This symptom causes substantial anxiety in the sexually active woman: the first unexpectedly missed period suggests pregnancy; prolonged absence raises the concern that something is seriously amiss. In contrast, management is usually straightforward, and helped by acknowledging the anxiety.
COMMON
pregnancy
physiological: rapid weight (10–15%) loss, and severe emotional stress
menopause (including premature ovarian failure)
polycystic ovary syndrome (PCOS)
drugs: phenothiazines, metoclopramide, valproate, cytotoxics
OCCASIONAL
hypo- and hyperthyroidism
anorexia nervosa
excessive exercise/training
severe systemic illness of any kind
contraception (progestogen-only pill, long-acting reversible contraception – common cause but rarely presented as a symptom)
RARE
adrenal disorders: Addison’s disease, Cushing’s disease, congenital adrenal hyperplasia
Sheehan’s syndrome
arrhenoblastoma, bilateral ovarian tumours
prolactinoma, other pituitary tumours
rare structural or chromosomal abnormalities (primary amenorrhoea)
anterior pituitary failure (Simmonds’s disease)
LIKELY: pregnancy test.
POSSIBLE: FBC, U&E, TFT, FSH/LH, testosterone, prolactin, ultrasound.
SMALL PRINT: CT with or without other imaging.
Pregnancy test whatever contraception is used: urinary HCG. Remember small false negative rate.
FBC, U&E, TFT: to assess for general severe systemic illness, adrenal disorders and hypo- or hyperthyroidism.
FSH, LH and testosterone: LH and testosterone high in PCOS, FSH very high in menopause.
Prolactin levels high in prolactinoma and with some drugs (e.g. phenothiazines).
Ultrasound useful to show multiple ovarian cyst formation and is a reliable check of pregnancy.
Specialist will arrange CT or similar imaging if prolactinoma suspected.
Amenorrhoea is common in young women, especially at times of stress; once pregnancy has been excluded and in the absence of any worrying symptoms or signs, only investigate if the problem persists beyond 6 months.
It is important to confirm a possible diagnosis of premature menopause, as the patient will require hormone-replacement therapy (HRT).
The same pathologies can cause both amenorrhoea and oligomenorrhoea, therefore take the same clinical approach to both.
Do not accept too readily the claim that there is ‘no chance of pregnancy’; if in any doubt, arrange a pregnancy test.
Consider anorexia – an emaciated body may be well hidden under baggy clothing, and the disease often presents with the absence of periods.
Early morning headache and visual disturbance associated with amenorrhoea suggest possible intracranial pathology – refer urgently.
Before attributing amenorrhoea to weight loss, make sure that the weight loss itself hasn’t been caused by thyrotoxicosis.
This is a common presenting complaint. The average GP can expect about 100 women to consult each year for menstrual problems (female GPs rather more) and many of these will be for menorrhagia. Normal menstrual blood loss is 20–80 mL. In practice, measurement is not feasible, so the definition rests on what the woman reports, although some efforts can be made to establish whether or not the bleeding is ‘excessive’.
COMMON
dysfunctional uterine bleeding (DUB)
cervical or endometrial polyps
endometriosis
fibroids
puberty and perimenopause
OCCASIONAL
hypothyroidism (and hyperthryoidism)
IUCD
iatrogenic (contraceptive pill, HRT)
cystic glandular hyperplasia (metropathia haemorrhagica)
chronic PID
RARE
adrenal disorders and hyperprolactinaemia
liver disease, especially alcoholic
clotting disorder
endometrial carcinoma
tuberculous endometritis
LIKELY: FBC.
POSSIBLE: TFT, ESR/CRP, transvaginal ultrasound and, after referral, endometrial sampling and hysteroscopy.
SMALL PRINT: LFT, HVS, clotting studies, endocrine assays.
FBC to check for anaemia and thrombocytopenia.
Check possible thyroid dysfunction with TFT.
ESR/CRP: elevated in PID.
LFT: if clinical suspicion of liver disease.
Clotting studies: if other history of abnormal bleeding or bruising.
Transvaginal ultrasound useful for confirming fibroids and suggesting endometrial pathology.
HVS very occasionally useful in chronic PID with discharge.
Endocrine assays: for hyperprolactinaemia or adrenal disorders.
Investigation after referral is likely to include endometrial sampling and/or hysteroscopy.
Self-reporting of the heaviness of the menstrual flow is notoriously unreliable. Attempt an objective assessment by enquiring about the number of pads or tampons used, flooding, the presence of clots, and by checking an FBC for iron-deficiency anaemia.
Establish the woman’s agenda. This presentation may be the passport to a prescription (e.g. the contraceptive pill in a young woman) or to discussion of a specific anxiety (e.g. fears about possible cancer or a need for hysterectomy).
Don’t forget to enquire about a ‘long-forgotten’ coil.
In a young woman who has painless heavy periods, is otherwise well and has a normal vaginal examination, it is reasonable to make a presumptive diagnosis of DUB and treat empirically.
Establish whether the problem really is simply ‘heavy periods’; if the bleeding is chaotic, or there is also intermenstrual or post-coital bleeding, the chances of a structural lesion are much higher – ensure the patient is appropriately investigated.
Blood clots suggest significant bleeding; do not forget to arrange an FBC.
Menorrhagia with secondary dysmenorrhoea, dyspareunia and pelvic tenderness on examination suggest endometriosis or chronic PID.
Irregular vaginal bleeding presents commonly in primary care – particularly to female GPs, as the patient will often anticipate a pelvic examination. This chapter covers all causes of this symptom throughout life including prepubertal, causes in early pregnancy and postmenopausal (causes in late pregnancy are not covered as they constitute a quite different clinical scenario). The key to appropriate management usually lies in a careful history.
COMMON
dysfunctional uterine bleeding (DUB)
breakthrough bleeding (BTB) on contraceptive pills and long acting reversible contraception; also HRT
cervical polyp or erosion
cervicitis and PID
post-menopausal atrophic vaginitis
OCCASIONAL
endometrial polyps
ovulatory bleeding (associated with mittelschmerz)
hypothyroidism (and less commonly hyperthyroidism)
perimenopause
bleeding during early pregnancy (20% of all pregnancies in first trimester); also miscarriage, ectopic pregnancy
RARE
uterine bleeding in the newborn
carcinoma (ovary, fallopian tube, uterus, cervix and vagina)
cystic glandular hyperplasia (metropathia haemorrhagica)
pyometra
hydatidiform mole (5% go on to chorionic carcinoma)
LIKELY: FBC, specialised gynaecological investigation (see below) for post-menopausal or intermenstrual bleeding.
POSSIBLE: HVS and endocervical swab, colposcopy, transvaginal ultrasound.
SMALL PRINT: TFT.
FBC to check for anaemia in heavy bleeding. Raised WCC in PID.
TFT: to check for possible thyroid dysfunction.
HVS and endocervical swab: to attempt to establish pathogen in cervicitis and PID.
Transvaginal ultrasound: to detect uterine and ovarian pathology, hydatidiform mole and to establish nature of problem in early pregnancy.
Colposcopy: if significant cervical pathology suspected.
Specialised gynaecological investigation (e.g. hysteroscopy and endometrial sampling): performed in secondary care, particularly for intermenstrual and postmenopausal bleeding.
Try to distinguish between intermenstrual bleeding and irregular periods, as the likely causes are different (the former suggests a structural lesion, the latter is likely to be DUB). Simply asking the patient if the bleed feels like a period, with associated period-type symptoms, may help.
Consider asking the patient to keep a menstrual diary. Very slight bleeding occurring consistently in mid-cycle with a slight pain and with no other worrying features suggests an ovulatory bleed.
Remember that missed doses, diarrhoea and vomiting, and the first few months of treatment can cause breakthrough bleeding when using oral hormonal preparations. It is worth waiting a few more cycles before changing treatment.
Post-menopausal bleeding is always abnormal. Even if atrophic vaginitis is present, do not assume this is the cause: this symptom requires a full assessment.
A very inflamed-looking cervix with a purulent discharge is likely to be caused by Chlamydia infection: consider referral to the local GUM clinic for further investigation and contact tracing.
A ‘recent’ normal cervical smear can provide false reassurance; if the cervix looks suspicious, do not take another smear – remember, this is a screening, rather than diagnostic, test. Instead, refer urgently for colposcopy.
Beware of ‘breakthrough bleeding’ in patients on hormonal contraception or HRT. If it persists, consider other causes and investigate or refer.
Unilateral pelvic pain with vaginal bleeding within a fortnight of a missed period suggests an ectopic pregnancy. Admit urgently.
Painful periods are extremely common: 50% of women in the UK complain of moderate pain, and 12% suffer severe, disabling pain. Primary dysmenorrhoea is pain with no organic pathology, usually starting when ovulatory cycles begin. Secondary dysmenorrhoea is associated with pelvic pathology, and appears later in life.
COMMON
primary dysmenorrhoea
endometriosis
chronic PID
IUCD
pelvic pain syndrome (‘venous congestion’)
OCCASIONAL
retroverted uterus
cervicitis
chocolate cyst of ovary
endometrial polyp
RARE
uterine malformation
imperforate hymen
uterine hypoplasia
cervical stenosis
psychogenic
LIKELY: none.
POSSIBLE: FBC, ESR/CRP, HVS and endocervical swab, ultrasound, laparoscopy.
SMALL PRINT: none.
FBC for anaemia if periods also heavy. WCC and ESR/CRP raised in PID.
HVS and endocervical swab for Chlamydia if vaginal discharge present – may help establish pathogen in chronic PID.
Ultrasound helpful to define uterine enlargement or other abnormalities and to detect ovarian cysts.
Laparoscopy is the usual investigation after referral to secondary care: will make diagnosis of PID and endometriosis.
Explore the patient’s agenda: young adolescents may use the symptom of painful periods as a passport symptom to obtain a prescription for the contraceptive pill.
Beware of the diagnosis of endometriosis. Even if detected laparoscopically, this may not be the actual cause of the patient’s pain (endometriosis is often asymptomatic). Unless it is explained that the treatment offered is not necessarily a panacea, the patient is likely to get frustrated at the apparent lack of progress.
A long-forgotten IUCD can be a cause of dysmenorrhoea. Enquire specifically about this possibility – and check the notes too.
Explain to patients early on in your management that a precise organic diagnosis isn’t always possible; this will help maintain a good doctor–patient relationship, which will facilitate the subsequent unravelling of any significant underlying psychological problems.
The chances of organic pathology are greater if the patient has secondary dysmenorrhoea which is severe enough to disturb sleep.
Half of women who undergo laparoscopy for secondary dysmenorrhoea have no obvious organic pathology. Consider psychological problems and avoid over-investigating and over-referring – a number of these women end up having surgery (e.g. TAH) but even then continue to have pain.
Consider other pathologies if the patient presents acutely with a self-diagnosis of ‘severe period pain’: non-gynaecological causes of pelvic pain such as appendicitis, renal colic or UTI may occur at the expected time of the period.
While painful periods are depressing, true clinical depression may lower the pain threshold of an otherwise normal woman and should not be missed.
