Examinations and tests
There are a number of ways in which menstrual problems can be investigated. These will depend on the nature of your problem and on your age at the time. You may not need any special investigations other than simple examination, particularly if you’re under the age of 40, when serious underlying problems, such as cancer, are extremely rare. Often your doctor may prefer to try medical treatment to start with and only organise investigations if it doesn’t work.
Pelvic (internal) examination
A simple pelvic (internal) examination will enable your GP or gynaecologist to tell whether your uterus or ovaries are enlarged and whether there are any tender areas. He or she can inspect your cervix by inserting a plastic or metal instrument called a speculum into your vagina and a smear can be taken at the same time. Swabs can be taken from the cervix or vagina to test for infection. A nurse or female chaperone should be present while you are being examined by a male doctor.
A simple pelvic (internal) examination
Ultrasound scan
Ultrasound scanning is a simple painless procedure that can be done either by moving the scanning device firmly over the lower abdomen (abdominal scan) or by placing the device in the upper vagina (transvaginal scan). Women often prefer the transvaginal method because, during the abdominal scan, you have to keep your bladder very full.
The choice of scanning method will vary according to the reason for the scan. If fibroids or an ovarian cyst is suspected, an abdominal scan may give more information; to investigate menstrual bleeding abnormalities, a transvaginal scan gives a clearer picture of the uterine lining (endometrium). Sometimes both methods are used but you will be given the opportunity to empty your bladder after the abdominal scan.
In some hospitals a special type of transvaginal scan may be used which involves injecting a small volume of fluid (saline) into the inside of the uterus through the cervix to identify possible fibroids or polyps inside the uterus. This entails a vaginal examination and insertion of a speculum before the scan but very little additional discomfort.
Ultrasound scan
An ultasound scan produces an echo image using sound waves
Blood tests
Blood tests are important in diagnosing anaemia and abnormalities of blood clotting. They are also useful if you have symptoms of an overactive or underactive thyroid (which occasionally causes menstrual upset) and for measurement of hormone levels if you are thought to be nearing the menopause.
Endometrial biopsy
Endometrial biopsy involves taking a sample of the lining of your uterus by first inserting a vaginal speculum and then passing a fine tube through your cervix. The sample is then sent to the laboratory for examination under the microscope. This may be necessary if you are having irregular bleeding or additional bleeding in between periods. The biopsy can be taken in the clinic or surgery and takes only a couple of minutes, during which time you will experience mild discomfort, similar to a period pain.
How an endometrial biopsy is taken
An instrument called a speculum is used to hold the vagina open while a thin flexible sampling tube is inserted into the uterus. A small sample of tissue is then drawn into the tube.
Hysteroscopy
Hysteroscopy is an examination of the inside (cavity) of your uterus with an instrument (hysteroscope) which is fitted with a light source and camera so that a view of the uterine cavity can be seen on a screen.
The hysteroscope is passed through the cervix via the vagina, and gas or fluid is used to expand the cavity of your uterus. Once the cavity has been inspected in detail, an endometrial biopsy is usually taken. This technique can detect the presence of polyps and fibroids and if these are small, they can sometimes be removed at the same time. Hysteroscopy is usually done in the outpatient clinic but may be done as a day case procedure under a general anaesthetic.
How a hysteroscopy is done
The hysteroscope with its own light source is inserted through the vagina into the uterus. The uterus may be filled with gas to allow the structures to be seen more clearly.
Dilatation and curettage
Dilatation and curettage (D&C) was the traditional method for investigating bleeding problems, but is now rarely used because, unlike the newer methods, it has to be done under a general anaesthetic. It involves first stretching open the cervix (dilatation) and then scraping out the uterine lining (curettage). It is still done, in conjunction with a hysteroscopy, in some women to investigate bleeding after the menopause. It must be emphasised that a D&C has no value in the treatment of period problems.
How a dilation and curettage is done
Laparoscopy
Laparoscopy may be recommended if your problem is mainly one of abnormal pain associated with your periods. The external surface of the uterus as well as the fallopian tubes, ovaries and the surrounding structures are inspected through a laparoscope, linked up by a fibreoptic light source and a camera to a TV screen.
Laparoscopy involves a general anaesthetic, one or two small abdominal incisions and a short stay in hospital, usually in a day surgery unit (no overnight stay). It is the most reliable way of diagnosing endometriosis. Laparoscopic surgery may be used to treat small ovarian cysts and areas of endometriosis. This is known as keyhole surgery (see chapter xx).
Measuring menstrual blood loss
One of the difficulties about treating women with heavy periods is that we have no accurate information about the amount of blood a woman is losing each month. Some hospitals measure menstrual blood loss by asking women to collect all their used pads and tampons. This is not a pleasant task but does provide invaluable information. For various reasons this is not done routinely and its use is normally confined to teaching hospitals undertaking research into menstrual problems.
KEY POINTS
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Pelvic examination by a GP or gynaecologist allows detection of enlargement of the uterus or ovaries and the cervix can be inspected through a speculum
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Bleeding problems in women under 40 rarely have a serious cause and do not usually require investigation
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Investigations may involve blood tests, endometrial biopsy, ultrasound scan, hysteroscopy or laparoscopy
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A D&C does not help menstrual problems and is not usually needed for the investigation of abnormal bleeding