Periods, pelvic floors and prolapses: the things women don’t talk about

Late or heavy periods. Prolapse. PCOS. Leaky bladder. If any of those sound familiar, you are not alone. Gynaecological issues can crop up any time from puberty onwards, and getting them checked out quickly is a good idea because often there are options to treat the symptoms and, where appropriate, their underlying cause.

That’s according to Dr Cliona Murphy, a consultant gynaecologist and obstetrician at the Coombe Women & Infants University Hospital in Dublin, where she sees patients with a range of symptoms.

Checking symptoms

In general, women are pretty diligent about getting gynaecological symptoms checked out, Murphy notes. “Women tend to have a pretty high awareness in this area, and while they might put it off because they have their hands full with work and family, plus they might feel nervous about going to the doctor, they do generally go to their GP or clinic to get symptoms seen to.”

That said, she has also seen patients – particularly older women – who put off seeking help for quite a while.

“I would see this particularly among older women with bad prolapse [in which the womb slips down from its normal position], where they might feel it’s just old age and it doesn’t warrant getting treatment, or they are afraid. And yet there is a lot that can be done to improve the situation once they get it checked out,” she says.

“And sometimes when people know that it isn’t a good sign – maybe older women having bleeding, bleeding after sex or abdominal swelling – they know they should be going to the GP about it but they are so afraid of what they might hear.

“They put it off and sometimes then when they go to their GP they might mention something, but not the whole story. Then when they get referred to the hospital it turns out that the bleeding has been going on for longer.”

In many cases, the anxiety of living with a symptom or anticipating a doctor’s visit can be quite high, says Murphy.

“You might be peppering, and literally not sleeping, but in the majority of cases it turns out to be quite treatable and not half as scary as you might think,” she says. “It can be a relief just to unburden yourself of that anticipation and anxiety, and if it is something that does need treatment, in general the sooner things are treated the better.”

Periods of change

Late, heavy or irregular periods are common symptoms that Murphy sees in her clinic, and in each patient she looks for the potential cause and ways to improve matters. “In younger patients, one of the most common things they present with is that their periods haven’t started yet,” she says. “And this might be quite normal for some people.”

The age of onset of periods, or menarche, has generally shifted downwards in western society, she notes. “That has to do with body fat and possibly diet in the western world, and some girls age 10 or 11 are getting periods; but then you also have outliers who are 16 or 17 and not getting periods.”

She also sees cases of irregular periods, where a young woman may get a period only every few months. “Obesity would be a big contender there as a contributing factor,” says Murphy. “I see that quite often where someone comes with irregular periods as the presenting complaint, but I would be more concerned about the overall weight issue, and one of the approaches is to support them in losing weight and the periods may become more regular.”

Meanwhile, having a low body mass index (BMI) is associated with lack of periods, she adds. “This can sometimes uncover an eating disorder that hasn’t been recognised.”

The broad view

Irregular or heavy periods might be a symptom of a condition called polycystic ovary syndrome (PCOS), where numerous cysts develop on the ovaries and hormonal balances are linked with changes in weight, fertility and hair growth, but Murphy is keen to take a broad view in such cases.

“[PCOS] is a continuum. Some people have a lot of symptoms – facial hair growth, weight gain, irregular periods, fertility issues – and some may just have slightly irregular periods and may have their family as planned,” she says.

“I think putting a label on someone at the age of 18 or 20 is counterproductive because this is a condition that can change. Sometimes if a person is overweight and they lose a little weight, some of the symptoms ease, and sometimes the symptoms may be particularly pronounced at a time of stress and then get better.”

Heavy and painful periods can be a sign of endometriosis, where tissue normally found lining the womb also grows outside the womb. Again, Murphy takes a broad view and looks to support the patient with pain management, hormonal contraceptives or, in some cases, keyhole surgery to address the issue.

“You have to weigh up the pros and cons for each person, and find out if they are losing a lot of time from school or work, or finding it hard to care for family members because of the pain and heaviness of the periods,” she says.

Smear sense

One of the recent gynaecological developments in Ireland has been the introduction of regular cervical smears to screen for the early signs and risk factors of cervical cancer. The procedure involves taking a small “smear” from the lining of the cervix at the opening of the womb and checking it for cells that look abnormal or slightly abnormal.

The approach is looking to reduce the number of women who develop cancer in that part of the body, explains Murphy.

“The screening programme is trying to reduce the burden of disease overall,” she says. “Not everyone who gets a positive result from a smear is going to develop cervical cancer, but by treating those who have high-grade [abnormalities], it reduces the overall likelihood of cervical cancer in the population.”

Women with abnormal cells in their smear results can undergo a colposcopy, which takes an in-depth look at the cervix; and possibly a biopsy; and then some of those women may undergo treatment.

“A common treatment is called a ‘loop excision’ where we take a circle of tissue off the cervix: it takes a few minutes and we typically do it under local anaesthetic,” says Murphy, though she is keen to stress that not all women who have an abnormal smear or even a colposcopy progress to a treatment.

She also reckons that addressing the human papilloma virus (HPV) through vaccines and awareness will bring down the numbers needing colposcopy, because the presence of some strains of HPV in the cervix are linked with increased risk of cervical cancer.

“That will take a while, but it’s hoped that tackling HPV in the community setting will ultimately reduce the numbers needing to go forward for colposcopy.”

The post-baby body

Pregnancy is a time of big change in the pelvis, and while the tissues and organs tend to settle back afterwards, some women still feel the effects long after the offspring has crawled, walked, been educated and even left the nest.

Prolapse and stress incontinence (springing an unexpected leak when you laugh, cough, break into a run or bounce on a trampoline) are two potential issues in the post-baby body, but Murphy points out that individuals vary.

“Some women will have several children and not have a problem later on, and others might have a small family and yet experience a prolapse while they are quite young,” she says, adding that pelvic floor exercises, genetic factors and occupation can have an influence here, and symptoms can be treated with physiotherapy and even surgery in some cases.

Speak up about symptoms

Murphy is keen for older women to seek help if they need it. “When older women come in with prolapse they may feel nothing much can be done for them,” she says. “But there is a lot we can do and it’s a case of coming forward and telling your GP or gynaecologist that there’s a problem.”

She also wants women to feel comfortable going to their doctor about gynaecological issues that interfere with sexual function, particularly as they get older.

“Vulval irritation or sexual dysfunction can have a big impact, and there’s a growing acknowledgement that people are sexually active in older age and are entitled to a good quality of life. If you are in your 50s, 60s or 70s and you have an issue, you could continue to have those symptoms for a long time if you don’t seek help for them.”