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Menstrual Disorders

Problems related to menstrual periods occur in 1 in every 4 women and include pain, heavy periods and/or a change in their frequency. Whilst most menstrual problems are not dangerous, they may impact quality of life and can be a substantial burden for women. Knowing that something may be done is the first step in addressing problem periods and the team at Alana have considerable expertise in offering the full range of medical and up-to-the-minute surgical techniques to help you to change your period problems to periods – no problem.

Abnormal Uterine Bleeding (AUB)?

Before we consider what is abnormal, it is important to consider the range of normal menstrual patterns.  Most women will have bleeding with their period that lasts for 3-8 days with an average duration between periods of 28 days and a range of 21-35 days.  It is important to note that for both obstetrics and gynaecological situations ‘Day 1 of the cycle’ is considered as the first day of menstrual bleeding.

Abnormal Uterine Bleeding (AUB) may therefore be:

  • Bleeding or spotting in between periods (also called intermenstrual bleeding)
  • Heavy periods or periods that last longer than normal (also called menorrhagia, although this term is no longer used medically)
  • Bleeding after sex (post-coital bleeding)
  • Bleeding after the menopause (post-menopausal bleeding)
  • Not having any periods for a minimum of 3 months (amenorrhoea)

What causes AUB?

AUB may have many different causes depending on the type of abnormal bleeding that is present.  We generally divide these problems into those that may be seen (structural problems like polyps) those that cannot be seen (this group would include hormonal irregularities).

Structural problems that may lead to AUB includes:

Polyps:  These are growths of the lining of the uterus. They are relatively common and most (>99%) are benign (non cancerous), but rarely they may have cellular changes of cancer or pre-cancer.  Your symptoms, the size of the polyp, the number of polyps and your personal history will be considered when considering treatment options if you are diagnosed with a polyp.

Adenomyosis:  Adenomyosis is a condition where the lining of the uterus has grown into the wall of the uterus.  It is often considered to be similar to endometriosis, since may of the symptoms are similar and the findings under the microscope are also similar, it is only the location (inside the uterine muscle rather than outside of the uterus) that causes its change of name.  Symptoms can include heavy and painful periods. A variety of medical and surgical options are used to treat this AUB problem.

Fibroids (Myomas):  These are benign growths of the muscular wall of the uterus and are very common.  They may cause a number of symptoms aside from bleeding issues and there is a full information available here.

Cancer:  Cancer of is a rare cause of bleeding compared to the other causes of AUB, but of course is very important to diagnose, since early detection and treatment of cancers often mean cures for women.  Certain types of cancer or pre-cancer may cause problems with bleeding such as vaginal, uterine or cervical cancer.  If you have abnormal bleeding, then it is important that you see your GP or gynaecologist and bleeding after menopause should never be ignored, since this is a time of increased disk of cancer of the lining of the uterus in particular.

The other major group of problems that may cause AUB are those that cannot be seen with the eye or on a scan.  This group includes clotting abnormalities in the blood, hormonal issues such as polycystic ovarian syndrome and some types of hormonal and other medications.  Your Alana doctor may do additional tests to help determine if this is the cause for the AUB in your particular circumstance.

How is AUB diagnosed?

Your Alana Doctor will ask you about your symptoms as well as your personal and family history.  If you have had previous scans or blood tests, you should bring these with you as they may be helpful.  An examination will be performed by your Alana Doctor that will include a speculum examination, pap smear and internal examination to check for any abnormalities.  Occasionally, these may be treated very simply at the same time as the examination, such as the removal of small polyps on the cervix.  Your Alana Doctor may also for further blood tests to be performed.

pelvic ultrasound is one of the most important investigations to help to diagnose the cause of AUB.  This may be performed at the time of your examination by your Alana Doctor and will help to provide very immediate and useful information about the diagnosis.

Your Alana Doctor may recommend that you have other tests such as a hysteroscopy (a long and narrow telescope that is gently inserted through the cervix and into the uterus) and biopsy of the lining of the uterus.  Your Alana Doctor will discuss this with you in more detail if it is required

What are the treatments for AUB?

The treatment of AUB will vary and depends on a number of factors, most importantly the cause, but also your age and desire to have children.  Generally, the treatments may be broken down into watch-and-wait (and perhaps a review), medical treatments and surgical treatments.

Medications:  Hormonal and other medications may be used to control AUB.  These range from non-steroidal anti-inflammatory medications (NSAIDs) such as Ponstan, Nurofen or Ibuprofen, medications to help clotting such as Cyklokapron, or hormones such as progesterone, the oral contraceptive pill or a hormone releasing intrauterine system (IUD).

Surgery:  Sometimes surgical removal of the cause of the AUB is required and this will be discussed with you by your Alana doctor.  Surgical procedures are commonly performed by hysteroscopy as mentioned above, or by laparoscopy (keyhole surgery in the abdomen) depending on what the cause is.  Other methods such as endometrial ablation, where the lining of the uterus is surgically and permanently removed may be recommended and your Alana doctor will discuss this with you in more detail after your specific problem has been considered.

Frequently Asked Questions

What are my chances of falling pregnant after an ectopic pregnancy?
It depends.  Some ectopic pregnancies are caused by certain conditions like endometriosis or as a result of previous pelvic inflammatory disease (PID) commonly caused by Chlamydia infection.  In these conditions the remaining fallopian tube may be scarred and increase the likelihood of another ectopic pregnancy.  In general, the risk of recurrence is up to 8-10% after one ectopic pregnancy.  The recurrence risk is of course dependent on whether or not you have any underlying conditions.  Many women (and doctors) think that the ovaries are taking turns in releasing an egg (left than right etc.) but this is not true.  The other commonly held belief is that, for example, the right fallopian tube only can pick up the egg released from the right ovary, which is not true either.  We know that in reality the ovaries are located rather close to each other (not like in the anatomy pictures), and ovulation occurs more “randomly” from each ovary (sometimes at the same time!) and that the fallopian tubes can pick up the egg from the ovary on the other side.  This is because of a complex process attracting the fallopian tube to move towards the ovary where the ovulation (release of the egg) has occurred. Therefore a previous ectopic pregnancy doesn’t half your chances of a next pregnancy.  Research has shown that around 65% of women with a previous ectopic pregnancy have an intrauterine pregnancy within 18 months.  This figure may go up to as high as 80% in two years, so that is promising.  If you do fall pregnant it is important to have an early pregnancy scan determining the location of the pregnancy, making sure it is inside the uterus. If you have trouble falling pregnant than depending of your age and underlying conditions we would recommend you to see one of our Alana specialists as the other fallopian tube may be scarred and preventing you from conceiving naturally. There is an ultrasound test called a HyCoSy (“Hysterosalpingo Contrast Sonography”) which can determine whether your other fallopian tube is functioning normally.  During this ultrasound investigation a speculum is inserted to allow a thin plastic tube to be placed inside the uterus.  Through this tube a mixture of air and normal saline is injected and this shows up on the ultrasound scan.  You can see if the fallopian tube is open (“patent”) as there is spill seen around the end of the fallopian tube and ovary.  This test may reassure you if normal.  If the fallopian tube is blocked it is worthwhile seeing one of our specialists at Alana who will discuss alternative ways for a pregnancy to occur (like IVF).
How long do I have to wait after my miscarriage to try to conceive again?
We recommend you have at least one normal period after your miscarriage.  If the first bleed is not quiet as normal than wait until you have a normal menstrual period in your next cycle as it takes time for your body to clear the pregnancy hormone.  When you have had a normal period we know your cycle has returned to normal, the pregnancy hormone is out of your system and that your body is ready for a new pregnancy.  Record the first day of your menstrual period (LMP) as this is important in dating your next pregnancy. Physically you do not need more than one period but allow yourself enough time to emotionally be ready as well.  Some time is also necessary to allow yourself to grieve about your pregnancy loss. We find that most women after a miscarriage are a little more anxious in their next pregnancy.  Your GP can refer you to the Alana Obstetricians for an early pregnancy scan and we recommend it to be done at around 8 weeks from your LMP as at this stage you should really be able to see your baby’s heartbeat.
I thought I was 7 weeks pregnant but the scan says I’m only 5 weeks and no heartbeat is seen, how is this possible?
To answer this question we firstly go back to basics to understand your cycle. The pregnancy is calculated based on the average menstrual cycle which is 28 days.  The first day of menstrual bleeding marks the first day of the menstrual cycle.  This is called your LMP (or “last menstrual period”).  Right in the middle of this picture perfect 28 day cycle is when ovulation occurs (day 14 of the cycle) and roughly 2 days before and after is when you are most fertile.  In real life not everyone has this picture perfect 28 day cycle, it may be longer or shorter, but we know that ovulation occurs roughly 14 day before your next period.  This is why many fertility doctors recommend to have intercourse every 3 days if you really are trying to have a baby because the ovulation may occur a little earlier or later than you may think. When calculating the weeks of pregnancy we include those two weeks from the first day of the LMP as this is the easiest part of the cycle to notice and to record.  We also will enquire about the length of your cycle and whether it is regular or irregular.  All of this is helpful in trying to establish the gestation.  For example, if your cycle is regular and 33 days long we would expect your ovulation to have occurred later (5 days) and an early pregnancy scan will most likely show a baby that measures 5 days less than you were expecting. Now to answer your question, it may be that you ovulated later in the cycle or have a longer cycle.  The pregnancy is truly only 5 weeks, a follow up ultrasound in 10-14 days is likely to show your baby’s heartbeat and all is well.  The other possibility is that unfortunately the pregnancy is not developing as expected at 7 weeks gestation and a follow up scan may reveal a miscarriage.  We understand that this is an anxious time and to have to wait for 10 -14 days seems very long but it is important to have this time in between scans to determine accurately what is taking place.
Why do I have spotting or mild bleeding in early pregnancy?
It is common to have some bleeding in early pregnancy.  It may occur in 20% (or one out of five) mums to be, and it is unlikely to be harmful to your baby.  It usually happens at about the same time that your period would have been due, and may last for a couple of days.  The bleeding is usually light (no large clots) and is not accompanied by strong period pains. There are many different causes for bleeding in pregnancy, and in the first trimester the bleeding may be caused by:
  • Breakthrough bleeding: which happens as the pregnancy hormones interfere with the hormones of your normal menstrual cycle.  This causes some the endometrial lining to be shed.  Spotting or light bleeding may come and go for several days.
  • Implantation bleeding:  which happens when the fertilised egg implants in the endometrial lining of the uterus. The endometrial lining has been prepared for the nestling of the fertilised egg during the menstrual cycle and has now got a very good blood supply.  The implantation may therefore be associated with some light bleeding.
  • Other causes:  which may include changes to your cervix by the pregnancy hormones; it softens the cervix and causes an area of cells covering the cervix to move towards the outside of the cervix.  These cells are more prone to bleeding, especially when touched during intercourse.  It is important to be up to date with your Pap smear screening tests as bleeding may also be caused by abnormal cells.  Bleeding can also be linked to vaginal or cervical infection which would require further investigation with a vaginal swab and may need treatment.  A harmless growth on the cervix called a polyp may also cause bleeding at any stage in the pregnancy.  A speculum examination (as is done with the Pap smear) will reveal this polyp, and usually nothing needs to be done about it during your pregnancy.
Bleeding in early pregnancy is common but it’s important to tell your doctor about it.  At Alana we will perform a physical examination which may include a speculum examination to see if the cervix is open or not and what the cervix looks like in general.  Depending on other symptoms we may take a vaginal swab if we think there is an infection.  We may also perform an (internal) ultrasound to measure the gestation and to determine where the pregnancy is located. We would recommend testing your pregnancy hormone level (“quantitated HCG”) which also helps in dating the pregnancy, and we would test your blood group. In general if the bleeding is light and settles down, and is not accompanied by bad period type pains, there is a good chance that all is well and that your baby is fine.
What if I have an urgent problem, do I need to wait?
If your condition is life threatening or of a serious urgent nature we recommend you present to the Emergency Department of your nearest hospital.  All other urgent requests we always try to accommodate, and we have a daily appointment time kept for the most urgent of issues related to abnormal bleeding. Our Alana Bleeding Clinic (ABC) is here to help your issues relating to abnormal bleeding and by contacting Alana on 9009 5255 we can arrange a soon appointment. For all other referrals, we run a triage service. This means we review your clinical needs and prioritise your clinical issue according to risk. Our administration team may also suggest the soonest available clinician to assist you with your problem.
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