Menstrual health

Menstrual disorders are common: 

  • They make up 12% of all referrals to gynaecology services; many are also managed in primary care.
  • The prevalence of heavy menstrual bleeding (HMB) in adolescents is up to 37%.
  • Over 70% of adolescents experience dysmenorrhoea.
  • Severe dysmenorrhoea is reported in up to 29% of women.
  • Up to 30% of women experience severe premenstrual syndrome (PMS), with 10% meeting the criteria for premenstrual dysphoric disorder (PMDD).

The impact of menstrual symptoms can be severe – dysmenorrhoea is associated with depression, anxiety, poor quality of sleep and reduced concentration and academic performance for women and girls in education. The 2020 Menstrual Health Coalition report found that stigma about HMB was preventing women from seeking medical help or speaking openly to their employer about the problems that they are facing. This is an area in which health inequalities are important; a 2018 cohort study found that deprivation was associated with more severe symptoms and worse quality of life at the first outpatient visit for HMB. A 2018 report by Plan International UK showed that more than 10% of women in the UK had difficulty with the cost of sanitary products – consider referring to your social prescribing link worker if this may be an issue, as well as letting those still in education know that their schools and colleges should be providing these products under the Period Products Scheme.

Symptoms such as dysmenorrhoea and HMB may be indicative of gynaecological pathology such as endometriosis or fibroids or may be idiopathic. All women need to have their symptoms treated in primary care when they present, and those women in whom there is suspicion of pathology need referral for diagnosis and definitive management of any underlying cause. In the case of HMB, the RCGP eLearning module clearly explains how to risk-stratify women and decide whether referral or empirical treatment is appropriate, a decision that can be made with no vaginal examination or scan, in women where there are no other symptoms and a low risk of pathology. The only test which is mandatory for all women with HMB is a full blood countClick here to see more about when it is safe to treat empirically. For women with dysmenorrhoea in whom there is suspicion of endometriosis, European guidance states that empirical management in primary care is an equally valid strategy as immediate referral for a laparoscopy – this decision should be made using the principles of shared decision making and might be based on factors such as the woman’s age, severity of symptoms, success of any past treatments, and whether she is trying to conceive. A list of specialist centres for endometriosis can be found here and may be useful to guide referrals.

Premenstrual syndrome is not usually indicative of any underlying pathology, but it can be severe and disrupt daily functioning. Symptoms occur during the luteal phase and abate with or soon after the onset of menstruation – they may be physical and/or psychological. Lifestyle advice and treatment of any dysmenorrhoea or HMB may help and the PMS itself can be treated with an anovulatory contraceptive method such as combined hormonal contraception taken continuously, or with an SSRI with or without CBT.

More information can be found in the following resources:

• NICE CKS pages on HMB, fibroids, endometriosis, PMS and dysmenorrhoea and NICE guidance on endometriosis and heavy menstrual bleeding.
• NHS information on HMB.
• Personalised care institute eLearning course on shared decision making.
• Information about the Period Products Scheme.
• Women’s Health Concern patient information leaflet on period pain.
• RCGP eLearning module on endometriosis and patient information from Endometriosis UK.
• RCGP NUBs (‘new and useful bits’) on HMB and endometriosis
• Patient information on PMS from the RCOG, and the National Association for Premenstrual Syndromes and on the more severe premenstrual dysphoric disorder from Mind.

Resources for commissioning GPs:

• Menstrual health coalition report ‘HMB – breaking silence and stigma’.
• ‘Patient pathways’ by the Primary care women’s health forum.