HealthCert Blog

Menstrual irregularities are common, with a prevalence of up to 34 per cent in some areas of the world. The management of irregular bleeding initially involves the exclusion of contributory pathologies such as cervical abnormalities (cervical ectropion, cervical cancer), uterine abnormalities (fibroids, endometrial hyperplasia), hormonal imbalances (menopause, thyroid disorders, polycystic ovary syndrome), genital infection (chlamydia, gonorrhoea), and haematological abnormalities (coagulation disorders). Pregnancy should also be ruled out, and the influence of any contributory medications (e.g. contraception, including emergency contraception) considered.

Irregular menstruation

Some women simply have irregular menstrual bleeding without any demonstrable pathology, which falls under the umbrella term of dysfunctional uterine bleeding (DUB), and is a diagnosis of exclusion. DUB is particularly common at the extremes of reproductive age (i.e. shortly after menarche, or around the time of menopause).

Once a full investigation has been carried out, and pathology excluded, it is prudent to provide reassurance, and to explain to the patient that it is normal for a menstrual cycle to display some variation, with up to an eight-day variation being entirely normal.

In addition, dietary intake and psychological stressors can impact menstruation, causing irregularity or oligomenorrhoea without any demonstrable pathology. Non-concerning irregular menstruation does not necessarily require any form of treatment, and management should be patient-focused, and is largely dependent on the patient’s desire for fertility.

Non-pharmacological management

Lifestyle changes such as ensuring an adequate nutritional intake and reducing psychological stressors can alone regulate menstrual bleeding. Weight loss if the patient is overweight can restore normal ovarian function and reduce menstrual irregularity that may be associated with anovulatory cycles.

Hormonal contraception

The mainstay of active management of irregular menstruation is the use of exogenous hormones, typically in the form of hormonal contraception, in an attempt to regulate bleeding patterns. Combined hormonal contraception (CHC) including both an oestrogen and a progestogen used in a cyclical manner often produces a regular, predictable bleed, which is acceptable to many women. CHC is available in pill, patch and vaginal ring forms, and is not suitable for all women (for example those with an increased risk of thromboembolism, or those who suffer from migraine with aura).

For those in whom CHC is unsuitable or contraindicated, therapy with a progestogen-only contraceptive may be advised. This may be in the form of a progestogen-only pill (POP), subdermal implant (SDI), progestogen-only injectable or a levonorgestrel-releasing intrauterine system (LNG-IUS) such as a Mirena coil. These contraceptives are more likely to result in amenorrhoea, and may therefore reduce the burden of irregular bleeding. It is important to adequately counsel women on the possible bleeding patterns associated with different contraceptives.

Irregular menstruation and fertility

For women in whom contraception is not acceptable, such as women who are actively trying to conceive, lifestyle measures should be encouraged. Onward referral to a fertility specialist should be considered for those who are having difficulty conceiving and who have irregular menstruation. Ovulation induction agents may be considered in these cases with e.g. letrozole or clomiphene.

In summary, irregular menstrual bleeding is a diagnosis of exclusion. Management should be patient-focused, and take into account the burden of the condition on the woman, and her reproductive aims.

Learn more about supporting women with menstrual irregularities in primary care with the HealthCert Professional Diploma of Women’s Health program.

Read more about managing menstrual irregularities in primary care.

References

1. BMJ Best Practice (2020). Abnormal Uterine Bleeding. https://bestpractice.bmj.com/topics/en-gb/658
2. The Best Practice Advocacy Centre New Zealand (2019). Investigating and managing abnormal vaginal bleeding: an overview. https://bpac.org.nz/2019/bleeding.aspx
3. American College of Obstetricians and Gynecologists (2012). Diagnosis of Abnormal Uterine Bleeding in Reproductive-Aged Women. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2012/07/diagnosis-of-abnormal-uterine-bleeding-in-reproductive-aged-women
4. American College of Obstetricians and Gynecologists (2013). Management of Acute Abnormal Uterine Bleeding in Nonpregnant Reproductive-Aged Women
5. Managing unscheduled bleeding in non-pregnant, premenopausal women (2013). https://www.bmj.com/content/346/bmj.f3251.long
6. International Journal of Gynecology & Obstetrics (2011). FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1016/j.ijgo.2010.11.011
7. Faculty of Sexual and Reproductive Health (2020). Combined Hormonal Contraception. https://www.fsrh.org/standards-and-guidance/documents/combined-hormonal-contraception/
8. Faculty of Sexual and Reproductive Health (2009). Management of Unscheduled Bleeding in Women Using Hormonal Contraception. https://www.rcog.org.uk/globalassets/documents/guidelines/unscheduledbleeding23092009.pdf
9. American College of Obstetricians and Gynecologists (2015). Management of abnormal uterine bleeding associated with ovulatory dysfunction. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2013/07/management-of-abnormal-uterine-bleeding-associated-with-ovulatory-dysfunction
10. Medscape (2018). Abnormal (Dysfunctional) Uterine Bleeding Treatment & Management. https://emedicine.medscape.com/article/257007-treatment