constant light-medium bleeding

[Guest Posts]

I am 36 and have been married for 11 years. I have always had painful heavy irregular periods. In 2014 I haemorrhaged and had a haemoglobin level of 4. I had a blood transfusion and I was put on Tranexamic acid and Norethisterone. I was told I have PCOS and when they carried out a Hysteroscopy, they found a polyp but nothing else. In 2018 I had ICSI treatment but I had empty follicles and resulted in Ovarian Hyperstimulation Syndrome and a twisted left ovary.

I was put on Cerelle in March 2020 and I have had constant light-medium bleeding since and I have pain where my left ovary is. My hospital appointment has been put off until next year. I am unsure what I should be doing now in the short and long term. I would be grateful for any help.

Many thanks

Joanne

[Dr Varsha Jain]

Dear Joanne,

Thank you for your question and I am sorry to hear of your gynaecological troubles.

In view of your history, I would agree that you do need a referral to gynaecology services. Heavy bleeding to the point where your haemaglobin dropped to 4, is classed as abnormal uterine bleeding (AUB). There are many causes of AUB, please see this link for more information: https://www.ed.ac.uk/centre-reproductiv ... -disorders
These include structural causes, which can be ruled out with scans and in your case a hysteroscopy, but there are also non-structural causes. If it has been a while since your last ultrasound scan, this may need to be repeated as ultrasound scans can now look for conditions like adenomyosis, whereas this wasn't necessarily as easy back in 2014.

If you have always had heavy bleeding, it would also be important for gynaecology services to understand the reason why this is occurring, including AUB-C or "coagulopathy"/bleeding disorder. This is often ruled out through screening questions and if necessary, you may be referred for special blood tests.

I can understand that gynaecology services are extremely busy at the moment as a lot of services have only just resumed post-lockdown and there is a long waiting list. The Royal College of Obstetricians and Gynaecologists released a joint statement in May 2020 for guidance on the management of menstrual bleeding problems during the pandemic. (https://www.rcog.org.uk/globalassets/do ... 180520.pdf)
It may be advisable for you to seek medical advice from your GP whilst you wait for your gynaecology appointment. If tranexamic acid has worked in the past for you, it can be used alongside your Cerelle (provided you do not have any known contraindications in your medical history to using tranexamic acid now). We do not normally prescribe norethisterone alongside Cerelle, as it is from the same family of the hormone, Progesterone, and so unlikely to helpful.

If you do bleed heavily again (where you feel you are anaemic), it is important to seek medical advice sooner rather than later. Your GP can also check your latest blood count and iron stores and decide on if you need iron tablets whilst you wait for your gynaecology appointment.

Your long term plan will ultimately be decided once the exact cause for your AUB has been found. Polyps, PCOS and hormonal medication can cause AUB, but in view of your ongoing history, a thorough investigation of all causes of AUB is ideal.

With regards to the painful aspect of your periods, there are many causes of painful periods including endometriosis and adenomyosis. Again, a thorough history and investigation during your gynaecology appointment will help to understand the exact cause. If you are not allergic, the GP may be able to prescribe medications to help ease the pain around the time of your periods e.g. mefanamic acid (again this would be dependant on whether you are able to tolerate this medicine).