imbalances mean increased oestrogen will make the endometrium (lining of the womb) thicker resulting in heavy bleeding. Both fibroids and polyps can be caused by and/or grow more with hormonal imbalances.

Irregular periods

Periods that may come, not every 28-35 days but more like every 55-60 days are classed as irregular. Irregular periods are most likely to be associated with hormonal imbalances. Doctors also have to bear in mind the age of the woman as they would expect younger women to have irregular periods because it can take time for the ovarian cycle to settle after the start of their periods (menarchy).

Possible causes:

-       Increased body weight.

-       Excessive exercise.

-       Stress/anxiety.

These factors can have an impact on the very complicated sounding hypothalam pituitary ovarian axis (HPO). In simple terms, hypolthalams and the pituitary are two glands in the brain that stimulate the ovarian function. Some women may not have regular periods because their HPO is, for example, disturbed by doing excessive exercise or too much stress and worry.

Irregular Periods

Absent Periods

Amenorrhoea is the medical term for absent periods. It can be categorised into primary amenorrhoea (the failure to start periods) and secondary amenorrhoea (the absence of periods for six consecutive months in a woman who previously had regular periods).   

Primary Amenorrhoea possible causes:

- Late development in reaching the menarche (first period).

- Malformations such as imperforate (blocked) hymen. Many women with this will experience pain as blood accumulates in the vagina. Another malformation is the absence of the uterus or vagina.

Secondary Amenorrhoea possible causes:

- Chronic illness.

- Weight loss.

- Obesity.

- Excessive exercise.

- Stress/anxiety.

- Hyperprolactinaemia: high levels of the hormone prolactin in the blood.

- Premature Ovarian Failure. This is women who are diagnosed with no eggs left in their ovaries and no periods. It can happen at any age. It can be a disaster for women who want to have a family. It’s not as common as other period problems but it is something Dr Nardo sees in the clinic.

- Polycystic Ovary Syndrome: These women may not have periods because they don’t ovulate (they produce eggs but they’re not released). They will produce increasing levels of oestrogen which is bad for the uterus as it causes increasing thickness lining.

- Post pill: This is when stopping oral contraceptives does not lead to a resumption of a normal menstrual cycle. It usually settles on its own within six months. Dr Nardo said: “It’s like driving a car and knowing you can’t go faster than 100mph because there’s an automatic break. When you take off that break you’ll start going 120mph. The pill modulates the periods and you have to allow time for periods to settle back down after the pill.”

- Early menopause.

- Result of medication.

Dr Nardo said: “I have a patient who is a young lawyer with no periods. She’s not menopausal but she exercises five times a week. She doesn’t have to stop exercising but she should reduce it. The average amount of exercise, in my opinion, for a woman should be three times a week. It’s very important. If this patient carries on, she might never have periods and therefore she may not have children.

“With many women we recommend to stop exercising, wait six months and see if the periods come back. Sometimes we can also give them the hormones they lack to kick start things.”

Treatments

Treatment must be individualised according to nature of the problem and age of patient. For example, if the patient is 30-years-old with heavy periods, a doctor would exclude hormonal and possibly also anatomical problems (endometriosis).

If the patient is in their mid 50s or has started menopause a doctor would exclude malignancy of the lining of the womb or the presence of a polyp. Doctors also first identify why some women have irregular periods to then identify treatment.

For absent periods, it’s important to establish what stage the patient has stopped having periods or if they ever started having periods in the first place. The approaches to both of these are different. 

For any age, the first line of management is a trans-vaginal ultrasound scan.

Dr Luciano G Nardo is a Consultant in Gynaecology and Reproductive Medicine. He is a Director of North West Fertility and GyneHealth - a comprehensive multidisciplinary independent sector service for women's health. He sees private patients regularly at his clinics in central Manchester, Cheshire and London, and is supported by a team of consultant colleagues, specialist nurses, counsellors, acupuncturists, reflexologists, dieticians, physiotherapists and administrative staff.

Useful links:

www.spiremanchester.com

www.lucianonardo.com

www.northwestfertility.co.uk

www.gyne-health.co.uk  (0161 827 7863 or email info@gyne-health.co.uk)