A period is the part of the menstrual cycle when a woman bleeds from her vagina for a few days.

For most women this happens every 28 days or so, but it's common for periods to be more or less frequent than this, ranging from every 23 days to every 35 days. Your period can last between 2 and 7 days, but it will usually last for about 5 days. The bleeding tends to be heaviest in the first 2 days.

When your period is at its heaviest, the blood will be red. On lighter days, it may be pink or brown. You'll lose about 20 to 90ml (about 1 to 5 tablespoons) of blood during your period, although some women bleed more heavily than this.

When do periods start?

Most girls start their periods when they're about 12, but they can start as early as 8, so it's important to talk to girls from an early age to make sure they're prepared. A delay in starting periods isn't usually a cause for concern. Most girls will be having regular periods by age 16 to 18. If you have any concerns about an early or delayed period for yourself or your child speak to your GP.

Changes in your periods

Your periods can change – for example, they may last longer or get lighter. This does not necessarily mean there's a problem, but it does need to be investigated. You can see your GP, or visit your nearest women's clinic or contraceptive clinic.

Bleeding between periods, bleeding after having sexual intercourse, or bleeding after the menopause needs to be checked by a doctor. It might be caused by an infection, abnormalities in the neck of the womb (the cervix) or, in rare cases, it could be cancer.

You could be pregnant if you miss a period and you've had sexual intercourse. See your GP if you've taken a pregnancy test and the result is negative (you're not pregnant) and you've missed 3 consecutive periods. They will investigate the cause and recommend any necessary treatment.

Getting pregnant

Ovulation is when an egg is released from one of your ovaries and travels down towards the uterus. This is when you are at your most fertile. Pregnancy happens when sperm enters a vagina, travels through the cervix and womb to the fallopian tube and fertilises an egg. You can only get pregnant around the time you are ovulating.

Working out when you can get pregnant – your fertile time – can be difficult. It's a 36-hour window around the time you ovulate. If you do not have a regular cycle see your GP who can suggest the next step.

If you want to work out when you ovulate, there are a number of things you can use:

• Using a period calculator to work out the length of your menstrual cycle – ovulation usually occurs around 12 to 16 days before your period starts, so you may be able to work out when you're likely to ovulate if you have a regular cycle.

• Your cervical mucus – you may notice wetter, clearer and more slippery mucus around the time of ovulation

• Your body temperature – there's a small rise in body temperature after ovulation takes place, which you may be able to detect with a thermometer

• Doctors can do blood tests for hormone levels which can indicate you are ovulating

• Ovulation predictor kits – hormone levels increase around the time of ovulation and this can be detected using ovulation predictor kits that measure the level of hormones in your urine. There are two popular ways of monitoring your ovulation.

  Urine home test kits - The at home urine kit tests detects a rise in luteinizing hormone (LH) in the urine. A rise in this hormone signals the ovary to release the egg. This at-home test is often used by women to help predict when an egg release is likely. This is when pregnancy is most likely to occur. These kits can be bought at most drug stores.

  Fertility monitoring -Fertility monitors are digital handheld devices. They predict ovulation based on electrolyte levels in saliva, LH levels in urine, or your basal body temperature. These devices can store ovulation information for several menstrual cycles.

Some women may experience other symptoms when they're ovulating, including breast tenderness, bloating and mild tummy pain, but these are not a reliable way of predicting ovulation.

You cannot get pregnant if you do not ovulate.

It is important to know that ovulation and mikvah night may not always coincide. If you are ovulating before mikvah please contact Chana who can guide you on this.

Read more about irregular periods and fertility in the menstrual cycle and infertility on in our other resources.

When do periods stop?

Your periods will continue until you reach the menopause, which usually happens when you are in your mid-40s to mid-50s. In the UK the average age of menopause is 51.

Your periods will not usually stop suddenly when you go through the menopause. They may start to become less frequent over a few months or years before stopping altogether. Please see our other resources on Menopause for more information.

References- https://www.nhs.uk/conditions/periods/

https://www.nhs.uk/conditions/periods/starting-periods/#:~:text=Most%20girls%20start%20their%20periods,and%20do%20not%20be%20embarrassed.

https://www.nhs.uk/pregnancy/trying-for-a-baby/trying-to-get-pregnant/

Irregular periods aren't always a sign of a problem, but sometimes it's a good idea to see a doctor about them just in case.

What are irregular periods?

You have irregular periods if the length of your menstrual cycle (the gap between your periods starting) keeps changing. Your periods may come early or late.

The average menstrual cycle lasts 28 days, although it's normal for it to be a bit shorter or longer than this. After puberty, many women develop a regular cycle with a similar length of time between periods. But it's not uncommon for it to vary by a few days each time.

Causes of irregular periods

There are many possible causes of irregular periods. Sometimes they may just be normal for you.

Common causes include:

• Puberty – your periods might be irregular for the first year or two

• The start of the menopause (usually between the ages of 45 and 55)

• Early pregnancy – take a pregnancy test to rule this out

• Some types of hormonal contraception – such as the contraceptive pill or intrauterine system (IUS)

• Extreme weight loss or weight gain, excessive exercise or stress

• Medical conditions – such as polycystic ovary syndrome (PCOS) or a problem with your thyroid

When to see a GP

You don't need to get medical advice if you have always had slightly irregular periods or you're still going through puberty.

But see a GP if:

• Your periods suddenly become irregular and you're under 45

• You have periods more often than every 21 days or less often than every 35 days

• Your periods last longer than 7 days

• There's a big difference (at least 20 days) between your shortest and longest menstrual cycle

• You have irregular periods and you're struggling to get pregnant

There might not be anything wrong, but it's a good idea to get checked out to see what the cause might be. You might be referred to a specialist called a gynaecologist if you need any tests or treatment.

Trying for a baby

It can be more difficult to get pregnant if you have irregular periods because you might not ovulate (release an egg) regularly. It can help to have intercourse every 2 or 3 days throughout your cycle. You don't need to time intercourse around ovulation.

Sometimes hormone medicine or fertility treatment may be needed if you're struggling to get pregnant naturally.

Heavy periods (also called menorrhagia) are common and may just be normal for you. Treatment can help if they're affecting your daily life.

You may have heavy periods if you:

-Need to change your pad or tampon every 1 to 2 hours, or empty your menstrual cup more often than is recommended

-Need to use 2 types of sanitary product together, such as a pad and a tampon

-Have periods lasting more than 7 days

-Pass blood clots larger than about 2.5cm (the size of a 10p coin)

-Bleed through to your clothes or bedding

-Avoid daily activities, like exercise, or take time off work because of your periods

-Feel tired or short of breath a lot

Heavy periods aren't necessarily a sign there's anything wrong, but they can affect you physically and emotionally, and cause disruption to your everyday life.

Causes of heavy periods

It can be normal to have heavy periods. They can sometimes be heavy at different times, like when you first start your periods, after pregnancy or during menopause.

Sometimes, they can be caused by:

Conditions affecting your womb, ovaries or hormones, such as polycystic ovary syndrome, fibroids, endometriosis and pelvic inflammatory disease

Some medicines and treatments, including some anticoagulant medicines and chemotherapy medicines

Stress and depression

Rarely, heavy periods can be a sign of womb cancer.

Treatment for heavy periods

Heavy periods do not always need to be treated. But there are treatments that can help if they’re affecting your daily life.

Treatments from a GP include: Some types of contraception, such as an intrauterine system (IUS) or the combined contraceptive pill, medicine to help reduce the bleeding, such as tranexamic acid or prescription-only anti-inflammatory painkillers, such as mefenamic acid or naproxen.

You should have a blood test to check if you have iron deficiency anaemia.

If these treatments do not work or a GP thinks a condition may be causing your heavy periods, they’ll usually refer you for tests or to see a specialist.

Stopped or missed periods

There are many reasons why a woman may miss her period, or why periods might stop altogether.

Most women have a period every 28 days or so, but it's common to have a slightly shorter or longer cycle than this (from 21 to 40 days). Some women do not always have a regular menstrual cycle. Their period may be early or late, and how long it lasts and how heavy it is may vary each time.

Why your periods might stop

There are several reasons why your periods can stop. The most common reasons are:

• Pregnancy: You might be pregnant if you're sexually active and your period is late. Pregnancy is a common reason why periods unexpectedly stop. It can sometimes happen if the contraception you're using fails. It might be that your period is simply late, so you could wait a few days to see if it arrives. If it does not arrive, you can do a pregnancy test to confirm whether you're pregnant. It's important to be aware that you can get pregnant in the days after your period is normally due. This can happen if the release of an egg (ovulation) is delayed – for example, because of illness or stress.

• Stress: If you're stressed, your menstrual cycle can become longer or shorter, your periods may stop altogether, or they might become more painful. Try to avoid becoming stressed by making sure you have time to relax. Regular exercise, such as running, swimming and yoga, can help you relax. Breathing exercises can also help.

  If you're finding it hard to cope with stress, cognitive behavioural therapy (CBT) may be recommended. CBT is a talking therapy that can help you manage your problems by changing the way you think and act.

• Sudden weight loss: Excessive or sudden weight loss can cause your periods to stop. Severely restricting the amount of calories you eat stops the production of hormones needed for ovulation. Your GP may refer you to a dietitian if you're underweight, which is when you have a body mass index (BMI) of less than 18.5. A dietitian will be able to advise you about how to regain weight safely.

  If your weight loss is caused by an eating disorder, such as anorexia, they may refer you to an eating disorder specialist or team of specialists.

• Being overweight: Being overweight can also affect your menstrual cycle. If you're overweight, your body may produce an excess amount of oestrogen, one of the hormones that regulate the reproductive system in women.

  Excess oestrogen can affect how often you have periods, and can also cause your periods to stop. Your GP may refer you to a dietitian if you're overweight, with a BMI of 30 or more, and it's affecting your periods. The dietitian will be able to advise you about losing weight safely.

• Doing too much exercise: The stress that intense physical activity places on your body can affect the hormones responsible for your periods. Losing too much body fat through intense exercise can also stop you ovulating. You'll be advised to reduce your level of activity if excessive exercise has caused your periods to stop. If you're a professional athlete, you may benefit from seeing a doctor who specialises in sports medicine. They'll be able to give you advice about how to maintain your performance without disrupting your periods.

• Taking the contraceptive pill: You might miss a period every so often if you're taking the contraceptive pill. This is not usually a cause for concern. Some types of contraception, such as the progestogen-only pill (POP), contraceptive injection and intrauterine system (IUS), particularly Mirena, can cause periods to stop altogether. However, your periods should return when you stop using these types of contraception.

• Menopause: You may start missing periods as you approach the menopause. This is because oestrogen levels start to decrease, and ovulation becomes less regular. After the menopause, your periods stop completely. The menopause is a natural part of ageing in women, which usually happens between the ages of 45 and 55. The average age for a woman to reach the menopause is 51 in the UK. However, around 1 in 100 women go through the menopause before the age of 40. This is known as premature menopause or premature ovarian failure.

• Polycystic ovary syndrome (PCOS): Polycystic ovaries contain many harmless follicles, which are underdeveloped sacs in which eggs develop. If you have PCOS, these sacs are often unable to release an egg, which means ovulation does not take place. PCOS is thought to be very common, affecting about 1 in every 10 women in the UK. The condition is responsible for as many as 1 in 3 cases of stopped periods. Periods can also sometimes stop because of a medical condition, such as heart disease, uncontrolled diabetes, an overactive thyroid, or premature menopause.

When to see your GP

See your GP if you're not pregnant – you've had a negative pregnancy test – and you've missed more than 3 periods in a row. If you're sexually active and you have not taken a pregnancy test, your GP may advise you to take one.

They may also ask you about:

Your medical history

Your family's medical history

Your sexual history

Any emotional issues you're having

Any recent changes in your weight

The amount of exercise you do

Your GP may recommend waiting to see whether your periods return on their own. In some cases, you may need treatment for your periods to return.

You should also see your GP if your periods stop before you're 45 or if you're still bleeding when you're over 55.

Referral to a consultant

If your GP thinks a medical condition might have caused your periods to stop, they may refer you to a consultant who specialises in the condition. Depending on what your GP suspects is causing the problem, you may be referred to:

A gynaecologist – a specialist in treating conditions that affect the female reproductive system

An endocrinologist – a specialist in treating hormonal conditions

You may have a full gynaecological examination and various tests, including:

Blood tests – to see whether you have abnormal levels of certain hormones

An ultrasound scan, CT scan or MRI scan – to identify any problems with your reproductive system or the pituitary gland in your brain

Treating underlying conditions

If test results show a medical condition has caused your periods to stop, you may be offered treatment for your condition.

For example, if the cause is PCOS, you may be advised to take the contraceptive pill or tablets containing a hormone called progesterone. If the cause is early menopause (premature ovarian failure), this means the ovaries no longer function normally. Hormone medicine is usually recommended. Treatments may include the contraceptive pill or hormone replacement therapy (HRT). If you have an overactive thyroid gland, you may be given medication to stop your thyroid producing too many hormones.

Chana is able to support any questions or guidance related to mikveh or fertility for women who are going through menopause or are having irregular periods.

References- https://www.nhs.uk/conditions/irregular-periods/

https://www.nhs.uk/conditions/stopped-or-missed-periods/

https://www.nhs.uk/conditions/heavy-periods/

Menopause is when your periods stop due to lower hormone levels. is the time that marks the end of your menstrual cycles. It's diagnosed after you've gone 12 months without a menstrual period. This usually happens between the ages of 45 and 55.

Most women first begin developing menopause symptoms about four years before their last period. Symptoms often continue until about four years after a woman’s last period. There are many factors that help determine when you will begin menopause, including genetics and ovary health. Menopause may start early naturally - or be caused medically by surgeries like oophorectomy or hysterectomy or by cancer treatments like chemotherapy.

Perimenopause

Perimenopause occurs specifically before menopause. Perimenopause is a time when your hormones begin to change in preparation for menopause and you have symptoms before your periods have stopped. It can last anywhere from a few months to several years. Many women begin perimenopause some point after their mid-40s. Other women skip perimenopause and enter menopause suddenly.

About 1 percent of women begin menopause before the age of 40, which is called premature menopause or primary ovarian insufficiency. About 5 percent of women undergo menopause between the ages of 40 and 45. This is referred to as early menopause.

During perimenopause, menstrual periods become irregular. Your periods may be late, or you may completely skip one or more periods. Menstrual flow may also become heavier or lighter.

Menopause is defined as a lack of menstruation for one full year.

Postmenopause refers to the years after menopause has occurred.

Menopause and perimenopause can cause symptoms like anxiety, mood swings, brain fog, hot flushes and irregular periods. These symptoms can start years before your periods stop and carry on afterwards. Menopause and perimenopause symptoms can have a big impact on your life, including relationships and work.

There are things you can do to help with symptoms. There are also medicines that can replace the missing hormones and help relieve your symptoms.

Common symptoms of menopause and perimenopause

Menopause and perimenopause symptoms can have a big impact on your daily life, including relationships, social life, family life and work.

It can feel different for everyone. You may have several symptoms or none. The first sign of the perimenopause is usually, but not always, a change in the normal pattern of your periods, for example they become irregular. Eventually you'll stop having periods altogether.

Mental health symptoms

• Changes to your mood, like low mood, anxiety, mood swings and low self-esteem

• Problems with memory or concentration (brain fog)

Physical symptoms

• Hot flushes, when you have sudden feelings of hot or cold in your face, neck and chest which can make you dizzy

• Difficulty sleeping, which may be a result of night sweats and make you feel tired and irritable during the day

• Palpitations, when your heartbeats suddenly become more noticeable

• Headaches and migraines that are worse than usual

• Muscle aches and joint pains

• changed body shape and weight gain

• Skin changes including dry and itchy skin

• Reduced sexual drive

• Vaginal dryness and pain, itching or discomfort during sex

• Recurrent urinary tract infections (UTIs)

How long do symptoms last

Symptoms can last for months or years and can change with time. For example, hot flushes and night sweats may improve, and then you may develop low mood and anxiety.

Some symptoms, such as joint pain and vaginal dryness, can carry on after your periods stop.

Lifestyle changes to help menopause and perimenopause Eating well, exercising and looking after your mental wellbeing can help with symptoms during perimenopause and menopause.

It can also help you keep as well as possible in the future.

Do

Get plenty of rest, including keeping to regular sleep routines

Eat a healthy diet

Have calcium-rich food like milk, yoghurt and kale to keep bones healthy

Exercise regularly, try including weight-bearing activities where your feet and legs support your weight like walking, running or dancing

Do relaxing things like yoga, tai chi or meditation

Talk to other people going through the same thing, like family, friends or colleagues

Talk to a doctor before taking herbal supplements or complementary medicines

Don’t

Do not smoke

Do not drink more than the recommended alcohol limit

Cognitive behavioural therapy (CBT) is a type of talking therapy that can help with a low mood and feelings of anxiety. It can also help with sleep problems.

Treatment for menopause and perimenopause

The main medicine treatment for menopause and perimenopause symptoms is hormone replacement therapy (HRT), which replaces the hormones that are at low levels.

There are other treatments if you cannot, or choose not to, have HRT.

Hormone replacement therapy (HRT) - HRT is a safe and effective treatment for most going through menopause and perimenopause. Your GP will discuss any risks with you. HRT involves using oestrogen to replace your body's own levels around the time of the menopause.

There are different types and doses of HRT. Using the right dose and type usually means your symptoms improve.

Oestrogen comes as:

Skin patches

A gel or spray to put on the skin

Implants

Tablets

Taking oestrogen and progesterone is called combined HRT.

Progesterone comes as:

Patches, as part of a combined patch with oestrogen

IUS (intrauterine system, or coil)

Tablets

If you have low sex drive because of menopause and HRT does not improve it, you may be offered testosterone.

Benefits of HRT The main benefit of HRT is that it can help relieve most menopause and perimenopause symptoms, including hot flushes, brain fog, joint pains, mood swings and vaginal dryness. Hot flushes or night sweats often improve within a few weeks. Other symptoms like mood changes and vaginal dryness can take a few months to improve. Taking HRT can also reduce your risk of hormone-related health problems including osteoporosis and heart disease.

Risks of HRT The risks of HRT are small and usually outweighed by the benefits. If you’re interested in HRT, your doctor or nurse can discuss the risks with you.

Oestrogen for vaginal dryness and discomfort Your vagina may become dry, painful or itchy because of the menopause and perimenopause. A GP can prescribe oestrogen treatments you can insert into your vagina, as a tablet, cream or ring. This can also improve any urinary symptoms caused by menopause and perimenopause, like discomfort when you pee. These vaginal oestrogen treatments do not get into your bloodstream and only work on the bit of the body where you put them. You can use them for the rest of your life. Symptoms usually come back when you stop using them. It's safe to use vaginal oestrogen with HRT.

Non-hormone medicines

There are non-hormone treatments if your symptoms are having a big impact on your life and you cannot, or choose not to, have HRT.

Hot flushes and night sweats There are some medicines that can help with hot flushes and night sweats. These include:

A blood pressure medicine called Clonidine

An epilepsy medicine called Gabapentin

Talk with a GP about these medicines and their side effects, and if they might be suitable for you.

You can also:

Wear light clothing, keep your bedroom cool at night, take a cool shower, use a fan or have a cold drink, try to reduce your stress level, avoid or reduce potential triggers, such as spicy food, caffeine, hot drinks, smoking and alcohol, exercise regularly, lose weight if you're overweight

Vaginal dryness There are vaginal moisturisers or lubricants you can get without a prescription at a pharmacy. There are other treatments for vaginal dryness that a doctor can prescribe speak to your GP to learn your options.

Mood symptoms Antidepressants can help with mood symptoms if you've been diagnosed with depression or anxiety.

Cognitive behavioural therapy (CBT) is a talking therapy which can help with:

Low mood and anxiety caused by menopause and perimenopause

Some physical symptoms like hot flushes and joint pain

Follow-up appointments

If you're having treatment for your symptoms of menopause or perimenopause, you'll need to return to the doctor or nurse who is prescribing your HRT for a follow-up review after 3 months.

When you and your doctor or nurse agree your treatment is working well for you, you'll need to see them once a year.

During your reviews, your doctor or nurse may:

• Make sure your symptoms are under control

• Ask about any side effects and vaginal bleeding

• Check your weight and blood pressure

• Review the type of HRT you're taking and make any necessary changes

You may need treatment for a few years, until most of your menopause and perimenopause symptoms have passed.

You can choose to continue taking HRT. The doctor or nurse prescribing your HRT can discuss with you the benefits and risks, so you can decide what’s right for you.

You can take HRT for as long as you need it. You can discuss this with your doctor or nurse at your yearly review.

Complementary and alternative therapies

Complementary and alternative treatments, such as herbal remedies and compounded bioidentical ("natural") hormones, are not recommended for symptoms of the menopause or perimenopause. This is because it's not clear how safe and effective they are. Red clover and black cohosh are herbal remedies but there is no strong evidence that they work. Some complementary and alternative therapies can also interact with other medicines and cause side effects.

Ask your GP or pharmacist for advice if you're thinking about using a complementary therapy.

Compounded bioidentical hormones

Compounded bioidentical hormones are sometimes offered in private clinics as HRT. They are not recommended because it's not known how well they work or how safe they are. They are not available on the NHS. They are different from regulated bioidentical hormones, also called body identical hormones. Bioidentical hormones are available on the NHS as HRT. They have been tested to see how well they work and how safe they are.

Speak to a health care professional

A GP, nurse or pharmacist can give you advice and help with your menopause or perimenopause symptoms.

There are also menopause specialists who have experience in supporting anyone going through perimenopause and menopause. Find your nearest NHS or private menopause specialist on the British Menopause Society website (this lists NHS and private specialists)

Psychological therapies like counselling or CBT (cognitive behavioural therapy) can help with symptoms of menopause and perimenopause. You can get NHS psychological therapies without seeing a GP first.

Chana is able to support any questions or guidance related to mikveh or fertility for women who are going through menopause and need guidance.

Reference: https://www.nhs.uk/conditions/menopause/

Early menopause happens when a woman's periods stop before the age of 45. It can happen naturally, or as a side effect of some treatments. For most women, the menopause starts between the ages of 45 and 55. If you're under 45 and have noticed your periods becoming infrequent or stopping altogether, you should speak to a GP.

Causes of early menopause

The ovaries stop working - Early menopause can happen naturally if a woman's ovaries stop making normal levels of certain hormones, particularly the hormone oestrogen. This is sometimes called premature ovarian failure, or primary ovarian insufficiency. The cause of premature ovarian failure is often unknown, but in some women it may be caused by:

• Chromosome abnormalities – such as in women with Turner syndrome

• An autoimmune disease – where the immune system starts attacking body tissues

• Certain infections, such as tuberculosis, malaria and mumps – but this is very rare

Premature ovarian failure can sometimes run in families. This might be the case if any of your relatives went through the menopause at a very young age (20s or early 30s).

Cancer treatments - Radiotherapy and chemotherapy can cause premature ovarian failure. This may be permanent or temporary. Your risk of having an early menopause will depend on:

Your age – girls who have not yet reached puberty can tolerate stronger treatment than older women

The type of treatment you're given – different types of chemotherapy may affect the ovaries differently

Where on your body any radiotherapy is focused – your risk of developing premature menopause is higher if you have radiotherapy treatment around your brain or pelvis

Surgery to remove the ovaries

Surgically removing both ovaries will also bring on premature or early menopause. For example, the ovaries may need to be removed during a hysterectomy (an operation to remove the womb).

Symptoms of early menopause

The main symptom of early menopause is periods becoming infrequent or stopping altogether without any other reason (such as pregnancy).

Hot flushes

Night sweats

Vaginal dryness and discomfort during sex

Difficulty sleeping

Low mood or anxiety

Reduced sex drive (libido)

Problems with memory and concentration

Women who go through early menopause also have an increased risk of osteoporosis and cardiovascular disease because of their lowered oestrogen hormone levels.

Diagnosing early menopause

A GP should be able to make a diagnosis of early menopause based on your symptoms, your family history, and blood tests to check your hormone levels.

You may be referred to a specialist.

Treatments for early menopause

The main treatment for early menopause is either the combined contraceptive pill or HRT to make up for your missing hormones.

A GP will probably recommend you take this treatment until at least the age of natural menopause (around 51 on average), to give you some protection from osteoporosis and other conditions that can develop after the menopause.

If you have had certain types of cancer, such as certain types of breast cancer, you may not be able to have hormonal treatment.

The GP will talk to you about other treatment options and lifestyle changes you can make to help protect your health.

If you're still getting symptoms, the GP can refer you to a specialist menopause centre.

Getting support

Going through the menopause early can be difficult and upsetting. Permanent early menopause will affect your ability to have children naturally.

You may still be able to have children by using IVF and donated eggs from another woman, or using your own eggs if you had some stored.

Counselling and support groups may be helpful.

Chana is able to support any questions or guidance related to mikveh or fertility for women who are going through menopause at any time or are having irregular periods.

Reference- https://www.nhs.uk/conditions/early-menopause/

Menopause is usually diagnosed in women over 45 who have not had a period for more than a year. Any bleeding from the vagina after this time needs to be checked by a GP.

What causes PMB?

There can be several causes of postmenopausal bleeding. The most common causes are:

• Inflammation and thinning of the vaginal lining (atrophic vaginitis) or womb lining (endometrial atrophy) – caused by lower oestrogen levels

• Cervical or womb polyps – growths that are usually non-cancerous

• A thickened womb lining (endometrial hyperplasia) – this can be caused by hormone replacement therapy (HRT), high levels of oestrogen or being overweight, and can lead to womb cancer

• Less commonly, postmenopausal bleeding is caused by cancer, such as ovarian cancer and womb cancer.

You have postmenopausal bleeding, even if:

It's only happened once

There's only a small amount of blood, spotting, or pink or brown discharge

You do not have any other symptoms

You're not sure if it's blood

Postmenopausal bleeding is not usually serious, but can be a sign of cancer of the cervix, uterus or vagina. Cancer is easier to treat if it's found early.

What should I do if I have PMB?

You should arrange to see your GP urgently so that it can be quickly investigated. The GP should refer you to hospital or a special postmenopausal bleeding clinic.

You should not have to wait more than 2 weeks to see a specialist.

What type of tests will I have?

You will be offered an internal examination and an ultrasound scan, usually done by inserting a small probe into your vagina. You may be offered a procedure called hysteroscopy, whereby a thin telescope is used to see inside your uterus. This can be done in the outpatient clinic or under general anaesthetic. A biopsy from the lining of your uterus may be done as an alternative to a hysteroscopy or at the same time.

What are my treatment options?

You may not need any treatment. If treatment is advised, it will depend on the cause of the bleeding, and your healthcare professional will discuss this with you. 9 in 10 women with PMB do not have cancer.

If cancer is found it is usually at an early stage and treatment can cure it.

Treatment for postmenopausal bleeding

Treatment for postmenopausal bleeding depends on what's causing it.

• Cervical polyps - The polyps may need to be removed by a specialist

• Vaginal or endometrial atrophy - You may not need treatment, but may be offered oestrogen cream or pessaries

• Endometrial hyperplasia -Depending on the type of hyperplasia, you may be offered no treatment, hormone medicine (tablets or an intrauterine system, IUS) or a total hysterectomy (surgery to remove your uterus, cervix and ovaries)

• Side effect of HRT - Changing or stopping HRT treatment

• Womb cancer - Total hysterectomy will often be recommended

• Ovarian cancer - Surgery to remove your ovaries and your womb (total hysterectomy)

References- https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/postmenopausal-bleeding-poster/

https://www.nhs.uk/conditions/post-menopausal-bleeding/