Gynaecology: Menstrual Disorders

• Basics: The Menstrual Cycle | Gynaecological History and Examination
• Bleeding problems: Heavy Menstrual Bleeding | Fibroids | Adenomyosis | Bleeding Between Periods or After Sex | Cervical Ectropion and Polyps | Postmenopausal Bleeding | Endometrial Hyperplasia
• Pain: Painful Periods | Endometriosis | Chronic Pelvic Pain | Premenstrual Syndrome
• Absent or irregular periods: Primary Amenorrhoea | Secondary Amenorrhoea | Polycystic Ovary Syndrome | Hypothalamic Amenorrhoea | Asherman's Syndrome
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩸 Menstrual disorders — heavy, painful, irregular or absent periods are among the commonest reasons women see a GP. They are often normalised and under-treated: endometriosis takes on average about 8 years to diagnose in the UK. Most problems are benign and treatable, but postmenopausal bleeding, persistent intermenstrual or post-coital bleeding, and an abnormal-looking cervix need prompt referral to exclude cancer.
Your four questions for every patient: Could she be pregnant? What is the bleeding or pain pattern, and how does it affect her life? Is there a red flag (postmenopausal bleeding, post-coital bleeding, abnormal cervix, pelvic mass, weight loss)? What does she want — contraception, fertility, or avoiding hormones?

The Menstrual Cycle

• Normal cycle — 24–38 days (average 28); bleeding for up to 8 days; menarche around 12–13; menopause around 51.
• Follicular phase (day 1 to ovulation — variable length):
  • FSH from the pituitary stimulates follicles to grow; one dominant follicle makes oestrogen.
  • Oestrogen thickens the womb lining (proliferative phase).
• Ovulation (about day 14 of a 28-day cycle):
  • Rising oestrogen triggers an LH surge; the egg is released about 36 hours later.
  • Some women feel mid-cycle pain (mittelschmerz).
• Luteal phase (fixed — about 14 days):
  • The empty follicle becomes the corpus luteum, making progesterone — the lining becomes secretory.
  • Without pregnancy, the corpus luteum fails, progesterone falls, and the lining sheds (menstruation).
  • With pregnancy, hCG keeps the corpus luteum going.
• Checking ovulation — serum progesterone 7 days before the expected period (day 21 of a 28-day cycle); over 30 nmol/L suggests ovulation.

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Gynaecological History and Examination

• Menstrual history — LMP, cycle length and regularity, days of bleeding, flooding or clots, pain, intermenstrual or post-coital bleeding, impact on life (work, school, sleep).
• Other — pregnancy chance, contraception, sexual history, cervical screening, pelvic pain, dyspareunia (deep or superficial), discharge, urinary and bowel symptoms, fertility wishes, menopause symptoms.
• Background — obstetric history, previous gynae surgery, medical conditions, drugs (anticoagulants, hormones, tamoxifen), family history (endometrial, ovarian, bowel and breast cancer; Lynch syndrome).
• Examination (with a chaperone offered and consent):
  • Abdomen — masses (fibroids, ovarian masses), tenderness.
  • Speculum — cervix (polyps, ectropion, lesions, discharge); take swabs.
  • Bimanual — size, shape and mobility of the womb; adnexal masses; tenderness (cervical motion tenderness suggests PID).
• Common tests — pregnancy test; FBC; STI swabs; transvaginal ultrasound; hysteroscopy and endometrial biopsy when indicated.

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Heavy Menstrual Bleeding

• Definition (NICE NG88) — bleeding that interferes with physical, social, emotional or material quality of life (it's defined by impact, not volume). Over 80 mL a cycle is heavy, but this isn't measured in practice.
• Causes:
  • No cause found (most) — "ovulatory dysfunction" or endometrial.
  • Fibroids; adenomyosis; endometrial polyps.
  • Endometrial hyperplasia or cancer.
  • Bleeding disorders (e.g. von Willebrand disease — heavy periods since menarche, other bleeding); anticoagulants.
  • Hypothyroidism; PCOS (irregular heavy bleeds); copper IUD.
• Assessment:
  • FBC for all (ferritin if anaemic).
  • Coagulation screen and von Willebrand testing if heavy since menarche or a personal or family bleeding history.
  • TFTs only if symptoms of thyroid disease.
  • Examination if structural or other pathology is suspected.
  • Transvaginal ultrasound — if the womb is enlarged or a mass is felt, or symptoms suggest adenomyosis, or examination isn't possible.
  • Outpatient hysteroscopy (with biopsy) — if symptoms suggest a polyp or submucosal fibroid, or risk factors for endometrial pathology — persistent intermenstrual bleeding, age 45 or over with treatment failure, obesity, PCOS, tamoxifen.
• Treatment (if no structural problem, or fibroids under 3 cm):
  • First line — levonorgestrel intrauterine system (LNG-IUS, e.g. Mirena) — the most effective medical treatment; also contraception. Irregular bleeding for the first 3–6 months.
  • If the LNG-IUS isn't wanted or suitable:
    • Non-hormonal — tranexamic acid 1 g three times daily during heavy days (up to 4 days) — reduces loss by about half; NSAIDs (mefenamic acid 500 mg three times daily) — also help pain. Both only taken during periods (good if trying to conceive).
    • Hormonal — combined hormonal contraception; cyclical oral progestogens (e.g. norethisterone 5 mg three times daily from day 5 to 26 of the cycle); DMPA injection.
  • Short-term control of a very heavy episode — norethisterone 5 mg three times daily (stops bleeding within a few days).
  • Specialist — GnRH agonists (short term, e.g. before surgery); endometrial ablation (if family complete); hysterectomy (definitive; when other treatments fail or are unsuitable and she wants no further periods).
• Treat iron deficiency with oral iron.

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Fibroids

• What they are: Benign tumours of the womb's smooth muscle (leiomyomas). Very common — up to 7 in 10 women by 50; more common, larger and earlier in Black women. Grow with oestrogen; shrink after the menopause.
• Types (by position):
  • Submucosal — bulge into the cavity: heavy bleeding, subfertility, miscarriage.
  • Intramural — within the wall (the commonest).
  • Subserosal — on the outer surface; may be pedunculated (on a stalk — can twist).
• Features:
  • Often no symptoms.
  • Heavy periods (and anaemia).
  • Pressure symptoms — urinary frequency, retention, constipation, abdominal swelling.
  • Pelvic pain, dyspareunia; subfertility.
  • Irregular, enlarged, firm womb on examination.
• Complications:
  • Red degeneration — haemorrhage into a fibroid, usually in pregnancy: pain, low fever, tender womb. Analgesia and rest.
  • Torsion of a pedunculated fibroid.
  • In pregnancy — malpresentation, obstructed labour, PPH.
  • Leiomyosarcoma — rare; suspect if rapid growth after the menopause.
• Diagnosis — transvaginal (and abdominal) ultrasound; MRI before some treatments; hysteroscopy for submucosal fibroids.
• Treatment:
  • No symptoms — no treatment.
  • Heavy bleeding:
    • Fibroids under 3 cm and a normal cavity — as for heavy menstrual bleeding (LNG-IUS, tranexamic acid, NSAIDs, hormones).
    • Relugolix combination therapy (oral GnRH antagonist with oestradiol and norethisterone add-back; NICE TA832) — for moderate to severe symptoms.
    • GnRH agonists (e.g. leuprorelin) — shrink fibroids before surgery (menopausal side effects; bone loss — short term only).
    • Ulipristal acetate — now restricted (rare severe liver injury).
  • Surgery and procedures:
    • Hysteroscopic resection — submucosal fibroids.
    • Myomectomy (laparoscopic or open) — removes fibroids, keeps the womb (for fertility).
    • Uterine artery embolisation — interventional radiology; avoids surgery.
    • Hysterectomy — definitive.

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Adenomyosis

• What it is: Endometrial tissue growing within the muscle wall of the womb.
• Who: Usually women in their 40s who have had children; often with endometriosis or fibroids.
• Features:
  • Heavy and painful periods.
  • Dyspareunia; chronic pelvic pain.
  • Bulky, tender, "boggy" womb (symmetrical enlargement).
• Diagnosis — transvaginal ultrasound or MRI.
• Treatment — as for heavy menstrual bleeding (LNG-IUS first, NSAIDs, tranexamic acid, hormonal treatment, GnRH analogues); hysterectomy is the only definitive cure.

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Bleeding Between Periods or After Sex

• Intermenstrual bleeding (IMB) and post-coital bleeding (PCB).
• Causes:
  • Hormonal contraception — the commonest cause of IMB (breakthrough bleeding, especially in the first 3 months or with missed pills).
  • Pregnancy — ectopic, miscarriage.
  • Infection — chlamydia, gonorrhoea (cervicitis — contact bleeding).
  • Cervical ectropion, cervical polyps.
  • Endometrial polyps, submucosal fibroids.
  • Cervical cancer (post-coital bleeding is a classic symptom); endometrial cancer.
  • Vaginal atrophy, trauma.
• Assessment:
  • Pregnancy test.
  • STI testing (chlamydia and gonorrhoea NAAT).
  • Speculum examination of the cervix — don't rely on cervical screening (it's not a diagnostic test).
  • Check cervical screening history.
  • Pelvic ultrasound if persistent.
• Refer:
  • Suspected cancer pathway (NICE NG12) — if the cervix looks abnormal (suspicious of cancer) on examination.
  • Persistent IMB or PCB with no cause — gynaecology (colposcopy, hysteroscopy).
  • Hormonal contraception users — if bleeding persists beyond 3 months, starts after a long time of good control, or with other symptoms.

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Cervical Ectropion and Polyps

• Cervical ectropion — the columnar (glandular) cells from inside the cervical canal extend onto the outer cervix, looking like a red ring around the os.
  • Causes — hormonal: combined pill, pregnancy, adolescence.
  • Features — often none; increased discharge; post-coital or intermenstrual bleeding.
  • Management — exclude infection and abnormality; reassure; stop the pill if troublesome; cryotherapy or cautery for persistent symptoms.
• Nabothian cysts — small mucus-filled cysts on the cervix; harmless.
• Cervical polyps — benign growths; can cause intermenstrual or post-coital bleeding; removed by twisting off (avulsion) and sent for histology.
• Cervical cancer and screening — see the Breast and Gynaecological Cancers chapter.

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Postmenopausal Bleeding

• Definition — bleeding 12 months or more after the last period (or unscheduled bleeding on HRT).
• Endometrial cancer must be excluded — found in about 5–10% of women with PMB.
• Causes:
  • Vaginal atrophy (the commonest).
  • Endometrial polyps; endometrial hyperplasia.
  • Endometrial cancer.
  • HRT (unscheduled bleeding); tamoxifen.
  • Cervical cancer or polyps; vulval or vaginal cancer.
  • Bleeding from the urinary tract or rectum mistaken for vaginal bleeding.
• Referral — suspected cancer pathway for women aged 55 or over with PMB (NICE NG12); consider for under 55 too.
• Investigations:
  • Transvaginal ultrasound — endometrial thickness:
    • Under 4 mm — cancer very unlikely (if no further bleeding).
    • 4 mm or more — endometrial biopsy (Pipelle) and/or hysteroscopy.
  • Recurrent bleeding — hysteroscopy even with a thin endometrium.
  • Speculum examination of the cervix, vagina and vulva.
• Risk factors for endometrial cancer — obesity, unopposed oestrogen, PCOS, diabetes, nulliparity, late menopause, tamoxifen, Lynch syndrome. See the Breast and Gynaecological Cancers chapter.

⚠️ Safety Pearl: Any postmenopausal bleeding — even a single episode of spotting — needs referral. Don't assume it's atrophy without imaging.

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Endometrial Hyperplasia

• What it is: Overgrowth of the womb lining from unopposed oestrogen (obesity, PCOS, oestrogen-only HRT with a womb, tamoxifen, anovulation).
• Types (WHO):
  • Hyperplasia without atypia — low risk of cancer (under 5% over 20 years).
  • Atypical hyperplasia (endometrial intraepithelial neoplasia) — high risk; up to 40% have a coexisting cancer.
• Features — abnormal bleeding (heavy, irregular, intermenstrual, postmenopausal).
• Treatment:
  • Without atypia — treat risk factors (weight loss, stop unopposed oestrogen); progestogens — LNG-IUS first line (or oral progestogens) for at least 6 months; biopsy every 6 months until two negative.
  • Atypical hyperplasia — total hysterectomy (with removal of tubes ± ovaries); fertility-sparing progestogen treatment with close surveillance if she wants children.

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Painful Periods

• Primary dysmenorrhoea — period pain with no underlying disease:
  • Starts within 1–2 years of menarche (once ovulatory cycles begin).
  • Cramping lower abdominal pain starting just before or with bleeding, lasting 1–3 days; may radiate to the back and thighs; nausea, headache.
  • Caused by prostaglandins (uterine contractions).
  • Treatment — NSAIDs (ibuprofen, naproxen, mefenamic acid) started at the onset of pain or just before; paracetamol; heat; exercise; combined hormonal contraception (or other hormonal methods) if NSAIDs aren't enough.
• Secondary dysmenorrhoea — period pain from underlying disease:
  • Often starts later in life or changes in character; pain may start days before bleeding; with dyspareunia, heavy bleeding, IMB, or pain at other times.
  • Causes — endometriosis, adenomyosis, fibroids, PID, copper IUD, cervical stenosis, pelvic adhesions.
  • Assessment — STI testing, examination, pelvic ultrasound; refer if suspected endometriosis or not responding to treatment.

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Endometriosis

• What it is: Tissue similar to the womb lining growing outside the womb — on the ovaries (endometriomas — "chocolate cysts"), pelvic peritoneum, uterosacral ligaments, pouch of Douglas, bowel and bladder; rarely further (diaphragm, lungs). It bleeds with each cycle, causing inflammation and scarring.
• How common — about 1 in 10 women of reproductive age.
• Symptoms:
  • Painful periods (dysmenorrhoea) that affect daily life.
  • Deep dyspareunia (pain deep in the pelvis during or after sex).
  • Chronic pelvic pain.
  • Cyclical bowel or bladder symptoms — painful bowel movements (dyschezia), painful urination, blood in urine or stool during periods.
  • Subfertility.
  • Cyclical pain elsewhere (shoulder tip, chest with pneumothorax — catamenial; scar pain).
• Signs — often normal; pelvic tenderness; fixed, retroverted womb; nodules on the uterosacral ligaments or in the posterior fornix; adnexal masses (endometriomas).
• Diagnosis (NICE NG73):
  • Normal examination and ultrasound do not rule it out.
  • Transvaginal ultrasound — finds endometriomas and deep endometriosis; MRI for deep disease.
  • Laparoscopy — the gold standard (see and biopsy, and can treat at the same time).
  • CA125 isn't useful for diagnosis.
  • Start treatment without waiting for a definite diagnosis.
• Treatment:
  • Pain relief — paracetamol and/or NSAIDs (3-month trial); neuropathic agents in specialist care.
  • Hormonal treatment (suppresses periods; not if trying to conceive):
    • Combined hormonal contraception (continuous or tailored, to reduce bleeds).
    • Progestogens — progestogen-only pill (desogestrel), injection, implant, LNG-IUS, or dienogest.
  • Second line (specialist) — GnRH agonists (with HRT "add-back" to protect bone), relugolix combination therapy.
  • Surgery — laparoscopic excision or ablation of endometriosis; removal of endometriomas; deep endometriosis (bowel, bladder) in a specialist centre; hysterectomy with removal of all visible endometriosis (and possibly ovaries) if family complete.
  • Fertility — surgery may improve chances; IVF.
• Refer to gynaecology if severe, persistent or recurrent symptoms, a pelvic mass, or suspected deep disease; to a specialist centre for deep endometriosis involving bowel, bladder or ureter.

💡 Clinical Pearl: Endometriosis is often missed because period pain is normalised. Painful periods that stop someone going to school or work, deep dyspareunia, and cyclical bowel or bladder pain should prompt you to think of it — and treatment can start without a laparoscopy.

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Chronic Pelvic Pain

• Definition — lower abdominal or pelvic pain for at least 6 months, not only during periods or sex, and not from pregnancy.
• Causes (often more than one):
  • Gynaecological — endometriosis, adenomyosis, chronic PID and adhesions, ovarian cysts, pelvic congestion (varicose veins in the pelvis — pain worse on standing, end of day).
  • Gut — irritable bowel syndrome (very common), constipation, IBD.
  • Bladder — bladder pain syndrome (interstitial cystitis) — pain with a full bladder, frequency, urgency, normal urine tests.
  • Musculoskeletal — pelvic floor muscle spasm, back problems, hernias, nerve entrapment.
  • Psychological — depression, anxiety; history of sexual abuse (ask sensitively).
• Assessment — pain diary; STI testing; examination; transvaginal ultrasound; laparoscopy if suspected endometriosis or adhesions.
• Management — explain and validate; treat specific causes; trial of hormonal suppression (cyclical pain); IBS treatment; pelvic floor physiotherapy; neuropathic pain drugs; psychological therapy; specialist pain clinic.

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Premenstrual Syndrome

• What it is: Physical and psychological symptoms in the luteal phase (the 1–2 weeks before a period) that settle when the period starts, and affect daily life.
• Symptoms:
  • Psychological — irritability, low mood, anxiety, mood swings, tearfulness, poor concentration.
  • Physical — bloating, breast tenderness, headache, tiredness, food cravings.
• Premenstrual dysphoric disorder (PMDD) — the severe, mainly psychological form.
• Diagnosis — symptom diary over 2 cycles (symptoms must clear after periods start — distinguishes from depression that worsens before periods).
• Treatment:
  • Lifestyle — exercise, sleep, stress reduction, regular meals, reduce caffeine and alcohol.
  • CBT.
  • Combined hormonal contraception — especially drospirenone-containing pills; taken continuously.
  • SSRIs (e.g. sertraline, fluoxetine) — continuously or just in the luteal phase; very effective for psychological symptoms.
  • Specialist — oestradiol patches with progestogen; GnRH agonists with add-back HRT; hysterectomy with removal of ovaries (rarely, for severe cases).

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Primary Amenorrhoea

• Definition — no periods by age 15 with normal secondary sexual characteristics (breasts, pubic hair), or by age 13 with no secondary sexual characteristics.
• Causes:
  • Constitutional delay — often a family history of late puberty.
  • Hypothalamic — low weight, excessive exercise, eating disorders, stress, chronic illness; Kallmann syndrome (with anosmia).
  • Pituitary — prolactinoma, other tumours (craniopharyngioma).
  • Ovarian (primary ovarian insufficiency) — Turner syndrome (45,X — short stature, webbed neck, wide-spaced nipples, coarctation), chemotherapy or radiotherapy, autoimmune.
  • Structural (with normal breasts and hair):
    • Imperforate hymen or transverse vaginal septum — cyclical pain with no bleeding; bulging bluish membrane (haematocolpos).
    • Müllerian agenesis (MRKH syndrome) — no womb or upper vagina; normal ovaries and hormones; 46,XX.
  • Androgen insensitivity syndrome — 46,XY; normal breasts (from converted testosterone) but scant pubic and axillary hair; no womb; testes in the abdomen or groins (cancer risk — removal after puberty).
  • Congenital adrenal hyperplasia (non-classic) — hirsutism.
  • PCOS; hypothyroidism.
• Assessment:
  • Height, weight, BMI, puberty staging (Tanner), signs of Turner syndrome, hirsutism, visual fields, sense of smell.
  • Pregnancy test.
  • LH, FSH, oestradiol, prolactin, TFTs, testosterone; 17-hydroxyprogesterone (CAH).
  • Karyotype (if raised FSH or suspected Turner or androgen insensitivity).
  • Pelvic ultrasound; MRI pituitary if indicated.
• Interpretation:
  • High FSH and LH — ovarian failure (Turner).
  • Low or normal FSH and LH — hypothalamic or pituitary cause, or constitutional delay.
• Refer to paediatric or adolescent gynaecology or endocrinology. See the Reproductive Endocrinology chapter.

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Secondary Amenorrhoea

• Definition — no periods for 3 months in a woman with previously regular periods, or 6 months with previously irregular periods. Oligomenorrhoea — cycles over 35 days apart.
• Causes:
  • Pregnancy — always exclude first; breastfeeding.
  • Hormonal contraception (especially progestogen injection, implant, LNG-IUS) or recently stopping it.
  • PCOS — the commonest pathological cause.
  • Hypothalamic amenorrhoea — weight loss, exercise, stress, eating disorders.
  • Hyperprolactinaemia — prolactinoma, drugs (antipsychotics, metoclopramide, domperidone).
  • Premature ovarian insufficiency (under 40) or menopause.
  • Thyroid disease (hypo- or hyperthyroidism).
  • Asherman's syndrome (scarring after surgery).
  • Sheehan's syndrome; Cushing's; CAH; androgen-secreting tumours (rapid virilisation); chronic illness.
• Tests:
  • Pregnancy test.
  • FSH, LH, oestradiol, prolactin, TFTs, testosterone (and SHBG).
  • Pelvic ultrasound (polycystic ovaries, endometrial thickness).
  • MRI pituitary if raised prolactin or other pituitary features.
• Interpretation:
  • High FSH (over 25–30 IU/L, repeated) — ovarian insufficiency.
  • LH higher than FSH, raised testosterone — PCOS (LH:FSH ratio isn't required for diagnosis).
  • Low FSH and LH with low oestradiol — hypothalamic or pituitary cause.
  • Raised prolactin — exclude drugs, hypothyroidism, then MRI.
• Why treat? — low oestrogen causes bone loss (and cardiovascular risk); prolonged amenorrhoea with oestrogen (PCOS) risks endometrial hyperplasia.

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Polycystic Ovary Syndrome

• The commonest endocrine condition in women of reproductive age (about 1 in 10).
• Diagnosis (Rotterdam / international guideline) — two of three, after excluding other causes:
  • Irregular or absent ovulation (irregular periods).
  • Hyperandrogenism — clinical (hirsutism, acne, hair loss) or biochemical (raised testosterone or free androgen index).
  • Polycystic ovaries on ultrasound (or raised AMH in adults) — not used for diagnosis within 8 years of menarche.
• Associated problems — insulin resistance, obesity, type 2 diabetes, gestational diabetes, dyslipidaemia, sleep apnoea, depression and anxiety, endometrial hyperplasia and cancer, subfertility.
• Management:
  • Lifestyle and weight loss — even 5% weight loss improves periods and fertility.
  • Irregular periods / endometrial protection — combined pill; or cyclical progestogen to induce a bleed at least every 3–4 months; or LNG-IUS.
  • Hirsutism and acne — combined pill; eflornithine cream (face); spironolactone (with contraception); hair removal.
  • Fertility — weight loss; letrozole (first-line ovulation induction) or clomifene; metformin; IVF.
  • Screening — HbA1c or OGTT, lipids, BP, mood; OGTT in pregnancy.
• See the Reproductive Endocrinology chapter for more detail.

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Hypothalamic Amenorrhoea

• What it is: The hypothalamus reduces GnRH release in response to energy deficit or stress — low FSH, LH and oestrogen.
• Causes:
  • Low weight and eating disorders (anorexia nervosa).
  • Excessive exercise — athletes, dancers (relative energy deficiency in sport, RED-S — with low bone density and stress fractures).
  • Psychological stress; serious illness.
• Risks — osteoporosis (DEXA scan if over 6–12 months), subfertility.
• Management:
  • Restore energy balance — increase intake, reduce exercise, treat eating disorders (specialist).
  • Oestrogen replacement (transdermal oestradiol with cyclical progestogen) if amenorrhoea persists, to protect bone.
  • Fertility — pulsatile GnRH or gonadotrophins once weight is restored.

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Asherman's Syndrome

• What it is: Scar tissue (adhesions) inside the womb, damaging the lining.
• Causes — surgical evacuation (especially after miscarriage or PPH), endometrial infection, myomectomy, TB (in some countries).
• Features — light or absent periods after a procedure; cyclical pain; subfertility; recurrent miscarriage.
• Diagnosis — hysteroscopy (normal hormones; no bleed after a progesterone or oestrogen–progesterone challenge).
• Treatment — hysteroscopic division of adhesions; sometimes oestrogen afterwards to regrow the lining.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 38-year-old has heavy periods with flooding, and is missing work. Examination is normal; Hb 108 g/L. She doesn't want more children.
Answer: Heavy menstrual bleeding with iron deficiency.

• LNG-IUS first line (also contraception).
• Alternatives: tranexamic acid ± mefenamic acid, combined pill, cyclical progestogens.
• Oral iron; ultrasound only if examination abnormal or treatment fails; hysteroscopy if risk factors.

2. A 26-year-old has severe period pain since her teens, deep pain during sex, and pain opening her bowels during periods. Examination and ultrasound are normal.
Answer: Probable endometriosis (normal tests don't exclude it).

• NSAIDs and paracetamol; hormonal treatment (combined pill or progestogen) if not trying to conceive.
• Refer to gynaecology if symptoms persist — laparoscopy to diagnose and treat; specialist centre if deep disease.

3. A 62-year-old has had one episode of vaginal spotting. She is obese and has type 2 diabetes.
Answer: Postmenopausal bleeding — exclude endometrial cancer.

• Suspected cancer pathway referral (55 or over).
• Transvaginal ultrasound: endometrial thickness 4 mm or more — biopsy and/or hysteroscopy.
• Examine the vulva, vagina and cervix.

4. A 24-year-old has had no periods for 8 months. Pregnancy test negative. She has lost 10 kg training for a marathon. FSH and LH low, oestradiol low, prolactin and TFTs normal.
Answer: Hypothalamic amenorrhoea.

• Increase energy intake, reduce training; screen for eating disorder.
• DEXA scan; consider oestrogen replacement (transdermal) if it persists.

5. A 30-year-old has post-coital bleeding. Her cervical screening is up to date and normal.
Answer: Post-coital bleeding — screening doesn't exclude cancer.

• Pregnancy test; chlamydia and gonorrhoea NAAT; speculum examination.
• Suspected cancer referral if the cervix looks abnormal; colposcopy if persistent and unexplained.

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Key Points

• Heavy menstrual bleeding is defined by its effect on quality of life; check FBC; LNG-IUS is first line.
• Tranexamic acid and NSAIDs are non-hormonal options taken only during periods.
• Heavy periods since menarche — think von Willebrand disease.
• Fibroids: heavy bleeding and pressure symptoms; treat by symptoms — medical, myomectomy, UAE or hysterectomy.
• Adenomyosis: heavy, painful periods with a bulky, tender womb in women in their 40s.
• IMB and PCB: exclude pregnancy and STIs and examine the cervix; refer if it looks abnormal.
• Postmenopausal bleeding: suspected cancer referral if 55 or over; endometrial thickness 4 mm or more needs biopsy.
• Atypical endometrial hyperplasia: hysterectomy; non-atypical: LNG-IUS.
• Endometriosis: dysmenorrhoea, deep dyspareunia, dyschezia, subfertility; normal scans don't exclude it; treat without waiting for laparoscopy.
• PMS: symptoms only in the luteal phase; SSRIs and combined pill help.
• Primary amenorrhoea: no periods by 15 (or 13 without puberty); karyotype if FSH raised or features of Turner or androgen insensitivity.
• Secondary amenorrhoea: pregnancy test first; then FSH, LH, prolactin, TFTs and testosterone.
• PCOS: two of irregular ovulation, hyperandrogenism and polycystic ovaries; protect the endometrium.
• Hypothalamic amenorrhoea: low FSH and LH from energy deficit — bone loss risk.

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Guidelines and Further Reading

• NICE NG88: Heavy menstrual bleeding — assessment and management
• NICE NG73: Endometriosis — diagnosis and management
• NICE NG12: Suspected cancer — recognition and referral (gynaecological cancers)
• RCOG Green-top Guideline 67: Management of endometrial hyperplasia
• RCOG Green-top Guideline 48: Management of premenstrual syndrome
• International evidence-based guideline for the assessment and management of PCOS (2023)
• NICE TA832: Relugolix–estradiol–norethisterone for uterine fibroids
• NICE Clinical Knowledge Summaries: Amenorrhoea; Dysmenorrhoea; Fibroids
• BNF — for current doses

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