How to get help
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Your doctor will probably ask you about your menstrual and reproductive health, including details about your period. If you have been tracking your period, this may be a good time to share it with your doctor. This type of information can help identify conditions like ovulatory disorders or blood clotting disorders, and some others as well.
You may also be asked questions about:
use of contraceptive methods (current or previous)
previous pregnancies and deliveries
sexual lifestyle, and if you have ever had a sexually transmitted infection
previous pap-smear or HPV test results
history of infertility
what medications you are taking (e.g., anticoagulants, antidepressants, corticosteroids, hormonal contraceptives or over the counter products)
Here’s a brief look at what your doctor (GP) or your specialist (gynaecologist) may ask about, and what they can do. For details see section below
What doctors might ask about, and what they can do
There are a variety of medical and surgical treatments to manage abnormal uterine bleeding.
The information shared with your doctor will help decide what sort of treatment, follow-up or further investigations you may need. The types of information your doctor or specialist may ask are shown below.
Menstrual and reproductive health
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Your doctor (GP) and specialist (gynaecologist) may ask about:
Menstrual and reproductive health
Family and whānau health
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Your doctor (GP) and specialist (gynaecologist) may recommend:
Physical and Pelvic Examination
Laboratory tests
Imaging
Aspiration endometrial sampling (Pipelle)
Your specialist might also recommend:
Hysteroscopy
Colposcopy
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Your doctor (GP) and specialist (gynaecologist) might refer you for:
An ultrasound - this will likely be a transvaginal ultrasound to look at your uterus and pelvic organs
Your doctor might also refer you to:
A gynaecology specialist (often based at a hospital)
if needed your specialist might refer you for:
Specialist imaging, investigation (such as MRI or hysteroscopy)
or refer you to other subspecialists
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If you are anaemic, treatment can include getting extra iron into your system. These can be by pills or intravenously (IV), or by a blood transfusion if you are very anaemic.
Medical treatments for bleeding may include:
Non hormonal options
Hormonal pills that can be contraceptives or non-contraceptives
An Intra-Uterine System that releases hormones inside your uterus (you may be referred to another physician to perform the procedure)
Procedures:
Removal of cervical polyps (cervical polypectomy) - these can be done by your GP or specialist in their office or appointment room
Other procedures your specialist may do are:
Hysteroscopy
Endometrial ablation surgical procedure that destroys the inner layer of the uterus
Hysterectomy - surgical removal of the uterus
Myomectomy - for surgical removal of fibroids
Referral for Fibroid Embolisation procedure that aims to destroy the blood supply to the fibroids to make them shrink.
Sources:
Magdalena Bofill. Evidence for treatment of heavy menstrual bleeding, women’s perceptions and current practice in New Zealand. PhD thesis. 2022. Available from https://hdl.handle.net/2292/64110
Assessment and management of Abnormal Uterine Bleeding (AUB) in non-pregnant women of reproductive age group. New Zealand AUB working group.
Family and whānau health history is collected to determine underlying causes of abnormal uterine bleeding, as some causes can be inherited (hereditary), such as blood clotting (coagulation) disorders. Also, they may ask if you have a family history of endometrial, ovarian, breast or bowel cancer.
Family and whānau health history
Risk factors for endometrial cancer
Your doctor may request additional information about you, which may be unrelated to your menstrual health but help with assessing your risk for developing endometrial cancer, such as your body weight, diabetes or polycystic ovarian syndrome, among others.
If you see a GP (General Practitioner) about experiencing abnormal uterine bleeding, it’s possible that they will refer you to see a gynaecologist or other specialist. If this happens, you may need to decide between public and private healthcare. Both are good choices and provide care from experienced specialists. Your decision should be made based on what suits your needs and circumstances. Public care is free for those eligible private care may be funded by insurance or self-funded. The initial appointment costs usually start from around $250. The full cost depends on investigations and interventions required.
Public and private healthcare
Investigations
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General physical examination, including abdominal exam. Your doctor (GP or gynaecologist) may ask to carry out an intimate examination (pelvic examination) if necessary, acceptable and appropriate. This is likely to involve using a vaginal speculum to look at your vagina and cervix, and may help identify the origin of the bleeding and check if there are any visible causes of AUB. It may also involve a bimanual examination (with two fingers through the vagina and the other hand on the abdomen) may be performed to examine the pelvis, it helps determine the size and nature of the uterus and ovaries (to assess the size and position, and if tender- where is it tender), this also helps to check for the presence of lumps (masses) in the pelvis.
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You may be asked to have blood tests. This can include (but may not be limited to):
Complete blood count (CBC). The complete blood count also known as full blood count (FBC), reports the number of different types of blood cells. This will inform, for example, if you have anaemia (this can be treated), if there are signs of infection, or the cells that participate in your ability to clot are normal.
Iron studies This is a group of blood tests that check the availability of iron. It may be indicative of iron deficiency, which can lead to anaemia, and may be due to HMB.
Additional tests which may include:
Testing for diabetes
Hormonal tests- such as testosterone or thyroid function
Clotting factors – if a bleeding disorder is thought to be likely based on initial assessment (history and examination)
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Transvaginal ultrasound (TVUS) is an internal scan of the pelvis, it involves inserting a long and narrow ultrasound probe, called a transducer, into the vagina to produce very detailed images of the organs in the pelvic region. It helps to assess the thickness of the lining of the uterus (endometrium), check for the presence of polyps or fibroids. and assessing the ovaries and their surrounding area.
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Your doctor may use the word “pipelle”. The full medical description is called aspiration endometrial sampling or endometrial pipelle biopsy. It is a procedure where a tiny (1-2mm) plastic tube is passed through the vagina and cervix into the womb to obtain a small sample of the lining of the womb. You are likely to be awake for this procedure, as it is usually attempted or performed as an awake outpatient procedure. The sample is sent to the laboratory for further analysis; it may take up to 4 weeks for the result to be available.
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It is a procedure where the gynaecologist uses a thin telescope called a hysteroscope to look inside of your uterus and the openings of the fallopian tube. They may be able to treat some causes of AUB (polyps and submucous fibroids) in the same procedure. A hysteroscopy may be performed as an outpatient procedure or under general anaesthetics.
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Colposcopy is a procedure where your cervix is assed under magnification using a speculum and a microscope called colposcope to look at your cervix and usually take a sample (biopsy). This can also be used to look at the vulva (vulvoscopy) and vagina (vaginoscopy). This procedure is commonly done while you are awake as an outpatient procedure.
Check out more information about colposcopy here: Kōpū Collective - Colposcopy 101 resource
Medical treatments
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Non-hormonal treatment options aim to decrease bleeding, but in general, they do not treat the cause There are two types:
Non-steroidal anti-inflammatory drugs, also called NSAID (such as ibuprofen or mefenamic acid)
Antifibrinolytic (such as tranexamic acid), a medication that improves the blood's ability to clot.
They can be used individually or in combination and are good options for people who wish to avoid hormones; additional benefits for anti-inflammatories include reducing your period pain (dysmenorrhoea). These treatments can be started while you are awaiting further tests and can be continued for as long as you wish if it helps you. You only take them during a short period of your cycle (while bleeding) and they are not contraceptives.
More information about tranexamic acid.
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There are a number of different hormonal options for treating abnormal uterine bleeding, they can be contraceptive or non-contraceptives, so ask your doctor about the effects.
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Progesterone is the non-contraceptive hormonal treatment for AUB.
In Aotearoa the most commonly used progesterone preparations in this setting are, Primolut N® and Provera®. It is used to treat abnormal uterine bleeding by slowing the growth of the lining of your uterus (endometrium) before menstruation and reduces bleeding during menstruation. It involves taking tablets up to 3 times a day, daily. These tablets are not contraceptives and do not stop you from getting pregnant.
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Most oestrogen and progesterone treatments are in the form of a contraceptive pill and are taken orally in different regimes. Your doctor may offer you to decide how often you want to have your period and you may be able to avoid monthly bleeding and swap it to every 3 or more months. If taken as directed, it is safe and it keeps the contraceptive effect.
Hormonal contraceptive treatments are usually taken to prevent pregnancy and they can be used to treat painful or heavy periods. There are several different types of contraceptive hormonal options for treating AUB. Many of these are in the form of a pill and are taken orally every day. include hormonal treatments such as combined oral contraceptive (which has both oestrogen and progestogen) and progestogen only.
Other ways of contraceptive hormonal treatment are in the form of an injection or in the form of an intrauterine device that releases hormones (this is different to the Copper IUD).
Progestogen injection is a contraceptive injection that you will have every 3 months, and it is very likely to stop your period. This is expected and safe.
Intrauterine devices (IUDs, also called intrauterine systems, IUS) are very small devices inserted through the vagina and cervix into the uterus, and they can stay in place in the lining of the uterus for long term (years). There are two types, with and without hormones. The ones without hormones can increase the amount of bleeding, so they are not useful for AUB. The ones with hormones work by releasing, daily, a very small amount of progestogen (usually levonorgestrel) locally into the uterus. This makes the lining of the uterus (endometrium) thinner, so you are likely to experience less menstrual bleeding, and therefore reduce heavy periods. For some people, their periods stop with this treatment. The levonorgestrel releasing IUD is also a reliable contraceptive and can stay in place for up to 7 years.
You and your doctor will decide if, and which type of, hormonal contraceptive treatment is right for you. You may not be able to take all types of hormonal contraceptive. For example, if you have a history of high blood pressure, if you are older than 35 and smoke, you will be advised against the use of a combined oral contraceptive pill.
More about information about progesterone only contraceptive pills; combined oral contraceptives; intrauterine devices (IUD) and injectable hormonal contraceptives is available on the Healthify website:
More informationabout progesterone only contraceptive pills
More information about combined oral contraceptives
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These are hormonal treatments that suppress the natural release of ovarian hormones. They are usually used for short periods as may have significant side-effects (e.g., menopausal symptoms, breakthrough bleeding, bone loss) if used without additional hormonal treatment. It is safe to be used for longer than 6 months if additional hormonal treatment is used (called addback therapy). GnRH may be used for fibroids in secondary care and is known to decrease menstrual bleeding, correct anaemia and reduce fibroid volume, which makes them a good option before surgery (hysterectomy or myomectomy) to reduce the size of the fibroids.
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Colposcopy is a procedure where your cervix is assed under magnification using a speculum and a microscope called colposcope to look at your cervix and usually take a sample (biopsy). This can also be used to look at the vulva (vulvoscopy) and vagina (vaginoscopy). This procedure is commonly done while you are awake as an outpatient procedure.
More information about colposcopy can be found here.
Frequently asked questions about contraceptive hormonal pills
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If you are taking hormonal contraceptive pills, your menstrual cycle may change. You may have withdrawal bleeding or breakthrough bleeding depending on which hormonal pills you are taking and how you have been advised (prescribed) to take the pills.
Withdrawal bleeding is common among those who use a combined oral contraceptive. It’s called withdrawal because your uterus is responding to a withdrawal from the hormones. This is a normal response. Depending on how you are taking the combined oral contraceptive will affect when, or even if, you have withdrawal bleeding.
If you are taking the combined oral contraceptive pill for 21 days and taking the non-hormonal pill for 7 days, you will have a withdrawal bleed in those 7 days. If you are taking the combined oral contraceptive pill for a few months in a row and then take 7 non-hormonal pills, you will have a withdrawal bleed in those 7 days. The bleeding will often be lighter than your period, and you may have less cramping. If you are taking the combined oral contraceptive pill continuously you are less likely to have withdrawal bleeding.
Breakthrough bleeding is common with progestogen only pills. Your bleeding pattern may be irregular. Often breakthrough bleeding stops as your body adjusts to the hormone. Not everyone will have breakthrough bleeding.
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This depends on which hormonal contraceptive pills you are taking.
If you are taking the combined oral contraceptive pills, possible side-effects may include: mood change, headache, nausea, breast tenderness. If you are taking progestogen only pills, possible side-effects may include: weight-gain, bloating, breast tenderness. If you experience new headaches, shortness of breath or chest pain or a swollen leg, it is important to see your doctor urgently.
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There is no ‘upper limit’ of the amount of time you can take contraceptive hormonal pills for.
Sometimes as you get older you develop a medical condition such as high blood pressure which means that you can no longer use combined oral contraceptives. If you smoke, you shouldn’t use the combined oral contraceptive pill over the age of 35. You would either need to stop smoking or stop taking the pill over the age of 35.
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There should not be any side effects from stopping hormonal pills, but you will probably experience bleeding soon after stopping. Once you have stopped taking the hormonal pills, the symptoms of abnormal bleeding may return. If you are using contraceptive hormonal pills, the contraceptive effect will no longer be present.
Progestogen injections,your natural periods and fertility may take about a year to return to normal once you stop using it.
Intrauterine devices, your natural fertility and periods return shortly after the IUD has been removed.
Surgical treatments
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An endometrial ablation is one surgical option for AUB treatment. It’s a surgical procedure that removes or destroys the inner layer (endometrium) of the uterus. The procedure can be done as an outpatient procedure, but it is commonly done under general anaesthetic. It is important to know that it is not a contraceptive. It is not recommended if you have not completed your family (you are considering future pregnancy), as it is related to very serious pregnancy-related complications.
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A hysterectomy is a surgical procedure that removes your uterus. There are different types of hysterectomy. It can be performed as open surgery (through a large cut on your abdomen, known as laparotomy), keyhole surgery (laparoscopically) or through the vagina. The procedure decision is based on multiple factors. Most women won't have a period ever again after a hysterectomy. On very rare occasions (not standard practice), a subtotal hysterectomy may have been performed (leaving the cervix in place), and women who have had a subtotal hysterectomy may still experience some bleeding. This is because the cervix has some of the same cells that line the uterus.
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A myomectomy is a surgical procedure where the fibroids are removed, but the uterus remains. The procedure can be performed through the abdomen (open surgery), keyhole surgery (laparoscopically) or using a hysteroscope (if the fibroids are in the cavity of the womb) depending on the fibroid’s characteristics, such as size and position. The procedure usually allows for future pregnancy.
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Fibroid embolisation is a procedure used to shrink fibroids. It is a minimally invasive treatment performed by an interventional radiologist. The procedure is done while you are awake with pain relief and sedation. It blocks the blood supply to the fibroids, causing them to shrink over time. You will usually stay in the hospital overnight.
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Polypectomy is a procedure where polyps are removed during a hysteroscopy.
Advocating for yourself in a medical environment
Going to the doctors can be a scary experience, and especially when you are going to talk about something as personal as your experience of a period. Here are some tips to help you advocate for yourself when you see your doctor.
Here is a link to a helpful resource from ACC with questions to support your visit with your doctor.
Can you book an extra appointment?
Booking a double appointment may mean that you can have more time to talk with your GP. There maybe an extra cost associated with this.
Write things down before you go to the doctors
It may be helpful to write down what you want to say to your doctor and take it for the appointment.
Asking questions and practicing what you would like to say
It may be helpful to think about what you want to say and then practise before you go to the appointment with your doctor. It might also be useful to practise some lines in case there is a moment where you feel misheard or don’t understand what your doctor is saying. For example, “Could you explain that again...” or “it’s not quite like that, it’s more like this…”
At the end of your consultation, you can ask your doctor to share, or repeat, your care plan. You could also repeat it back to your doctor. This is a good way to summarise and check what has been discussed. For example, you could say something like: “Please can you repeat the care plan, I’d like to check I have it clear in my mind…” or, “For my understanding, I’d like to repeat back what you’ve said about my care plan …”
Bring a support person
Doctor’s appointments can sometimes be overwhelming. Bringing a trusted support person to an appointment could help you. They can be there to help if you find yourself feeling worried or frustrated; as well as being another set of ears and someone to take notes, they could also ask questions on your behalf.
Think about getting a second opinion
If you feel unsure about the advice your doctor gave you, you have the right to look for a second opinion. You can get a second opinion even if you're just curious about other approaches.
Keep learning
Learning about your body and what’s going on can be an empowering thing, especially in medical spaces. Understanding your own medical experience can help you stay an active decision-maker in your healthcare plan.
Which treatment is right for you?
As there are lots of different treatments, there is a lot to think about. Some of the treatments mean you may have to take pills every day. Others are irreversible like a hysterectomy. You, your whānau, support people and your doctor can work together to choose the treatment option that's best for your personal circumstance and experience of abnormal uterine bleeding. You have the right to health information that meets your needs and the right to make the decision that is right for you. This is outlined in the Code of Health and Disability Services Consumers' Rights (the Code). The Code establishes the rights of consumers, and the obligations and duties of providers to comply with the Code. It is a regulation under the Health and Disability Commissioner Act.
When deciding on treatment options, some helpful things to ask may be, what are the possible side effects? What is the recovery like (if it is a surgical procedure)? What are the short and long term effects? What is the success rate of this treatment? How long can I be on this medication for?
Dr Geeta Kumar has developed a decision making aid for people in the United Kingdom. It has been made available by the University of Edinburgh and can be downloaded at the link below. It outlines the different treatment options, benefits and risks and was designed to help support decision making. It may be useful to use this aid to talk with your friends, whānau and family and with your doctor or specialist.
Take good care of yourself
Often easier to say than do, but taking care of yourself is really important because you are really important.
There are lots of things that you can do for you. Even if it is only for five minutes a day.
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Can you see or speak to a rongoā practitioner? There are lots of rongoā to try. Kawakawa has a long history as a rongoā. Kawakawa was sent to Papatūānuku the Earth mother, from Io Mātua Kore, to heal her broken heart after separating from Ranginui. The heart-shaped leaves of kawakawa remind us of this story and also are a symbol of its healing power. The leaves and fruit are used to make a wairākau (tea) or incorporated into a balm. It’s important to note that kawakawa thins the blood, so people who on heart medication should check before taking it. Some people use kūmarahou, a versatile traditional Māori rongoā used as a general tonic to treat chest complaints; coughs, colds, bronchitis, asthma, arthritis, menstrual pain, blood purification and liver cleansing. https://tuturongoamaori.co.nz/products/driedkumarahouleaf?variant=42132706459822
Some people have also found kohekohe helpful, it focuses on healing, maintaining and relieving pain levels and hormones that you experience. This rongoā relaxes your cervix in order to do it's mahi (not to be taken when pregnant). https://www.kawakawaspa.com/products/kohekohe
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Supplements such as iron can help with side effects of anaemia (like increasing your energy levels) and the heaviness of bleeding (taking vitamin C can help with increasing absorbency of iron). Always take medication as directed and speak to your doctor before you start especially if you are taking other medication(s).
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Getting out and about (even just for a bit) can help lower your stress levels, which may be a contributing factor to bleeding. Moving can also increase blood flow and relieve period pain (dysmenorroea). Some gentle exercise like walking, stretching or yoga can be helpful, especially if your energy levels are low. Can you get out to nature to get a breath of fresh air?
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Sometimes resting and relaxing is what you need. This may be easier said than done, or you may feel like moving about instead. Listen to your body, trust your instincts.
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Sometimes symptoms can be lessened with changes to what you eat and drink. Are you able to consume more foods and drinks that nourish your body? Eating foods high in iron such as leafy greens, beans, nuts and seeds can increase energy levels. Don’t make any drastic changes to what you eat or drink without talking to your doctor. Losing weight can sometimes be helpful, but often, it’s hard to do.
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Abnormal uterine bleeding may feel difficult to manage or isolating at times. It is really important to look after your mental health just as you look after your physical health. Reach out to friends and whānau or a trained counsellor to talk about your experience with your period.
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There are many non-medical ways to help with symptoms of abnormal uterine bleeding. Make sure you do you do your research about these options before trying them.