Period Problems
Symptoms, Causes & Treatment
Understanding period problems: what causes heavy, painful, or irregular periods, how they are investigated, and the effective treatments available.
What Are Period Problems?
Period problems (menstrual disorders) encompass a range of conditions affecting the regularity, duration, heaviness, and comfort of menstrual periods. They are among the most common reasons women seek medical advice, yet many women suffer in silence for years, either believing their experience is normal or feeling that their concerns will be dismissed.
A "normal" menstrual cycle lasts 21–35 days (measured from the first day of one period to the first day of the next). A normal period lasts 2–7 days. Menstrual bleeding is considered heavy if it regularly exceeds 80ml per cycle, though in practice, heaviness is defined by its impact on quality of life rather than by precise measurement.
The main categories of period problems are:
- Heavy menstrual bleeding (menorrhagia) -- periods that are excessively heavy, prolonged, or both.
- Painful periods (dysmenorrhoea) -- period pain that is severe enough to affect daily activities.
- Irregular periods (oligomenorrhoea / metrorrhagia) -- periods that are unpredictable in timing or that occur too frequently or too infrequently.
- Absent periods (amenorrhoea) -- the complete absence of menstrual periods for three or more months in a woman who has previously had periods (secondary amenorrhoea) or failure to start periods by age 15 (primary amenorrhoea).
- Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) -- physical and psychological symptoms occurring in the luteal phase (the two weeks before a period) that significantly impact daily life.
- Intermenstrual bleeding -- bleeding between periods or after sex.
Period problems are not something you simply have to live with. Effective treatments are available for all of these conditions.
What Are the Symptoms of Period Problems?
Period problems encompass a wide range of symptoms affecting the frequency, duration, volume, and pain associated with menstruation.
Heavy periods (menorrhagia) · Painful periods (dysmenorrhoea) · Irregular periods · Absent periods (amenorrhoea) · Premenstrual syndrome (PMS) · Intermenstrual bleeding · Bleeding after sex (postcoital bleeding) · Unpredictable cycle length · Passage of large blood clots
Very heavy bleeding soaking a pad/tampon per hour for 2+ hours — may require emergency care · Postcoital or postmenopausal bleeding — requires urgent investigation · Intermenstrual bleeding with pelvic pain — possible PID or ectopic · Sudden missed period with pelvic pain (possible ectopic pregnancy — call 999)
Postcoital bleeding (after sex), postmenopausal bleeding, or very heavy bleeding soaking through sanitary products per hour requires urgent clinical assessment. Any sudden severe pelvic pain with a missed period could indicate ectopic pregnancy — call 999.
What Causes Period Problems?
Period problems have many causes — structural, hormonal, and systemic. Accurate diagnosis guides the most effective treatment. Most period problems are treatable.
Uterine fibroids, polyps, adenomyosis, and endometriosis are common structural causes of heavy, painful, or irregular periods requiring investigation and targeted treatment.
PCOS, hypothyroidism, hyperprolactinaemia, and perimenopause all disrupt ovulation and hormonal balance, causing irregular or absent periods.
Uterine fibroids are benign smooth muscle tumours affecting 20–40% of women over 35. They cause heavy, prolonged, and painful periods. Size and location determine severity and treatment options.
Adenomyosis — endometrial glands embedded in the myometrium (uterine muscle) — causes heavy, painful periods and a bulky uterus. Often co-exists with endometriosis. Definitively treated with hysterectomy.
Primary dysmenorrhoea (painful periods with no underlying cause) results from excess prostaglandin release causing uterine cramping. It is the most common cause of painful periods in adolescents and young women.
Thyroid disorders — both hypothyroidism and hyperthyroidism — frequently cause menstrual irregularity. Hypothyroidism causes heavy periods; hyperthyroidism causes scanty or absent periods. Always check TFTs in menstrual irregularity.
Key Risk Factors
How Are Period Problems Investigated?
A thorough history is the most important part of investigation — including cycle length, blood loss volume, pain character, and associated symptoms. Blood tests and pelvic ultrasound are standard first-line investigations for most presentations.
How Are Period Problems Treated?
Treatment depends on the type of period problem, its cause, and whether the woman wishes to preserve fertility. NICE recommends starting with the least invasive, most effective options.
Supportive Measures
For painful periods, NSAIDs taken continuously from the first day of pain (rather than waiting for pain to peak) are more effective. Heat therapy provides meaningful symptom relief. For heavy periods, iron-rich foods and iron supplementation prevent anaemia — which can significantly worsen fatigue. Tracking your cycle with an app helps identify patterns and provides useful information for clinical consultations.
When Period Problems Don't Respond to Treatment
Period problems that fail to respond to first-line medical treatment warrant specialist gynaecology referral. Hysteroscopy can identify and treat intrauterine pathology (polyps, fibroids). Endometrial ablation offers effective reduction in heavy periods for women who have completed their family. Hysterectomy is a last resort for treatment-resistant menorrhagia. All surgical options should be discussed with a specialist.
When Should You Seek Medical Advice?
Sudden severe pelvic pain with a missed period — possible ectopic pregnancy, call 999 · Very heavy bleeding soaking a pad per hour for 2 hours or more — attend A&E · Postmenopausal bleeding — requires urgent investigation within 2 weeks.
Your periods are significantly affecting your quality of life · You have intermenstrual or postcoital bleeding · Periods have stopped unexpectedly and you are not pregnant or menopausal · You are using pads and tampons simultaneously and still flooding · You have pelvic pain alongside your period symptoms.
Managing Period Problems
Many period problems can be effectively treated or significantly reduced. These key principles apply across most types of menstrual problem.
For heavy periods, the Mirena IUS is the most effective non-surgical treatment and should be considered before hysterectomy. It reduces blood loss by up to 90%.
Menstrual cycle tracking using an app or diary helps identify patterns, quantify blood loss, and provides objective data for clinical consultations. Include pain scores, blood loss estimation, and associated symptoms.
Iron-deficiency anaemia from heavy periods worsens fatigue and reduces quality of life. Ferrous fumarate or ferrous sulphate 200mg twice daily should be taken alongside treatment for the underlying cause of heavy bleeding.
TENS (transcutaneous electrical nerve stimulation) machines, heat patches, and relaxation techniques reduce dysmenorrhoea without medication. These are particularly useful for women who cannot take NSAIDs.
Preoperative optimisation, healthy weight, and smoking cessation all reduce surgical risks for women who require gynaecological procedures (ablation, hysterectomy) for period problems.
Psychological support — including CBT, body image therapy, and peer support groups — significantly improves quality of life in women with PCOS. Self-compassion approaches have emerging evidence in PCOS.
Speak to a Clinician About Period Problems
Through The GP Service, a licensed clinician can assess your menstrual symptoms, arrange appropriate investigations, and prescribe treatment for heavy or painful periods — without a lengthy wait.
Expert clinical advice, when you need it.
Period Problems FAQs
Heavy periods (menorrhagia) are defined as periods that significantly affect quality of life. NICE defines heavy menstrual bleeding as excessive blood loss that interferes with a woman’s physical, emotional, social, or material quality of life — not a specific volume. The most effective non-surgical treatments are the levonorgestrel IUS (Mirena), tranexamic acid, and the combined oral contraceptive pill. The Mirena is recommended as first-line treatment by NICE, reducing blood loss by up to 90% in most women. Surgery (endometrial ablation or hysterectomy) is reserved for cases where medical treatment has failed.
Premenstrual syndrome (PMS) affects 3 in 4 women to some degree. Severe PMS — known as PMDD (premenstrual dysphoric disorder) — causes significant psychological and physical symptoms in the second half of the cycle that resolve within days of the period starting. PMDD is a recognised medical condition, not a personality trait. Effective treatments include SSRIs (taken daily or just in the luteal phase), the combined pill (particularly drospirenone-containing pills), dietary changes (reducing caffeine and salt), exercise, and CBT. In severe cases, GnRH analogues or even surgical menopause may be considered.
Irregular periods have many causes including PCOS, thyroid disorders, hyperprolactinaemia, perimenopause, significant weight loss, excessive exercise, eating disorders, and stress. A single irregular period is rarely cause for concern. Consistently irregular cycles — longer than 35 days or shorter than 21 days — warrant investigation with a blood test (FSH, LH, thyroid, prolactin) and a pelvic ultrasound. A missed period in a woman of reproductive age should always prompt a pregnancy test before other investigations.
Pericarditis is inflammation of the sac surrounding the heart, typically caused by a viral infection. It produces a sharp, stabbing chest pain that is typically worse when lying flat and relieved by leaning forward. It may be associated with fever and a pericardial friction rub on examination. Treatment is with NSAIDs (ibuprofen or aspirin) and colchicine for 3 months. Rest and avoidance of strenuous exercise during treatment are important. Pericarditis must be distinguished from myocarditis and aortic dissection, both of which are more serious.
Cardiac syndrome X (also called microvascular angina) causes typical angina symptoms — chest tightness on exertion — with a normal coronary angiogram, in the absence of coronary artery narrowing. It is caused by dysfunction of small coronary blood vessels. It is more common in women, particularly postmenopausal women. Treatment includes nitrates, beta-blockers, and sometimes hormone therapy. It is often undertreated because the normal angiogram can lead to symptoms being dismissed. Referral to a cardiologist is appropriate if symptoms persist despite standard measures.
Endometriosis is an oestrogen-dependent condition that is inactive after the menopause once oestrogen levels fall. For most women, symptoms resolve after the final period. However, deep infiltrating endometriosis and adhesions from previous disease may continue to cause problems. Women on HRT after menopause may experience recurrence of symptoms if oestrogen levels are restored. Adding a progestogen to HRT after endometriosis helps protect against reactivation.
Endometriosis significantly increases the risk of infertility but does not make pregnancy impossible for most women. Around 70% of women with mild-to-moderate endometriosis will conceive naturally. For moderate-to-severe disease, IVF success rates are similar to the general infertile population, though may require more cycles. Laparoscopic surgery to remove endometrioma or adhesions before IVF can improve outcomes in some cases. Early referral to a reproductive specialist is recommended for women with known endometriosis who are trying to conceive.
Yes. During pregnancy, oestrogen levels rise significantly, increasing glycogen in vaginal cells which promotes Candida growth. Thrush is more common and more persistent in pregnancy. It is safe to treat with topical clotrimazole or other azole pessaries and cream — oral fluconazole is not recommended in pregnancy due to potential fetal risk. BV also occurs more frequently in pregnancy and should always be treated because it is associated with preterm birth, late miscarriage, and postpartum infection. Treat promptly with metronidazole (safe after the first trimester).