Heavy Periods & Abnormal Bleeding
Changes in menstrual bleeding are common, but persistent heavy, painful, irregular or unexpected bleeding can have a significant impact on daily life and may need investigation.
I assess and treat a wide range of menstrual and bleeding problems, including heavy periods, bleeding between periods, irregular bleeding, bleeding after sex and bleeding associated with conditions such as fibroids, adenomyosis or uterine polyps.
You do not need to know what is causing the bleeding before arranging an appointment. A consultation is an opportunity to review your symptoms, consider possible causes and decide whether any investigations are needed.
Investigations
.The right investigation depends on the pattern of bleeding, your age, associated symptoms and any previous treatment or investigations. Assessment usually begins with a detailed history and, where appropriate, examination, ultrasound and blood tests. A full blood count may be useful to look for anaemia associated with heavy bleeding.
Pelvic ultrasound, usually performed transvaginally, can assess the womb and ovaries and may identify conditions such as fibroids, adenomyosis or ovarian cysts. In some patients, treatment can be started without extensive investigation; in others, the symptoms suggest that further assessment is helpful.
Hysteroscopy
Hysteroscopy allows the inside of the womb to be examined directly using a fine telescope passed through the cervix. It is particularly useful when a polyp, a fibroid projecting into the cavity of the womb, or a problem with the womb lining is suspected.
Where appropriate, a biopsy can be taken or some abnormalities can be treated at the same time.
MRI
MRI scanning is not routinely needed for heavy periods, but it can provide useful additional information in selected cases. This may include more detailed assessment of fibroids or adenomyosis, or planning treatment where the exact size, position and number of fibroids are important.
For example, MRI may be considered when further anatomical detail is required before treatments such as uterine artery embolisation or surgery.
Hormonal & Medical Treatments
Medical Treatments
Treatment is tailored to the likely cause of the bleeding, how troublesome the symptoms are, your general health and whether future pregnancy is important to you.
For many patients, treatment can begin with medication rather than surgery. Options may include non-hormonal treatments to reduce menstrual bleeding, hormonal contraception or progestogen treatment.
Hormonal Treatments
The Mirena® intrauterine system releases a small amount of progestogen within the womb and can substantially reduce menstrual bleeding. It is an important treatment option for heavy periods and can also be helpful for some patients with adenomyosis or smaller fibroids where the uterine cavity is not significantly distorted.
Irregular bleeding is common during the first few months after insertion, and the full benefit can take several months to become apparent.
Newer oral treatments for fibroids, endometriosis and adenomyosis
There are also newer oral GnRH antagonist treatments for selected patients with moderate to severe symptoms caused by uterine fibroids, adenomyosis and endometriosis. These work by altering the hormonal stimulation of fibroids and endometriosis and can reduce heavy bleeding and other related symptoms.
Treatment needs to be individualised because suitability, side effects, contraception requirements and the use of accompanying hormone therapy vary between preparations.
Options include Ryeqo (relugolix/oestradiol/norethisterone acetate) and Yselty (linzagolix)
Procedures and Surgical Treatments
Uterine Artery Embolisation
Uterine artery embolisation (UAE) is a minimally invasive treatment performed by an interventional radiologist. It reduces the blood supply to the uterus or fibroids, causing fibroids to shrink and symptoms such as heavy bleeding to improve.
It is an established treatment option for symptomatic fibroids and may also be considered in selected patients with adenomyosis. Suitability depends on symptoms, imaging findings and future fertility plans. If this treatment is being considered, an MRI would normally be arranged and an onwards referral to an interventional radiologist would be arranged.
Hysteroscopic removal of polyps and fibroids
Polyps and fibroids that project into the cavity of the womb can often be removed hysteroscopically, using instruments passed through the cervix without abdominal incisions.
This can both treat the underlying abnormality and improve heavy or irregular bleeding.
Novasure Endometrial Ablation
NovaSure® endometrial ablation is a minimally invasive treatment that removes or destroys the lining of the womb to reduce heavy menstrual bleeding. It may be suitable for selected patients who have completed their family and whose uterine cavity is appropriate for the procedure.
Pregnancy is not recommended after endometrial ablation, so reliable contraception remains important where relevant.
Laparoscopic Hysterectomy
Laparoscopic hysterectomy provides definitive treatment for heavy menstrual bleeding by removing the womb. It may be appropriate when symptoms are severe, when conditions such as significant fibroids or adenomyosis are present, or when other treatments have been unsuccessful or are unsuitable.
Where hysterectomy is being considered, the alternatives, benefits and potential risks should be discussed carefully so that the decision reflects your symptoms and priorities.
NHS Decision Making Aid
NHS England has produced a useful decision-support guide comparing treatment options for heavy periods. It includes information about benefits and risks and pages you can use to think through what matters most to you before your appointment
Finding the right treatment for you
There is rarely a single treatment that is right for everyone with heavy or abnormal bleeding. My approach is to establish the likely cause of your symptoms and then discuss the available options, ranging from medical treatment through to minimally invasive procedures or surgery where appropriate.