Menorrhagia is the medical term used to describe abnormally heavy and prolong periods. It varies from woman to woman. Heavy periods for one woman may be normal for others. If you are worried that your periods are getting heavier or prolonged or if you have other symptoms such as bleeding in-between your periods or pain then you may need medical advice. If you bleed after your menopause you should see the doctor urgently to rule out any sinister causes.

Causes of heavy bleeding:

1. Hormonal imbalance: Due to imbalance of female hormones lining of the womb grows and increases in size. This will then lead to shedding of large lining to cause heavy periods. This can happen with PCOS, thyroid dysfunction, obesity, etc. If you don’t ovulate (anovulation), you don’t produce enough progesterone hormone. This can lead to hormone imbalance and heavy periods.
2. Fibroids: Fibroids are muscle growth as a mass in the womb. They are mostly benign. It can increase the size of the womb and lining of the womb. This can cause heavy periods. Fibroids can also cause increased blood flow to the womb and this also increases bleeding. In particular the fibroids within the lining of the womb (sub mucous fibroids) can increase periods compared to one outside the lining of the womb.
3. Polyps: These are small skin tag like growths within the lining of the womb. They are usually benign. This can cause heavy periods as well.
4. Adenomyosis: This abnormal thickening of the muscle of the womb due to tissues from the lining of the womb become embedded within the muscle of womb. This is similar to endometriosis but within the muscle of the womb.
5. Copper coil: Copper coil within the uterus can cause heavy periods.
6. Bleeding disorders: Any bleeding diseases that you may have, can increase the bleeding. This is due to abnormal clotting / bleeding mechanism
7. Pregnancy complications: Complications in early pregnancy such as miscarriage can cause heavy periods. Therefore, it is important to rule out pregnancy if you experience heavy periods.
8. Cancer: Cancer of the womb or neck of the womb can cause heavy, prolonged or irregular bleeding.
9. Medication: Some medications especially that interfere with clotting mechanism (anti-coagulant) can cause heavy periods. Warfarin and heparin are some of those.
10. Medical condition: Some medical conditions can cause heavy periods. This includes liver or kidney disease.


1. Pelvic examination to rule out any cervical growths
2. Ultrasound scan of the uterus and pelvis
3. Blood test including iron levels. Thyroid test may be useful bassed on your history


1. Medicines without hormones: Tranexamic acid and mefenamic acid.
Success rate- around 50 -60%
2. Medicines with hormones: Oral contraceptive pill, progesterone tablets. Success rate: around 50%
3. Mirena coil: It is a medicated coil with progesterone.
Success rate is in the region of 80 – 85%
4. Endometrial ablation: This is a procedure to destroy the lining of the womb. Success rate- around 90%. This is a permanent procedure and NOT suitable for those wishing to have more children. This can be performed under local or general anaesthesia
5. Myomectomy: Surgery to remove fibroids. This can be done via telescope, key hole or tummy cut, depending on the size and location of the fibroids
6. Hysterectomy: This is a permanent procedure to remove the womb completely. This can be done via key hole, tummy cut or vaginally.

What are fibroids?

Fibroids are benign growth from the muscle of the womb. Their size andlocation vary. Size varies from small seeding thatare not seen to human eyes to very large ones that completely distort uterus and extends in to tummy.

Are they Malignant?

Even though they are mostly benign, there is small risk that they may become precancerous or cancer. Risk is small, in the region of 1 in 350 to 1 in 5000.

Who develops fibroids?

Anyone can develop fibroids. Around 1 in 3 ladies develop fibroids.It is more common in some ethnicity than others (more common in Afro Caribbeans than in Caucasians). Common age of presentation is from 30 to 50 years of age.

Why develops fibroids?

Genetic factors determine the development of fibroids. Africo – Carribeans have higher risk of developing fibroids. Oestrogen hormone (female hormone produced by ovaries) increase the growth of fibroids. Therefore, fibroids are likely to grow or increase in size when oestrogen hormone levels are high (pregnancy, pre menopause) and tend to shrink after menopause.

What are the types of fibroids?

1. Submucous: They grow in to the cavity of the womb
2. Intramural: They grow within the muscle of the womb
3. Subserous: They grow outside from the muscle of the womb
4. Pedunculated: They grow outside the womb with a pedicle

What are the symptoms of fibroids?

a. Heavy periods
b. Pain- In the abdomen, pelvis and during sex
c. Pressure symptoms – Frequent urination, painful urination, constipation, rectal pain, abdominal cramps
d. Enlarged uterus and abdomen
e. Miscarriage / subfertility
f. Incidental finding on USS

2. How to diagnose fibroid?

a. Abdominal and pelvic examination
b. Ultrasound scan of the pelvis: It is usually diagnostic and do not need any other investigations
c. MRI scan of the pelvis: rarely needed

3. What is the treatment for fibroids?

  • a. Conservative: Needs monitoring of the growth
  • b. Medical: This is mainly for the symptoms or to reduce the size of the fibroids before surgery.
    • i. Heavy periods: Hormonal pills / mirena coil / Tranexamic acid tablets
    • ii. GnRH agonist injection: They block the hormones and shrink the fibroids. Because of the side effects, they are recommended only for up to 6 months. Once you stop the injection fibroids grow back faster
    • iii. Ulipristal acetate tablets: This can also be used to shrink the fibroids especially before surgery. Close monitoring of liver function is essential due to liver injury associated with its use.
  • c. Radiological embolisation: Small particles are injected in to the vessels feeding the fibroid to block its blood supply and to reduce its size. This may not be suitable for ladies wishing to have more children
  • d. Surgical: (see treatment section for more details)
    • i. Hysteroscopy
    • ii. Myomectomy
    • iii. Hysterectomy

What is Ovarian cyst?

Ovarian cyst is a fluid filled sac that develops on the ovary. Ovarian cysts are very common and not all of them need treatment. Their size varies from few cm to several cm. Most of them are benign (not cancerous) and may go away spontaneously without any treatment. However, some are cancerous and needs urgent treatment to remove them completely. There are mainly 2 different types of ovarian cysts,
1. Functional cysts: Cysts that develops as part of menstrual cycle. They are physiological and harmless. They are very common and usually disappear within few weeks
2. Pathological cysts: These are due to abnormal growth of cells.

Who develops Ovarian cyst?

Anyone who has ovaries can develop ovarian cysts. Ovarian cysts are more common before menopause and most of them are benign. If you have a family history of ovarian or breast cancer you may carry a gene called BRCA. If you carry this gene, you are at high risk for ovarian cancer.

What are the symptoms of Ovarian cyst?

Ovarian cyst usually causes symptoms only when it ruptures, becomes large or when its blood supply is blocked (due to twisting of its pedicle). Common symptoms include pelvic pain, painful sex, pain or difficulty in opening bowel, frequent urination, bloated tummy, feeling very full after eating a little or swelling of the tummy. Difficult to get pregnant or painful periods may be a sign of endometriotic ovarian cyst. Sometimes ovarian cysts are diagnosed incidentally during ultrasound scan for a different reason.

How to diagnose Ovarian cyst?

Pelvic ultrasound scan confirms the diagnosis of ovarian cyst. Occasionally an MRI scan of the pelvis and or blood tests may be necessary to confirm the nature of the cyst. Sometimes ultrasound scan may need to be repeated in 6 – 8 weeks to assess the progress of the cyst and to confirm a functional cyst as functional cysts usually disappear within 6 – 8 weeks.

How to treat Ovarian cyst?

Treatment depends on the nature, sizeand symptoms of the cyst.
Functional cyst: Can be managed conservatively with repeat US scan to confirm its resolution

When do I need surgery?

This depends on the nature, size and symptoms of the cyst. Surgery is recommended for cysts that are large, causing symptoms or if there is a suspicion of cancer. Surgery involves either removal of the cyst (cystectomy) or removal of ovary (oophorectomy). Type of surgery depends on several factors including age, risk of cancer and fertility wishes.

How surgery is performed if I need one?

Surgery is performed by laparoscopy (key hole surgery). You will have 3 small cuts in your tummy.

What is endometriosis?

Endometriosis is a condition where lining of the womb cells is found outside the lining of the womb. Most common sites are ovaries, fallopian tubes and pelvis.

Who develops endometriosis?

It can affect around 1 in 10 women during their reproductive years. You are more likely to develop if your mother or sister has had it.

Why develops endometriosis?

Exact cause of endometriosis is not clear. It is hormone dependant and responds to monthly hormonal cycles. Just like lining of the womb, endometriosis also bleeds during periods. This causes pelvic pain, scarring and possibly damage your pelvic organs.

What are the symptoms of endometriosis?

Common symptoms include Pelvic pain, Painful periods, painful sex and struggling to get pregnant (subfertility). Sometimes it gives rise painful bowel movements (especially during period times), painful urination, lower back pain and general long term fatigue. Occasionally you will not have any symptoms at all and endometriosis is diagnosed incidentally.

How to diagnose endometriosis?

Endometriosis can sometimes be difficult to diagnose because symptoms can differ from patient to patient and can be similar to other illnesses such as irritable bowel syndrome or pelvic inflammatory disease. On average, it takes 7.5 years for a woman to be diagnosed with endometriosis. Diagnostic pathway includes,
1. History and pelvic examination
2. Ultrasound scan of the pelvis
3. MRI scan of the pelvis
4. Laparoscopic surgery: You can be treated at the same time.

How to treat endometriosis?

Treatment depends on your symptoms, extend of organ involvement and fertility wishes. Endometriosis is a chronic condition. Therefore, long term follow up may be necessary. Therefore, it is important that you are cared for by gynaecologists with experience in endometriosis.

  • 1. Medical:
    • a. Hormonal:
      • i. Combined contraceptive pill
      • ii. Progesterone tablets
      • iii. Mirena coil
      • iv. GnRh injections
    • b. Symptomatic treatment: Analgesia for pain

2. Surgery: Laparoscopic (key hole) treatment. This includes excision of ovarian cysts, endometriotic deposits, scar tissue, relieve of scar tissue (adhesiolysis) and laser / helica/ diathermy destruction of endometriotic deposits. Surgery produces long term benefits. However, endometriosis is a chronic condition and it can recur. Therefore, long term follow up and menstrual suppression with medications may be necessary. It is also important that your surgery is performed by a gynaecologist with experience in endometriosis surgery to remove as much endometriosis as possible to improve outcome.

What is PCOS?

PCOS is a condition that affects your ovaries which in turn affects your hormones, periods, fertility and appearance. This is a common condition affecting around 1 in 5 women I UK.

What are Polycystic ovaries?

Polycystic ovaries contain large number of underdeveloped follicles (egg filled sacs). Even though ladies with polycystic ovaries have large number of follicles (with eggs), they do not release their eggs regularly. This leads to anovulation with irregular and delayed periods. Having polycystic ovaries does not mean you have PCOS. PCOS means you have polycystic ovaries as well as symptoms.

Why develops PCOS?

Exact cause of PCOS is unknown. It runs in families. It appears to be due to several factors working together including high levels in insulin hormone, insulin resistance and high levels of androgen hormones (male hormones).

What are the symptoms of PCOS?

1. Delayed periods or no periods
2. Hirsutism (excessive body hair)
3. Loss of hair from head
4. Acne and greasy skin
5. Overweight or difficulty is losing weight
6. Subfertility (difficulty in getting pregnant)
7. Patches of thickened, darkened skin (acanthosis nigricans)
Some women have more symptoms while others have only few symptoms.

How to diagnose PCOS?

PCOS is diagnosed if you have any two of the following,
1. Signs and symptoms suggestive of PCOS
2. Blood tests showing increased androgen hormones (male hormones)
3. Ultrasound scan showing polycystic ovaries

What are the long term risks of PCOS?

1. Insulin resistance and Diabetes mellitus
2. High blood pressure
3. Cancer of lining of the womb
4. Depression and mood swings

How to treat PCOS?

Treatment options vary as different women have different symptoms.
1. Life style changes:In overweight women reducing body weighthelps to reverse long term health risks associated with PCOS. Eating healthy balance diet and regular exercise can help to reduce weight.
2. For delayed or absent periods: Contraceptive pill can be used. This will also help to reduce the long term risk of cancer of lining of the womb. Mirena coil is another option to keep the lining of the womb thin
3. Fertility problems: Failure to release egg from the ovary is the main reason for failure to conceive. Medications can be used to release egg.
4. Excess hair growth: Medications or local skin creams can be used. Some women prefer to use shaving, laser, plucking of excessive hair.

Is there a cure for PCOS?

There is no permanent cure for PCOS. Healthy life style and medications help to manage the symptoms and prevent long term complications of the condition.

What is ectopic pregnancy?

When pregnancy develops outside the womb, it is called ectopic pregnancy. By far the most common site is within one of the fallopian tubes (up to 98% of ectopic pregnancies develop within the fallopian tube). Risk of anyone developing ectopic pregnancy is 1 in 90.

How ectopic pregnancy develops?

In a normal pregnancy, the fertilised egg moves from the fallopian tube into the uterus, where the pregnancy grows and develops. If this does not happen, the fertilised egg may implant and start to develop outside the uterus, leading to an ectopic pregnancy. An ectopic pregnancy can be life-threatening because as the pregnancy gets bigger it can burst (rupture), causing severe pain and internal bleeding. Ectopic pregnancy is potentially life threatening condition as it can cause life threatening internal bleeding if not diagnosed and treated early.

Who develops ectopic pregnancy?

There are some risk factors for developing ectopic pregnancy. This includes previous ectopic pregnancy, previous fallopian tube surgery, previous pelvic infection, conceived while copper IUCD is in place, IVF / ICSI pregnancy and if you smoke. However, in about 3rd of ectopic pregnancies there are no identifiable risk factors.

What are the symptoms of ectopic pregnancy?

Symptoms differ from patient to patient. Some have minimal symptoms, others have many symptoms whereas some have no symptoms at all. If you have irregular periods, you may not aware you are pregnant.
Common symptoms include positive pregnancy test along with,
1. Abdominal pain or upset
2. Bleeding per vagina
3. Shoulder tip pain
4. Felling dizzy or collapse
Sometimes ladies present with no symptoms at all or presented with feeling unwell and diagnosed on ultrasound scan.

How to diagnose ectopic pregnancy?

1. Positive pregnancy test
2. History and clinical examination
3. Ultrasound scan of the pelvis.
4. Blood pregnancy hormone test. Usually you need at least 2 blood tests of 48 hours apart to see the trend
5. Laparoscopy: Key hole surgery

How to treat ectopic pregnancy?

1. Conservative approach: This is possible if your blood hormones levels are low and decreasing, small size ectopic pregnancy on ultrasound scan, you have no symptoms and no internal bleeding noted on US scan
2. Medical: This is by giving an injection called methotrexate. Success rate is around 90%. Around 15% will need a 2nd injection. It is important you need to wait for 3 months before getting pregnant again as this injection may be harmful to future pregnancy if conceived within 3 months.
3. Surgery: Laparoscopic removal of damaged fallopian tube or laparoscopic opening of fallopian tube and removing ectopic pregnancy. This is performed under general anaesthesia and you will be staying overnight after surgery.