Menstrual disorders are common in primary care.
Menorrhagia
Bleeding that is heavier than the patient’s normal flow. Blood loss may be a problem but is often less than the patient perceives.
History
- Ask if the cycle is regular or not, the usual cycle interval, bleeding, pain and dyspareunia. A menstrual chart helps establish the pattern. Normal cycles may vary from 22 to 34 days.
- Establish the amount of blood loss. More than 80 ml per cycle is menorrhagia. Ask about the number of pads or tampons used, clots and the number of days of heavy bleeding.
- Exclude any co-morbidity or history of HRT, tamoxifen, irregular pill-taking or any herbal medicine.
Examination
Exclude anaemia and evidence of thyroid disease. Examine the abdomen for any obvious mass or tenderness in the lower abdomen. Vaginal examination is mandatory if there is a history of an irregular cycle in perimenopausal or post-menopausal women or if there is menorrhagia with intermenstrual or post-coital bleeding.
Investigations
FBC; FSH, LH, testosterone, prolactin; clotting screen; pelvic scan.
Common Causes of Menorrhagia
- Functional – hormonal imbalance is a diagnosis by exclusion.
- Fibroid and/or endometriosis – most common above 30 years.
- Pelvic inflammatory disease.
- Carcinoma.
- Systemic disease (e.g. hypothyroidism).
Management
- Treat anaemia, exclude pathology, and beware of cancer in patients around menopause with co-morbidity like diabetes.
- If no apparent pathology try mefenamic acid or tranexamic acid, then oral contraceptive pill (OCP) to achieve better cycle control.
- In peri-menopausal women, if contraception is needed and the scan is normal, consider a Mirena®. This has reduced the number of hysterectomies for menstrual disorders.
- Refer all cases of post-menopausal bleeding, and patients with an abnormal scan (e.g. submucous fibriods or fibroids larger than 5–6 cm, and endometriosis) for hysteroscopy and/or laparoscopy.
Dysmenorrhoea
Dysmenorrhoea can be primary or secondary. In primary dysmenorrhoea, no cause is detected. It occurs in young women soon after puberty or when regular ovulation is established. Prostaglandin and other inflammatory substances are thought to cause uterine cramps and spasm of blood vessels.
Secondary dysmenorrhoea is associated with an existing condition. The most common is endometriosis. Other causes include fibroids, adenomyosis, ovarian cysts and pelvic congestion and the presence of IUD.
Diagnosis
In primary dysmenorrhoea, typical symptoms are pain, lower abdominal cramps from a few days before menstruation and lasting for the first half of the cycle. Other symptoms include vomiting, diarrhoea, constipation, headache and fainting attacks.
In secondary dysmenorrhoea carry out a full examination and a vaginal examination to detect any tenderness or lumps, a cervical smear, vaginal and cervical swabs.
A pelvic scan and laparoscopy is useful if endometriosis is suspected.
Treatment
For secondary dysmenorrhoea, treatment depends on the cause.
For primary dysmenorrhoea, consider NSAIDs or OCP. Complementary measures like changing posture during cramps, stopping smoking, yoga, omega-3 foods and exercise may all help.
Intermenstrual and Post-Coital Bleeding
The cause is commonly local to the cervix (e.g. a cervical polyp or erosion). Do a speculum and internal examination to exclude the above causes, infection or pregnancy. If no local cause is found, refer for hysteroscopy to exclude an endometrial polyp. Malignancy is uncommon but must be considered in all patients.
Post-Menopausal Bleeding
Any vaginal bleeding after 1 year after stopping menstruation, whether a normal period or just spotting, must be taken seriously. Take a full history and internal examination. Refer for a pelvic scan and hysteroscopy (2-week pathway to exclude malignancy). The return of normal periods is uncommon but can be confirmed by a normal level of FSH or a normal scan.
Polycystic Ovarian Syndrome
The incidence is about 5–10% in women in the reproductive period and 20% in patients with subfertility. It may present with amenorrhoea, oligomenorrhoea, hirsutism, acne, subfertility, recurrent miscarriages or obesity in young adults. There is a wide spectrum of symptoms. In mild cases menstruation may be normal, the patient may conceive but then go on to have miscarriages.
Underlying Cause and Long-Term Effect
The exact cause is unknown. There is:
- Increased incidence with a family history.
- Imbalance in hypothalamic–pituitary–ovarian axis feedback mechanism. The ovaries secrete more testosterone resulting in symptoms. Ovulation may cease because of changed levels of luteinising hormone (LH) and follicle-stimulating hormone (FSH).
- PCOS is often associated with insulin resistance resulting in obesity, hypertension, diabetes and coronary heart disease later.
- Endometrial hyperplasia may occur due to cycle reduction (<3/yr) and without the protection effect of progesterone lead to endometrial cancer.
- An increase in the incidence of ovarian cancer.
- Depression and mood swings because of lack of progesterone.
History
Ask about menstruation (length and amount of bleeding), age of menarche, onset and distribution of excess hair, weight gain, family history of PCOS or diabetes.
Treatment
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