Amenorrhoea / post-pill amenorrhoea

• Amenorrhoea (CKS)

Delaying Menstruation

• How can I delay my period (NHS Choices)

Dysmenorrhoea, Premenstrual syndrome (PMS)

• painful cramping, usually in the lower abdomen, which occurs shortly before or during menstruation, or both

• NSAID e.g. ibuprofen, naproxen, mefenamic acid, flurbiprofen, or tiaprofenic acid (concerns that mefenamic acid is more likely to cause seizures in overdose than other NSAIDs)

• Paracetamol

• 3–6 month trial of a hormonal contraceptive as an alternative first-line treatment.

  1. Monophasic combined oral contraceptive (COC) preparations containing 30–35 micrograms of ethinylestradiol and norethisterone, norgestimate, or levonorgestrel are usually first choice.

  2. Oral (desogestrel 75 micrograms), parenteral (Depo-Provera^® or Sayana Press^®, and Nexplanon^®), and intrauterine progestogen-only (Mirena^®) contraceptives may also be considered after a full discussion of the advantages and disadvantages.

• If the response to individual treatments is insufficient, a combination of an NSAID (or paracetamol) and hormonal contraception may be considered.

• Non-drug measures:

  1. Local application of heat (for example, a hot water bottle or heat patch).

  2. Transcutaneous electrical nerve stimulation (TENS) — set to a high frequency.

• Patient information:

  1. The NHS website (www.nhs.uk) has patient information on Period pain.

  2. Women’s Health Concern (WHC) (www.womens-health-concern.org) leaflet on Period pain.

• Dysmenorrhoea (CKS), Premenstrual syndrome (CKS)

Endometriosis

• Growth of endometrium-like tissue outside the uterus (deposits are most commonly distributed in the pelvis; on the ovaries, uterosacral ligaments, pouch of Douglas, rectum and sigmoid colon, bladder, and distal ureter. Extrapelvic deposits, such as in the bowel, diaphragm, umbilicus, and pleural cavity, are rare)

• Endometriosis is hormone mediated and is associated with menstruation. The hormonal changes in the menstrual cycle induce bleeding, chronic inflammation, and scar tissue formation

• Endometriosis (CKS), Endometriosis (BMJ, 2014)

​Adenomycosis

• Cells of the lining of the womb (endometrium) are found in the muscle wall of the womb (myometrium)

• Adenomycosis (GSTT)

Endometrial Cancer

• Cancer of the uterus (NHS Choices)

Fibroids

• leiomyomas are benign tumours (mixture of smooth muscle cells and fibroblasts) which form hard, round, whorled tumours in the myometrium

• Fibroids (CKS) / Fibroids (NHS Choices)

Menorrhagia

• Levonorgestrel intrauterine system (LNG-IUS) first-line.

• Tranexamic acid or NSAID

• Combined hormonal contraception (CHC) or a cyclical oral progestogen

• Uterine artery embolization, surgery (myomectomy, hysterectomy, or second-generation endometrial ablation (e.g. fibroids ≥3 cm)

• Menorrhagia (CKS)​, Heavy menstrual bleeding: assessment and management (NICE, 2016)