Women in West Cork are fortunate to have a gynaecology service based in Bantry General Hospital. This is a satellite of Cork University Maternity Hospital (CUMH) gynaecology service. Two clinics, one morning and one afternoon, run on the third Friday of every month. Dr Aenne Helps is the Bantry lead gynaecologist. In order to be seen in Bantry and not in Cork city, your GP must select Dr Aenne Helps as consultant of choice. If they do not, your appointment will be in Cork.
I work alongside Dr Helps in Bantry, and this allows for more patients to be seen, resulting in a waiting time of only two to three months.
Gynaecology procedures such as a pelvic scan and hysteroscopy are undertaken in Bantry. Hysteroscopy is an investigation, done by the consultant, to look up inside the womb. Unfortunately, West Cork GPs are currently not able to access a pelvic scan in Bantry directly; they need to refer to Gynaecology in Bantry and we will arrange the scan for you.
My periods have changed, doctor, should I worry?
A change to a woman’s periods can mean nothing or can be a sign of an underlying problem. Rarely, it is an early warning symptom of cancer. What women want to know is when to worry: how abnormal is abnormal? Hence I’m going to run through the kinds of changes that might happen to the menstrual cycle and what they may signify.
What is normal?
Periods usually start between ages of 12- and 13-years and can take a year or so to settle into a pattern. Not every woman has a bang-on four-week cycle. Your period will arrive if the egg you produced that month was not fertilised. A woman will shed the blood and endometrium, or womb lining that is not needed to nurture a foetus. This results in a bleed of a certain duration; some women bleed two or three days, others from seven to 10 days. When that bleed finishes, there should be no more bleeding until the next period begins. The interval between periods is counted from the first day of one period to the first day of the next. This is usually the same, give or take; one to three days for a woman throughout her reproductive years. This interval is classically 28 days or four weeks but can be 21 days or 35 days. Whatever the interval, that is what is normal for that woman.
Changes to menstrual pattern Flow: In the absence of a recent pregnancy, if your periods become heavier for a duration of three months or more, you should see your GP as this may need investigation.
Intermenstrual bleeding (IMB) – Bleeding in-between periods: It can be normal to have spotting or a very light bleed at the time of ovulation, which usually happens two weeks after the first day of your last period. However, if you start to bleed or spot in-between your periods and this lasts for three or more months, see your GP. The bleeding might be unprovoked and random or only after sex and can occur at any time in the cycle.
Interval between periods changing: Whatever the number of days in between your periods, that is what is normal for you. If you notice a change to the interval going on for more than three months, you need to go see your GP.
Oligomenorrhoea: If your periods become more spaced-out with a cycle length of seven or more days longer than usual for more than three months, this is called oligomenorrhoea and is a significant change that needs investigation.
Polymenorrhoea: Periods might begin to come closer together than usual; this is called polymenorrhoea. If your periods have been closer together for more than three months, see your GP.
Premenstrual Syndrome (PMS): PMS has been the topic of one of my previous West Cork People articles, which can be accessed online. Changes to a woman’s cycle are not only about the bleeding. PMS can start to occur for the first time or become very severe over the age of 40. If you are noticing cyclical emotional and or physical symptoms occurring in the week or so before your period starts, which completely disappear once the bleeding starts, this is PMS; go see your GP.
What check-ups do I need?
History, history, history… Most gynaecological problems can be diagnosed by your doctor taking a careful history.
The number of times I have asked: “Are there any problems with your periods?” and get the answer: “No, they’re normal, doctor” only for careful questioning to reveal that the woman is flooding for 10 days a month, changing tampons every one to two hours for the first three days. What is normal for one woman is not always normal.
If you feel your periods are different in any way for more than three months, your GP needs to know the following:
• How many days do you bleed for?
• How heavy? Do you get clots or flood through sometimes? How often do you change your tampon/sanitary pad on a heavy day
• Is there pain and has that changed?
• Once your period has finished and that includes the last bit when the tail end of a period can be just some brown spotting; when that is all done: how many days until the next one starts again? Has that gap between your periods changed?
• After one finishes and before the next one starts; is there any pink, brown or red spotting in-between?
• Is there bleeding; even pink spotting, after sex?
• Do you have any new urinary symptoms of cystitis or are you passing urine very often?
• Are there any changes to your vaginal discharge?
Examination
• Internal as well as speculum examination.
• Infection screen. Genital infection with Chlamydia can cause IMB, as well as bleeding after sex.
• Blood test. If you have very heavy bleeding your GP will want to check you are not anaemic.
• Pelvic scan to rule out problems in the womb, the ovaries and the endometrium or womb lining.
• If the pelvic scan is abnormal, your GP may refer you to see a gynaecologist. You can choose to be seen in Bantry.
• Smear test. Abnormal cervical cells can result in IMB or bleeding after sex. However if you are within the usual recall time since your last smear; within three years for women under 45 and five years for women over 45, then there is no point taking a smear, as HSE screening labs will not analyse it.
If your examination shows that your cervix looks abnormal in any way, your GP will refer you for a procedure called a colposcopy, which looks at the cervix in detail. This will be in CUH in Cork city.
What might be wrong, doctor?
• Sexually transmitted disease: Chlamydia can cause IMB or bleeding after sex.
• Ovarian cysts: Certain types of ovarian cysts can cause changes to your bleeding.
• Premature Ovarian Insufficiency (POI): POI was the topic of one of my previous articles, which can be accessed online. POI means that menopause occurs under the age of 40 and has significant health implications. POI is often diagnosed late and that can have catastrophic implications, not just for that woman’s fertility but for her overall health and longevity. The European Society of Human Reproduction and Embryology, ESHRE, 2024 updated guidance on the diagnosis and management of POI contains the amended diagnostic criteria of; menstrual disturbance {amenorrhoea or oligomenorrhoea} for at least four months and an FSH (follocle stimulating hormone) over 25IU/L on one occasion only, taken at any time in the cycle, under the age of 40 years. It is vital to diagnose and treat POI early in order to avoid the health sequelae of osteoporotic fractures, heart attacks, stroke and early dementia.
• Cervical cancer: Abnormal cervical cells can cause IMB and bleeding after sex.
• Fibroids: This is a completely benign condition involving the muscle layer of the womb, the myometrium. This can become thickened or knotty occurring in either a diffuse way, throughout the wall of the womb, called adenomyosis, or in a more localised way, which is called a fibroid. This condition can be seen on a pelvic scan. Fibroids and adenomyosis can result in very heavy bleeding. They do not, however turn into cancer and do not necessarily need to be removed.
Endometrial polyps
Benign polyps will cause
• IMB: These are easily treated by removing at hysterocopy, which can be done for you in Bantry. Having an endometrial poly does not put you at increased risk for endometrial cancer.
• Endometrial cancer: The incidence of cancer of the womb lining or endometrium has increased 50-fold in the last 25 years. In the past, it was mainly seen in women over 60. We are now seeing women diagnosed at younger ages. Now, being aged 45 years or over is regarded as a risk factor. The increase in prevalence is thought to be driven by the obesity epidemic because obesity is a major risk factor for endometrial cancer. Other risk factors include a history of polycystic ovary syndrome, not having children, Type 2 diabetes and a family history of endometrial cancer. Overstimulation of the endometrium is also a risk factor and this will occur if you use the oestrogen component of your HRT but not the progestogen. Caught early, endometrial cancer has a very good prognosis with up to 95 per cent of women being alive, well and disease-free five years after hysterectomy plus removal of ovaries following a diagnosis of endometrial cancer. If the diagnosis is made later, after the cancer has spread outside the womb, the prognosis is much worse.
If you have a change to your periods – perhaps they are heavier or you get some bleeding in-between, please do not assume that this is just a sign of getting older or put it down to perimenopause.
Yes, women in perimenopause often get much heavier periods because of the hormone fluctuations occurring at this time and sometimes the bleeding becomes completely chaotic but it can also be an early sign of endometrial cancer; do not ignore.
If your GP feels it necessary for you to see a gynaecologist, you can choose to be seen in Bantry rather than CUMH. Your GP, when doing the gynaecology referral, must select consultant Dr Aenne Helps in order to ensure you are seen in Bantry.
I hope this has been helpful.
