Periods are the monthly shedding of the lining of the womb (menstruation). They start during puberty (usually between the ages of 10 -16) and continue until the menopause (average age 52). Monthly changes in hormones cause the lining of the womb to build up and then shed, following ovulation (the menstrual cycle).

The normal menstrual cycle lasts for 28 days but this can vary between 24 and 35 days. During the menstrual cycle a “period” occurs when the lining of the womb is shed, causing bleeding (menstruation). This normally lasts between 2 and 7 days, although 4-5 days is the average. Every woman will have a different menstrual cycle and bleeding will vary in regularity, duration and heaviness. Everyone has a different threshold for what she considers to be normal or not.

Period problems most commonly mean either painful or heavy periods, but can also include irregular bleeding (bleeding between periods) or no periods at all. A few underlying causes of abnormal bleeding and pain include:
 

• Fibroids: these are benign (non cancerous) enlargements of muscle in the wall of the womb.  
   
• Endometrial polyps: benign outgrowths of the lining of the womb.  
   
• Endometriosis: the cells lining the womb grow elsewhere in the pelvis.  
   
• Pelvic inflammatory disease: ongoing infection of the pelvis often due to STIs (sexually transmitted infections) especially chlamydia and gonorrhoea.  
   
• Polycystic Ovarian Syndrome (PCOS).  
   
• Cancer of the womb lining (Endometrial Cancer), which is rare, especially in premenopausal women.  
   
• Intrauterine contraceptive devices (the Coil).  
   
• Hormonal imbalance (peri-menopause).  
   
• Stress.

A change in the normal pattern of your periods can signify the start of a problem and any concerns about period irregularities should be discussed with a GP.

Painful periods (dysmenorrhoea)

Women all experience different levels of pain and bleeding during periods and therefore they can differ in opinion over what might be considered to be a painful or problematic period. Often women will also have premenstrual symptoms, such as bloating, tender breasts, a swollen stomach, lack of concentration, mood swings and tiredness.

There are different types of pain associated with periods. Teenagers and younger women commonly experience pain that starts at the same time as the menstrual bleeding (primary or spasmodic dysmenorrhoea). These pains tend to be “crampy” in nature and usually finish before the end of a period. Pain relief with non-steroidal anti-inflammatory drugs such as mefenamic acid are usually effective. The combined oral contraceptive pill often helps and in severe cases a doctor may prescribe three packs taken one after the other, without the usual week’s break to reduce the number of periods.

Painful periods may also start before the onset of the period and not disappear until the period stops (secondary or congestive dysmenorrhoea). This type of pain may be related not just to the menstrual flow but could be related to other problems in the pelvis, such as chronic infection or endometriosis (where the lining of the womb appears outside the womb). It tends to affect a slightly older group of women and is also often associated with painful sex.

If you are experiencing any pain similar to that described above, you should consult your doctor. It is important that a diagnosis is made.

Heavy periods

Ten years ago around 20 percent of women would have had a hysterectomy by the age of 60 for heavy periods. In recent years much progress has been made including new drugs and better solutions to treating heavy periods. Heavy periods (menorrhagia) can be difficult to define, as each woman will have a very different perception of what they consider to be normal. Heavy periods are usually associated with flooding or clotting and often the requirement to control menstrual flow with double sanitary protection.

Medically ‘menorrhagia’ is defined as losing over 80mls blood each month. Continuous heavy loss of blood at this level can increase the risk of developing anaemia (low haemoglobin) and treatment should be initiated when a woman feels it is affecting normal life and daily activities.

An absence of periods

Periods can stop for a variety of reasons, the most usual is pregnancy, so it is important that this is excluded as a cause.

Polycystic Ovarian Syndrome (PCOS) affects some women and may cause periods to stop. Sportswomen, ballet dancers or athletes on extreme training programmes may stop having periods.
 

Extreme weight loss and anorexia can cause periods to stop and stress is a well known factor.
If no other health issues exist then periods should restart once a normal diet and / or fitness regime is resumed.

It is always important to discuss your concerns about lack of periods with your GP in case there is another underlying health problem.

Bleeding between periods

Intermittent bleeding should cause concern and it is an important symptom in many conditions which need treating. In most cases these symptoms are due to benign conditions or even infection but sometimes irregular bleeding can indicate a more serious problem. N.B. women who are close to the menopause may often have irregular bleeding as a result of hormonal changes in their body as the ovaries gradually stop working.

If you experience intermittent bleeding after sexual intercourse, between periods or particularly after the menopause you should ensure that you discuss this with your GP.

Diagnosis

In all cases of abnormal periods it is important to discover if there is any underlying problem. This is done by means of a pelvic examination. The doctor will probably need to examine the vulva, vagina and cervix (neck of the womb) to make sure there is no abnormality that could account for the problem. At the same time the doctor can check for signs of other conditions such as fibroids or endometriosis.

Sometimes further tests are needed. These can include:
 

• Transvaginal ultrasound scan: A small s probe is inserted into the vagina, to give an accurate picture.
• Endometrial biopsy: A small sample of the womb lining is taken and examined under a microscope to check that it looks normal.
• Hysteroscopy: A small telescope is passed through the neck of the womb so that the womb cavity can be examined.
• Laparoscopy: A camera is inserted through a small incision in the umbilicus to allow the doctor to look at the womb, ovaries, fallopian tubes and other pelvic organs.

Treatments

There are lots of different ways to treat abnormal periods. Depending on the exact symptoms and other factors (for example, age, weight, general health) the doctor may suggest several options:

Medical

Non-hormonal medications
 

• Tranexamic acid
• Mefenamic acid

Tranexamic and mefenamic acid can lead to a reduction in blood loss. Tranexamic acid may lead to a blood loss of around 50 percent and mefenamic acid, generally used more to treat period pains and cramps, can reduce blood loss by around 25 percent.

Hormonal medications
 

•  Combined Oral Contraceptive pill – several types are available. This can help to reduce flow, improve regularity and reduce pain.  
   
•  Contraceptive injection - this can be used to stop periods, treating pain and heavy flow. It is a long acting progestogen which is generally used as a long-term form of contraception. Usually given into the muscle of the buttock or upper arm, the injection produces a reservoir of the hormone in the muscle, which is then continuously released into the bloodstream over a period of 12 weeks.  
   
•  Implant - a small plastic implant  which is inserted under the skin of the upper arm. (The area will be numbed first using a local anaesthetic). The plastic implant continuously releases a synthetic female hormone into the bloodstream and is designed to provide contraception for 3 years. It is effective for most women, reducing pain and stopping or reducing blood flow.  
   
• Intra-uterine system - is a hormonal implant (coil) placed inside the womb. This is small, made of plastic, and shaped like the letter “T”. It contains a synthetic female hormone which is released slowly into the uterus (womb). It is an efficient contraceptive; it reduces blood flow by at least 80 percent after 3 months and also protects the lining of the womb. For the first few months periods may be chaotic (but generally lighter than usual), after which most women stop having periods altogether and pain is reduced. The implant lasts for 5 years.

Surgical

• Endometrial ablation- the lining of the womb is removed to treat excessive bleeding. It is a short surgical procedure usually performed under general anaesthetic, but it involves no cutting and can be done in a morning. There are a number of methods, but essentially a probe is inserted into the womb through the cervix applying heat to the lining which destroys it. This is usually  effective and around 60 percent of women stop having periods altogether, with the remainder experiencing a much lighter blood loss.  
   
• Hysterectomy- the removal of the womb. For small group of women, where other diseases exist or other methods do not work, this is the last alternative and it should only be undertaken after extensive consultation with the surgeon.

Some women find that relaxation techniques, aromatherapy and massage can alleviate symptoms. Other lifestyle changes, such as cutting down on both alcohol and smoking, are as so often found to help.

Try to be aware of what is normal for your own body and take action if unusual symptoms develop. Recent developments mean that help can be provided using a wide range of treatments, many simple and non-invasive. If you do feel your periods have changed and you are worried by this, you should discuss this with your GP or seek specialist help.

If you would like to tell us your story so we can help and inform other women; there is more information available HERE

This interview was recorded in August 2009.

Period Problems: Text Version

Welcome to this month’s Wellbeing of Women health podcast. Today our topic is period problems and we discuss why these may happen the impact they may have on quality of life – and what treatments exist.

Problems with periods cause almost 60% of women to visit their GP at some point during their life. A diversity of problems can arise. For younger women the issue may be pain-related or perhaps irregular periods or even no periods at all. For older women it is commonly the heavy flow that causes an issue. These problems can seriously impair the quality of life of the women experiencing them, causing them stress, embarrassment, pain or tiredness and requiring them to take time off work. And because of the highly personal nature of these problems, many women are uncomfortable seeking help or believe nothing can be done to help.

A number of significant advances have been made over the years in the treatment of period problems and these days, treatment by hysterectomy is considered the last resort. Just over 10 years ago, one in five women had a hysterectomy by the age of 60. Nowadays it is fewer than one in ten.

Peter Bowen-Simpkins, Medical Director of the London Women’s Clinic is here to discuss the subject.

Hello Peter and thanks for coming today.

What are the main problems that women experience with their periods?

Well it is really divided into two age groups, the younger age group – teenagers and the 20’s tend to have problems associated with pain, whereas the older woman approaching the menopause, it tends to be with heaviness.

Can you tell me a little bit more about painful periods and the problems that women experience?

Yes there are two sorts of painful periods; medically they are called primary dysmenorrhoea and secondary dysmenorrhoea. Primary dysmenorrhoea is the one that most young people get and that is colic type pain, it’s a spasm that occurs, which usually starts with the period and most often finishes before the end of the period. It is the kind of thing that stops them going to school or perhaps having to take a day off work. Secondary dysmenorrhoea is much different; it is seen really in people who are in their late 20s and in their 30s. It is associated with disease in the pelvis, the two most important reasons are endometriosis and pelvic inflammatory disease, and that means a chronic infection usually from an organism called Chlamydia.

Can you say what constitutes abnormal pain?

It is difficult to define pain because it is so subjective. But for a young woman if it is the sort of pain that stops her from going to school or going to university or work, then that is severe enough for her to seek medical treatment. As far as the older women where we were talking about secondary dysmenorrhoea, this sort of pain starts before the period and carries on through, and is a constant dull ache. Analgesics may help but really the most important thing is to seek medical advice, because the causes can seriously damage their fertility.

And what treatments are available?

Well for the young girl, the most obvious ones are the sort of pills that you can buy over the counter in the chemist. They are readily available and are usually based on what are called non-steroidal anti-inflammatory agents, but are also things like panadol, paracetamol and codine, and they are very effective. The other thing is that if you stop them ovulating, then their periods are less painful, and to stop somebody ovulating, they go on the pill. That is usually quite effective, and going on to the pill is something many young women want to do anyway for contraceptive reasons. The side affects are very very carefully explained to them before they start them, and are obviously contained within the packaging as well. But I think if for a young person, either of these remedies or both together don’t help then they really must seek medical advice.

And what about the other sort of pain?

Well for these women the pain itself is not the underlying problem, if you’ve got endometriosis or pelvic inflammatory disease, not only might you have painful periods but they are likely to be heavier and intercourse is likely to be painful as well. The point here is not just to suffer it and take analgesics but go and seek medical advice.

So can we move on to talk about heavy periods? Can you define what a heavy period is?

Well there is a scientific answer to that and its anything above 80 mls, which is just under half a tea cup. But obviously patients don’t measure the amount that they lose, what they will notice is that they are using more sanitary protection. As far as a doctor is concerned if a woman comes along and says my periods are heavier, we are more interested in that observation than the actual amount that she is losing. Because if they change, then obviously it needs investigation and treatments are so good now.

Why do some women develop heavy periods?

There are a lot of reasons, the inside of the womb is lined by endometrium and that is what comes away at a period. Plainly the bigger the cavity inside the womb the more there is to come away, and so that is going to give somebody heavier periods; so anything that enlarges the womb is going to give them heavier periods. A good example would be fibroids, because that stretches the womb. Other conditions we have already mentioned like endometriosis, because it increases the blood supply to the womb and causes heavy periods. Stress is a very major reason, and we often find that people who have either got stress at home because of domestic problems or even stress at work, may have very heavy periods. The important thing is that if a woman’s periods change and they are getting heavier and there is no obvious simple reason for it, then they must seek medical help.

What treatments are available?

Well lets start with medical treatments, most young people will have noticed that when they go on the pill that their periods get much lighter. So for a younger person that would be the first approach. Otherwise there is a medicine called tranexamic acid its other name is Cyklokapron which is non-hormonal, which is taken just at the time of the periods and entirely at the woman’s wish. So when she has got to go out or thinks she is going to have flooding at night say, then she can take them then. They will reduce bleeding by up to 50%, and that really is the first line of treatment that most family doctors will go for. If it is associated with pain as well, they might suggest another compound called mefenamic acid otherwise known as Ponstan and can be bought over the counter. That not only will reduce the loss probably by only about 25% but that does help with the pain considerably.
Those really are the mainstay of simple medical treatment. Nowadays apart from the contraceptive pill we don’t tend to use hormones so much, because they have got a lot of side affects like weight gain, breast tenderness and even mood changes.

What about other treatment options?

Well two things have happened over the last ten to fifteen years, the first of these is called an intrauterine system, better known as the Mirena but that is its trade name. This is shaped like a contraceptive coil, but it contains a hormone which is released at a constant rate into the womb, and it will last for 5 years. So it does need fitting like a contraceptive coil, but once it is there it can stay there. After about 6 months there is about an 85% reduction in blood loss, and after a year it is up to 95%; in fact many women their periods stop altogether. It is very easy to fit particularly if the woman has had a baby, and it is entirely and rapidly reversible should they want to have another pregnancy. They can just be pulled out and it is not a painful procedure, that really has been a huge revolution in our management of heavy periods. The other thing that came in initially about 20 years ago but has been refined considerably is something called endometrial ablation, now that means essentially destroying the lining of the womb. Initially we did that by actually cutting it out under direct vision but nowadays we use very much safer pieces of machinery that heat it up and destroy the lining of the womb altogether so it can’t re-grow. The most popular methods - one of them is using microwaves, and it takes about three minutes and really is exceptionally successful. We find that about 60% of women after this treatment won’t have periods at all again, and of the remaining 40%, at least 25% of them will have very light periods. The only problem with it is it cannot be changed and as it destroys the lining of the womb it must never be offered to somebody who is considering having another baby, as pregnancies would be extremely dangerous after this operation.

What about hysterectomy? Is that still considered an option?

Well hysterectomy is the ultimate answer and there are one or two patients that for a variety of reasons either don’t react well to the sorts of treatments I have outlined, or for other surgical reasons need their womb removed. But I must stress that nowadays it is very very much the last option. Hysterectomies in this country over the last ten years have halved because of the introduction of particularly the Mirena and endometrial ablation. So I would say to people don’t go to your doctor thinking well the end of this is going to be a hysterectomy, because it is very very rare that we would do a hysterectomy nowadays for somebody with heavy periods.

So we have talked about heavy periods and painful periods, but what if a woman has no periods?

The first and most obvious answer is that she must check that she is not pregnant, because plainly that is the most common reason for someone’s periods to stop. Again one has to look at the young woman and the older woman. For young women periods can stop because their weight has gone below a certain level, there is something called a body mass index which is just the relationship between height and weight, if that falls below 19 then almost certainly the periods will stop. We see this commonly in what are called elite athletes, people like ballet dancers, long distant runners, oars women and so on. Quite simply a return to a normal weight means a return of their period, unfortunately nowadays there are people who lose weight because of dieting and if their periods stop, then that is a sign that they are already too thin. It is important that if you don’t have a period for three months and plainly you are not pregnant, then you must go and seek advice. There are some very simple blood tests that can be done and proper advice or treatment can be given. Then there is polycystic ovarian syndrome which has been covered in a previous podcast, and then as people get older if their periods stop, the first thing one must think about is if they have got something called ovarian failure. Namely that their ovaries have got no eggs left and therefore their periods stop. We would consider the menopause to happen normally between 45 and 55, most people being around 50. There is a small group of women whose periods may stop in their 30’s, obviously it is important that they go and get this sorted out. Unfortunately if it is shown that their ovaries have run out of eggs, then it is irreversible and one can’t get them ovulating again. For some of them it is just a matter of say stress, people who travel a lot are changing time zones - such as air hostesses and that can be very simply sorted out. Most people are worried about lack of periods because they want to know that their fertility is still there, and simple blood tests will reveal the answer and give you the right treatment.

Are there any other problems such as bleeding in between periods that you would like to comment on?

Well that is a very important one, and if anybody gets bleeding in between their periods whether it is spontaneous or whether it is after intercourse they must go and see their doctor. In 95% of cases there is absolutely nothing to worry about at all, but it is the hallmark of things like cancer of the neck of the womb. For the woman who has gone through the menopause if she starts bleeding again one year after her periods have stopped, once again she must go and see her doctor, because that is the hallmark of the cancer of the lining of the womb. Now in most cases there is nothing at all, and it is something very very simple which can be explained straight away, but it is essential that you go and seek help.

Peter, Thank you very much.

As a final question what advances do you think could be seen in the future?

Well I think we are on the way already, because there has been a big shift from major surgery to minimal access and medical treatments. Good examples of that are mirena and endometrial ablation, which I have talked about already. As far as fibroids are concerned, there is tremendously new and exciting things going on there and I also see improvements in our treatment of endometriosis. Essentially all of these things mean there is going to be less surgery and being able to treat people very simply and effectively.

Peter, thank you. That is a very comprehensive comment on the problems women can have with periods. If you would like to know more about some of the conditions that Peter has referred to such as endometriosis or PCOS, there are articles and podcasts on our website on those topics. If you would like any further information on women’s health please visit www.wellbeingofwomen.org.uk
 

Myths have surrounded menstruation since records began. Losing blood was a sign of illness and this confounded many civilisations, the women being separated from the community as unclean. Discover the truth behind some common myths about periods.

You can’t have sex during menstruation

This is totally untrue. It may not be aesthetically pleasant to some, but no harm can come from it. It derives from the belief that women are ‘unclean’ during menstruation.

Washing your hair or getting your feet wet is unsafe during period time

It is not known how this myth started, but there is no basis to it.

You can’t use tampons from the time of your first period

There is no reason why a small tampon cannot be used. The hymen is stretchy and provided the instructions are followed carefully, it shouldn’t hurt to insert one.

You can’t get pregnant if you are having your period

This is a dangerous myth. For women with a short cycle, say 24 days, ovulation will occur on day 10. Sperm can survive for 7 days and so intercourse on day 3 or later, even if there is bleeding, can result in pregnancy

Tampons can get lost if pushed in too far

There is some truth in this. If a woman forgets that she has a tampon and has intercourse, it can be pushed high up in the vagina and may become forgotten. It can get infected and lead to a foul smelly discharge. It requires an expert to remove it usually.

You can’t go swimming when you have a period

Lots of reasons have been given for this but the only possible one is that it would be impractical when wearing a sanitary towel. With tampons it is perfectly safe.

You shouldn’t take exercise when you have your period

This again possibly derives from days when sanitary towels were bulky & inefficient. Exercise actually helps period pains and is quite safe.

A menstrual cycle should be 28 days

Women’s cycles normally vary between 24-35 days. There is nothing unusual about having a long or short cycle. The 28 days myth derives from the Pill which always leads to a 28 day cycle.

To find out about our research follow these links:
 

• New treatments for Pelvic pain

• Research into heavy periods (menorrhagia)

• The Royal College of Obstetricians and Gynaecologists website has a wide range of information and guidelines on many women’s health topics. This can be found at: http://www.rcog.org.uk/womens-health/patient-information 

• NHS Choices website also has a range of health information. This can be found at: http://www.nhs.uk/Pages/HomePage.aspx