Pelvic pain, periods and general gynaecology

How I approach general gynaecology

Most gynaecological problems become clear through listening carefully, examining gently and, where it helps, scanning. At Parkside Hospital and the CRP Clinic I can perform an ultrasound scan during your consultation, so we can usually discuss what it shows at the same visit. I will explain what I have found, set out every reasonable option, including the option of doing nothing for now, and give you my recommendation. We then decide together, and you will receive a detailed letter swiftly after your consultation.

Heavy or painful periods

Heavy periods are periods that interfere with your daily life: needing to change protection every hour or two, flooding, passing clots or needing to plan around your period. NICE (the National Institute for Health and Care Excellence) defines them in the same way, by their effect on your life rather than by a measured amount ^[1]. Painful periods that stop you working or studying are not something you should have to put up with.

Common causes include fibroids, polyps, adenomyosis (tissue similar to the lining of the womb growing into its muscle wall) and endometriosis, and sometimes no structural cause is found. I start by asking about your bleeding and your general health, and usually suggest a blood test to check for anaemia (a low blood count). A scan, and sometimes a hysteroscopy (looking inside the womb with a slim telescope), helps to find the cause.

Treatment depends on the cause and on whether you hope to become pregnant. If your periods are heavy but you are coping and not anaemic, no treatment for now is a reasonable choice, and we review things if they change. Medicines usually come first: non-hormonal tablets taken during a period, or hormonal treatments such as the hormonal coil, which NICE recommends trying first when no cause is found, or with adenomyosis or small fibroids ^[1], or the contraceptive pill. A hormonal coil needs about six months before we judge how well it works, and then a review.

Procedures follow if medicines do not help or do not suit you: removal of polyps or fibroids, endometrial ablation (a short procedure that destroys the lining of the womb) and, for some women, a keyhole hysterectomy (removal of the womb by laparoscopic or robotic surgery through small incisions). Ablation is only for women who do not want a future pregnancy, because pregnancy afterwards is risky, and contraception is still needed.

Painful periods are treated by their cause, often with the same tablets and hormonal treatments, and when they do not help I consider endometriosis. I give you my recommendation and we decide together.

You can read more on the fibroids, adenomyosis and endometriosis pages.

Polycystic ovary syndrome (PCOS)

Many small follicles on the ovaries can be one feature of polycystic ovary syndrome (PCOS), a hormonal and metabolic condition. Follicles on a scan do not by themselves mean you have the condition: the diagnosis also depends on your periods, symptoms and blood tests. I can assess this and advise you, although its long-term care is often shared with your GP.

Pelvic pain

Pelvic pain that lasts for six months or more has many possible causes, gynaecological and otherwise, and often more than one is involved: endometriosis, adenomyosis, adhesions (scar tissue), the bowel, the bladder, the muscles of the pelvic floor and the nerves. Long-standing pain can also change the way the nervous system processes pain, which is why treating it well often needs more than one approach ^[2].

With colleagues in the CHORUS group, which works to agree how treatments for women’s conditions should be measured, I have published systematic reviews in chronic pelvic pain. We found that the trials measured their results in very different ways, which makes them hard to compare ^[3], and that of the questionnaires used to measure quality of life, half were developed without involving patients and most were general questionnaires not designed for pelvic pain ^[4].

We also reviewed what women with chronic pelvic pain had said in interview studies. Five things came through: accepting the pain, quality of life, how the pain is managed, communication, and support ^[5].

In a further review of the national and international guidelines, the recommendations they agreed on included a thorough pain history, care from more than one kind of specialist, recognising the pelvic floor muscles as a cause of pain, and assessing quality of life ^[6]. That is how I work.

I take a full history, examine you and usually scan you. Where endometriosis is suspected, I will discuss whether a laparoscopy (a keyhole look inside the abdomen) would help. Endometriosis often takes years to be recognised, and my article on why endometriosis takes so long to diagnose explains why. Treatment may include medication, hormonal treatment, surgery, pelvic floor physiotherapy and referral to a specialist pain service, and I will explain why I recommend each. We agree a plan together, with a review at three months to see whether it is helping.

Menopause and HRT

The menopause, and the years leading up to it (the perimenopause), can bring hot flushes and night sweats, poor sleep, low mood, anxiety, difficulty concentrating, joint pain, vaginal dryness and bladder symptoms. For some women these are mild; for others they affect every part of life.

I offer menopause consultations covering your symptoms, your personal and family history, and the options. HRT (hormone replacement therapy) is the most effective treatment for hot flushes and sweats, and NICE sets out how its benefits and risks should be discussed ^[7]. For women under 60, or within ten years of the menopause, who have no reason not to take it, the North American Menopause Society concluded in 2022 that the benefits outweigh the risks for troublesome hot flushes and sweats, and to prevent bone loss ^[8].

HRT comes in several forms, including tablets, patches, gels and sprays, and in local forms for vaginal symptoms.

Non-hormonal treatments and lifestyle measures help too, and are particularly important if HRT is not suitable for you. Doing nothing for now is also a choice if your symptoms are mild. I will help you weigh the benefits and risks for you personally, and I write to your GP so that any ongoing prescription continues smoothly.

PMS and PMDD

Premenstrual syndrome (PMS) is the name for physical and emotional symptoms in the days before a period that ease once it starts. Premenstrual dysphoric disorder (PMDD) is a severe form, in which mood symptoms such as depression, anxiety and irritability can be overwhelming.

Keeping a symptom diary over two or three cycles helps to confirm the pattern, and the Royal College of Obstetricians and Gynaecologists recommends it before any treatment is started ^[9]. Treatment ranges from lifestyle measures and psychological therapies to medicines and hormonal treatments that settle the cycle. For a small number of women with very severe symptoms that have not responded to other treatments, surgery is sometimes considered, after a trial of treatment that temporarily switches off the ovaries ^[9].

Bleeding after the menopause

The bleeding after the menopause page explains how it is assessed and what to expect.

Hormonal coil fitting

The hormonal coil (an intrauterine system, or IUS) is a small T-shaped device placed in the womb, which releases a hormone that makes periods much lighter and provides contraception. It is also used to protect the lining of the womb as part of HRT. I fit hormonal coils, and can often do so at the same appointment as a scan, or with a hysteroscopy if that is also needed. At the CRP Clinic you can choose inhaled pain relief if you would like it.

Gynaecological ultrasound

Ultrasound is a safe and quick way of looking at the womb and ovaries, and most women find it comfortable. A transvaginal scan, using a slim probe placed in the vagina, gives the clearest picture; an abdominal scan is an alternative. I perform and interpret scans myself at Parkside Hospital and the CRP Clinic, which means I can relate what the scan shows directly to your symptoms and discuss it with you at the same visit.

Other pages that may help

These pages explain each of these in full.

Ovarian cysts, including endometriomas and dermoid cysts. Sudden severe pelvic pain can mean a cyst has twisted or burst: go to your nearest emergency department or call 999. See the ovarian cysts page.

Prolapse, treated first with physiotherapy or a pessary, and by keyhole surgery when an operation is the right choice, including options with and without mesh. See the prolapse page.

Trucheck blood test for cancer, which I offer at the CRP Clinic in Epsom. See the Trucheck page.