Period problems

The menstrual cycle is controlled by female hormones that generally cause a regular bleed, often called a ‘period’. How long it lasts and how heavy it is varies for each woman.

It can be bright red, dark red or dark brown in colour, and may contain small clots (dark firmer pieces of blood).

On average a woman will lose 20-80 mL of blood during a period.

20mL = 4 teaspoons

80mL = ⅓ cup

Though it’s not quite so easy to measure that.

In the first two to three years after a girl’s period has started, the periods may be irregular and can take a while to regulate.

On average the periods begin about the same time each month (26-29 days apart) but can be as often as every 3 weeks, or as far as 8 weeks apart. Ovulation can still occur regularly or irregularly until menopause.

Most women will menstruate for about 40 years, and can expect to have about 500 period cycles in their lifetime.

Heavy periods (menorrhagia)

Heavy menstrual bleeding (also known as menorrhagia) is excessive and/or prolonged menstrual bleeding. The amount varies from woman to woman and can change at different stages in your life, for example, approaching menopause.  It is defined as blood loss greater than 80ml (equal to 1/3 of a cup) per cycle, or periods lasting more than seven to eight days. Heavy menstrual bleeding affects about one in five women and is a common problem in the 30-50 year old age group.

How do you know if your bleeding is too heavy?

It is very difficult to determine whether your bleeding is too heavy.  The best guide is to decide whether your period is impacting on your quality of life, causing you to be housebound, interrupting your daily activities or causing you stress and anxiety.  The following signs may indicate you are experiencing heavy bleeding:

  • Bleeding or ‘flooding’ not contained within a pad/tampon (especially wearing the largest size)
  • Changing a pad/tampon every hour or less
  • Changing a pad overnight
  • Clots greater than a 50 cent piece in size
  • Bleeding for more than 7-8 days

How can heavy bleeding affect you?

You may:

  • feel fatigued, exhausted, dizzy and look pale
  • have low iron levels because of the blood loss
  • have cramping and pain in the lower abdomen
  • have to change sanitary products very frequently
  • fear bleeding through to your clothes and this affects your daily activities

Period Pain (dysmenorrhoea)

While some women experience minimal or mild discomfort during menstruation, other women suffer from severe, debilitating pain that prevents them from doing their day to day activities. None of us know what another woman’s pain is like, so it is useful to understand what periods should feel like and then decide if all is normal. Some women may have always experienced painful periods, others may develop pain. Period pain is more common in adolescents and women in their 20s, but can also occur in older women.

Period pain happens when the muscles in the uterus contract or tighten. Pain may include cramping and heaviness in the pelvic area, as well as pain in the lower back, stomach or even legs. Some women also experience nausea, vomiting, paleness, diarrhoea or loose bowels.  Women who experience painful periods may have higher levels of prostaglandins – a natural body chemical that causes contractions of the uterus, bowel and blood vessels.

Period pain is the most common cause of pelvic pain.

What is normal period pain?

Period pain should only be considered ‘normal’ if:

  • the pain is only there on the first one or two days of your period
  • it goes away if you use the contraceptive pill or take period pain medications
  • your ability to do your normal activities is not impaired

If the pain is not like this, it is not normal.

What causes period pain?

Painful periods can be due to:

  • pain in the uterine (womb) muscle (myometrium) especially if the pain is on the first one or two days of a period
  • pain from endometriosis and/or adenomyosis, especially if the pain is there for more than one to two days before the period starts

Many women with strong period pain have both these problems and women with adenomyosis have a more painful uterus than other women, even if it looks normal. Adenomyosis is a condition where the cells which normally form a lining on the uterus also grow in the muscle wall of the uterus. Endometriosis is a condition where tissue, like the lining of the uterus, grows outside the uterus where it shouldn’t be.  It used to be thought of as an uncommon problem of women in their 30s and 40s.  We now know it is a common problem that usually starts in the teens (see our page on Endometriosis).

Symptom relief for painful periods

Apply heat on the belly or lower back To help relax muscles.
Exercise To release endorphins (natural feel-good hormones).
Relax with rest, warm baths or meditating To release stress.
Pain relief: ibuprofen, naproxen or diclofenac Take period pain medications at the onset of pain and take regularly during the days you normally have pain. All these medications can cause stomach irritation, so they are best taken with food and discuss the pros and cons of using them with your doctor.
The oral contraceptive pill (OCP) Ask your doctor about:

  • a pill with more progestogen than oestrogen for the best effect
  • planning a period only every 2-3 months or not at all
Mirena® intrauterine device (IUD) Currently the most effective treatment for pain from the uterus and lasts up to 5 years.

It slowly releases a progestogen medication to the uterus that makes periods lighter, less painful and it’s also a contraceptive.

It’s common to have irregular bleeding and cramp pains for the first few months but these problems usually settle.

If you have not had children or have a tender pelvis you can ask to have it inserted under an anaesthetic.

Irregular periods

Common regularity issues

Irregular periods – oligomenorrhoea Periods may be irregular in the lead up to menopause, following childbirth, miscarriage or termination of a pregnancy or as already mentioned, in the first few years after they begin. Some women however, never establish a regular cycle. Irregular periods may be due to:

  • stress
  • starting or changing contraception
  • pregnancy, miscarriage or an ectopic pregnancy (where the baby grows in the fallopian tube or somewhere else outside the uterus)
  • polycystic ovary syndrome (PCOS) – a common hormone disorder
  • change in diet or sudden weight loss or gain
Absence of periods – amenorrhoea Absence of periods (other than in pregnancy) may occur because of a hormonal disturbance caused by factors including weight gain or loss, over exercising, anxiety or stress, travel, dietary changes and conditions such as PCOS. Amenorrhoea may be temporary with periods returning after some months. Women experiencing amenorrhoea for longer than six months should consult a doctor.
Heavy menstrual bleeding A heavy period (more than 80ml) can significantly interfere with everyday life. While it is difficult to accurately measure the amount of menstrual fluid, having to change your pad or tampon hourly, needing to change during the night, or having to get thicker pads or larger tampons to contain the blood flow, is a good guide that your period is heavy.

A number of factors, including fibroids, polyps, endometriosis, adenomyosis and, rarely, uterine cancer, can cause heavy bleeding. Heavy bleeding may then lead to anaemia (low haemoglobin blood count), with symptoms of fatigue, paleness, lack of energy and shortness of breath.

When no cause is found hormonal medications to reduce bleeding are usually prescribed. These include the oral contraceptive pill and progestin hormone therapies including tablets or a progestin hormone-releasing intra uterine device (IUD).

Spot bleeding between periods Bleeding between periods may be caused by diet, stress, being underweight, doing too much exercise, sexually transmissible infections (STIs), endometriosis, fibroids, PCOS, thyroid disorders or gynaecological cancer. It can also be a side effect of some contraceptives or medications.

Any bleeding between periods should be investigated by a doctor, particularly for postmenopausal women who are at higher risk of endometrial cancer. “When you visit your doctor it helps if you can describe your pattern of bleeding,” says Jean Hailes gynaecologist and founding director Dr Elizabeth Farrell. “The doctor will also need to know if bleeding occurs after sex or if there is any accompanying pelvic or lower abdominal pain.”

 

Premenstrual syndrome (PMS)

In the days leading up to a period (menstruation) up to 30% of women experience emotional and physical symptoms, often called premenstrual syndrome (PMS). Most women experience one or two premenstrual symptoms that can be managed. Symptoms start about four to ten days before a period and usually stop after bleeding begins.

What are the symptoms of PMS?

Symptoms of PMS vary in intensity from woman to woman and can vary from one cycle to the next. The most common symptoms include:

EMOTIONAL SYMPTOMS PHYSICAL SYMPTOMS
  • irritability
  • anxiety
  • nervous tension
  • lower coping ability
  • difficulty concentrating
  • wanting to be alone
  • lower libido
  • reduced interest in work and social life
  • mood swings
  • depression
  • aggression
  • fluid retention (swollen fingers or ankles)
  • bloating around the abdomen
  • breast swelling and tenderness
  • skin problems such as acne
  • headaches and/or migraines
  • poor coordination or clumsiness
  • tiredness, lethargy, insomnia
  • increase in weight
  • constipation and/or diarrhoea
  • food cravings
  • aches and pains

What is premenstrual dysphoric disorder (PMDD)

Premenstrual dysphoric disorder (PMDD) is a more serious form of PMS. Women who have PMDD experience severe PMS symptoms that interfere with daily life. PMDD affects about three to eight per cent of menstruating women.

Causes of PMS & PMDD

It’s not clear why some people develop PMS and PMDD. There appear to be very complex interactions between certain chemicals in the brain and progesterone that lead to symptoms. PMS does not occur if there is no ovulation or post menopausally.  Stress levels, psychological state, poor physical health, our genetic makeup, cultural and social environment and changes in neurotransmitters (like serotonin) may all influence the development of PMS symptoms. Having a high body mass index (BMI) and smoking are also risk factors.

How are PMS & PMDD different to depression?

PMS and PMDD have similar symptoms to depression but with PMS and PMDD, the symptoms get better completely as soon as menstruation begins, but those of depression do not.

PMS and PMDD need to be distinguished from underlying depression because the treatments are different.

Management & treatment of PMS symptoms

There are a number of things you can do yourself to manage and reduce your PMS symptoms.

Be physically active Physical activity increases endorphins (feel good hormones) that can reduce symptoms. Endorphins also act as natural painkillers and help you feel more relaxed and in control.

Choose a form or variety of physical activity you enjoy, and aim for 30 minutes of moderate intensity activity on most, if not all days, especially when symptoms are at their worse.

Reduce stress levels Stress can exacerbate PMS symptoms.

Talk to your family about your PMS and help them develop strategies to be supportive during this time and take time out to relax and enjoy your own interests.

If you feel your levels of stress are increasing, consider professional counselling as cognitive behavioural therapy (CBT) and relaxation therapies can assist.

Maintain a healthy lifestyle
  • Eat regular, healthy meals including plenty of vegetables, fruit, mixed grains and cereals
  • Eat small meals to maintain stable energy levels
  • Drink less caffeine, particularly if you are suffering breast tenderness
  • Try drinking 6-8 glasses (1.5-2 litres) of water each day
  • Cut down salt and salty foods to help reduce fluid retention
  • Get enough rest, sleep and exercise to help manage stress
  • Try relaxation techniques like yoga or meditation
  • Don’t smoke – if you need help, call the Quitline on 13 7848 or visit www.quit.org.au
  • Wear a well-fitting cotton bra if you suffer tender, painful breasts
  • Write down your symptoms to help you identify a pattern for things that might trigger or worsen your symptoms
Vitamins, minerals and herbs Although the evidence is not strong, some supplements that may be effective in treating PMS include:

  • vitamin E
  • magnesium pyrrolidone
  • vitamin B6
  • chaste tree

Calcium has been shown to improve symptoms in the dose of about 600mg twice a day

Consult your health practitioner before taking any supplement, as they may have unwanted effects or interact with other medications you are taking.

Hormonal treatments These treatments can suppress ovulation and reduce the hormones of the premenstrual phase. Hormone therapies can include contraceptive therapies such as the oral contraceptive pill. Consult your doctor for further information regarding hormone treatment options.
Medication There is a range of medications available that have been proven to help, such as the antidepressants known as selective serotonin reuptake inhibitors (SSRIs), anti-prostaglandin (for pain/cramps), anti-inflammatories, and spironolactone diuretic (for bloating). See your doctor to discuss these.

Things to keep in mind:

  • Premenstrual syndrome (PMS) refers to the range of emotional and physical symptoms some women experience in the lead-up to their period, which may interfere with their quality of life
  • Most PMS symptoms can be managed with lifestyle modifications, such as exercise, diet and supplements
  • If symptoms persist and interfere with daily activities see your doctor or seek referral to a gynaecologist with expertise in PMS
  • It may be useful to keep a detailed daily diary of at least two menstrual cycles to see if there is a pattern with your symptoms so you and your doctor to talk about the best treatment options for you

When to see your doctor

It is important to see your doctor if you experience any issues with your period which worry you. Keeping a menstrual diary, including when you get your period, the length, heaviness and anything else you notice, will help your doctor work out how best to help you.

You should consult your doctor if you:

  • have not started menstruating by the age of 16-17
  • notice your period has suddenly stopped
  • are bleeding for more days than usual
  • are bleeding excessively or more than you usually do
  • bleed between periods or after sexual intercourse
  • experience pain during your period that interferes with your quality of life
  • have clots that are bigger than a 50 cent piece in size

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