Periods - what's normal and what's not?

It can be hard to know what is ‘normal’ when it comes to periods, as every person’s menstrual cycle is unique to them. However, if bleeding is affecting your quality of life and stopping you from doing physical and social activities, it’s time to talk to your General Practitioner. In this article, Oxford Women’s Health Gynaecologist Dr Madeleine Stringer shares information on the many causes of abnormal bleeding and what can be done to treat and manage it.

It's estimated that up to 25% of women will experience heavy bleeding but many don’t seek help straight away. This is often because we find it difficult to describe the heaviness of our periods or know what is normal.

If bleeding is so heavy that you must change your period products more than every two hours; it happens irregularly; it lasts longer than seven days; or it is disrupting your everyday life, it’s time to seek advice. Abnormal bleeding can happen at any age, with intermenstrual bleeding occurring outside of the monthly menstrual phase; post-coital bleeding happening after sex; and post-menopausal bleeding appearing more than 12 months after your final period.

To work out what might be causing heavy bleeding, your GP may ask you what products you are using; how often you are changing them; if you need to wake up in the night to manage the bleeding; and if your period is causing you to miss days at school or work. Even if your main worry is not the bleeding itself, and you are more concerned about pain or fertility issues, let your doctor know as it could help to narrow down what is causing your symptoms.

There are many reasons for abnormal uterine bleeding. It may be coming from a physical problem, such as endometrial polyps; leiomyomas (fibroids); adenomyosis; caesarean section scars; retained products after having a baby; and sometimes cancer. Other reasons may include coagulation disorders; ovulatory dysfunction (such as polycystic ovarian syndrome); blood vessel issues; and endometrial causes, such as infection or inflammation. Some lifestyle factors, medical conditions and medicines can also affect your menstrual cycle.

To determine the cause of the bleeding, your GP will complete an assessment of the size of the uterus and assess the cervix, vulva, and vagina. They may need to refer you for a pelvic ultrasound and/or specialist treatment, and request that swabs, a Pipelle endometrial biopsy, and a hormone profile are completed. In many cases it is safe to start treatment without investigation if there are no red flag symptoms.

Following the initial assessment, your GP will discuss treatment options, which include Tranexamic acid, which is highly effective at reducing bleeding. Anti-inflammatories are also effective, and the two treatments are often used together. 
 

Dr Madeleine Stringer 

For some people, they will benefit from a hormonal treatment such as the combined contraceptive pill or Mirena intra-uterine device, which both help thin the endometrium (lining of the womb) and result in lighter bleeding. Any treatment can take time to work, so we would usually check up again in another six months.

Teenagers
As teens are still maturing in their endocrine development, irregular and heavy bleeding is common in this age group. We don’t often find a physical cause, and many cases will improve with time as the cycle regulates. If the bleeding is heavy or causing anaemia, then treatment should be considered and can usually be safely started without many investigations.

Perimenopause
During perimenopause there are increased risk factors for endometrial hyperplasia (enlargement) or cancer, so we are more likely to recommend investigations. Sometimes patients in this age group have been using contraception for some time and when it stops, an underlying problem may become noticeable that contraception was managing. There may a period of overlap where you need to take contraception and HRT at the same time, which your GP will discuss with you.

Bleeding after sex
There are a few factors to rule out when someone is experiencing bleeding after sex. While it is important to exclude cervical cancer with an examination, HPV and smear test from the cervix, the most common cause is infection, which can be tested with a swab and is easily treatable. It is important to let your GP know for how long the bleeding has been happening; if you have any new sexual partners; if there is abnormal discharge; and what contraception you are using to assist with the diagnosis. It may be that your contraception needs to be adjusted as certain medications, such as Depo-Provera, can thin the endometrium or cause the vaginal walls to become thin and dry.

If your GP refers you for a specialist appointment, we may recommend further investigations if you haven’t already had an ultrasound or a hysteroscopy. Along with medications, there are a variety of surgical treatments available if needed, depending on the cause of the abnormal bleeding.
 

Introducing Ginny

With a background as a Registered Comprehensive Nurse, Ginny Eggleston made the decision to retrain as a Clinical Psychologist and qualified in 2004.

She has since worked in a range of predominantly physical health areas, including respiratory, haematology, child oncology, consult liaison, and oncology. She also spent three years as a Research Fellow working on a treatment for depression study at the University of Otago, Christchurch.

Ginny’s special clinical interests include supporting people with their physical and emotional wellbeing, mood, and anxiety; through grief, loss, and various life changes; and adjusting to physical health conditions. She has trained in Cognitive Behavioural Therapy (CBT), Schema Therapy (ST), Acceptance and Commitment Therapy (ACT), Emotionally Focussed Therapy (EFT), and other mindfulness-based therapies.
 

Ginny Eggleston

In her spare time, she enjoys spending time with her family and friends, reading, listening to music, and watching movies. She also keeps active by enjoying hill, park, and beach walks with her dog; doing yoga, and mindfulness.

Find an Oxford Women's Health Clinic near you

As well as being in the Forté Health building in central Christchurch, you’ll find Oxford Women’s Health clinics located throughout the South Island.

We hold specialist satellite clinics in Blenheim, Greymouth, Pegasus, Ashburton, Queenstown, and Invercargill to make sure South Island women can benefit from our expertise.

In Queenstown, we’re based at the Queenstown Centre of Medical Excellence at Kawarau Park. The Oxford Women’s Health clinic is located in unit G, opposite the Southern Cross Hospital on the Frankton side of Queenstown. 
 

We also hold clinics at the Pegasus Medical Centre; at Eastfield Health in Ashburton; Coastal Health in Greymouth; and at the Southern Cross Hospital in Invercargill. In Blenheim, you’ll find us at the Churchill Private Hospital and Specialist Centre, on the grounds of the Wairau Hospital. You’ll find more details about our locations, HERE.
 

Welcome back, Kate

We are delighted to advise that after spending some time overseas, Dietitian Kate Collins has returned to Oxford Women’s Health. As a New Zealand Registered Dietitian, Kate is passionate about how nutrition can be used to help manage the symptoms associated with many women’s health issues.

Her special clinical interests include nutrition in pregnancy (including management of hyperemesis gravidarum); diabetes (including gestational diabetes); pelvic pain; Polycystic Ovary Syndrome (PCOS); nutrition management after bariatric surgery; endometriosis; irritable bowel syndrome (IBS); and disordered eating.

Kate has recently returned to Oxford Women’s Health after spending time in the UK where she gained experience working at NHS hospitals in Liverpool and London. During this time, she worked across departments in women’s health; gynaecology oncology; diabetes; bariatric surgery (including pregnancy after bariatric surgery); maternal nutrition; and renal and general medicine.

Prior to heading overseas, Kate worked at Oxford Women’s Health from 2022 to 2023. She also has experience working at Christchurch Women’s Hospital where she provided specialist
 

Kate Collins 

outpatient support for gestational diabetes and women’s health conditions; has worked as a diabetes dietitian; and as a rehabilitation dietitian in chronic pain management.

Kate sees her role as being that of a client advocate, working with people to seek a diagnosis, manage pain, interpret clinical information, and learn more about the function of the human body.

“I’m passionate about empowering women to understand their bodies and feel confident using nutrition as a tool to reduce symptoms they may be experiencing,” she says.

Understanding stress and urge incontinence

Urinary incontinence is far more common than most people realise—and far less talked about. As a pelvic health physiotherapist, Niamh Clerkin says she sees women in her clinic of all ages suffering with varying conditions of bladder leakage, urgency and OAB (overactive bladder). One in four New Zealanders will experience incontinence and it can be a hugely embarrassing condition to discuss. You're not alone, and there is so much that can be done to help. In this article, Niamh breaks down two of the most common types: stress incontinence and urge incontinence.

What is stress incontinence?
Stress incontinence happens when there’s a leak of urine during activities that increase pressure inside your abdomen, such as:

·       Coughing or sneezing
·       Laughing
·       Jumping or running
·       Lifting something heavy.

These actions put pressure on the bladder and pelvic floor. If the pelvic floor muscles are weakened or not coordinating well, they may not be able to keep the urethra closed during those moments.

Common causes include:
·       Pregnancy and childbirth
·       Menopause (due to changes in                estrogen and tissue elasticity)
·       Chronic coughing
·       High-impact exercise – such as                trampolining, rugby, and netball
·       Pelvic surgery or trauma.

What is urge incontinence?
Urge incontinence is when you feel a sudden, strong need to wee—and sometimes can’t make it to the toilet in time. It’s often associated with an overactive bladder and can be triggered by things like:

·       Hearing running water
·       Putting the key in the door
·       Cold temperatures
·       Feeling anxious or rushed.

Unlike stress incontinence, urge incontinence isn’t necessarily linked to weakened pelvic floor muscles, but more about how the bladder and brain are communicating.

Can you have both?
Absolutely. Many people experience mixed incontinence, which means they have symptoms of both stress and urge types. Recognising which symptoms are which is a crucial first step in tailoring effective treatment.

What can be done?
The most important message I share with my clients is: you don’t have to just “live with it”. 
 

Niamh Clerkin  

Bladder leaks may be common, but they are not normal. The first line of treatment is assessing your pelvic floor, trunk, and pelvic area and teaching accurate pelvic floor exercises. 

It is important to note for “some” people their pelvic floor can be high tone/overactive, so we don’t 100% always teach pelvic floor strengthening to begin with. We want the pelvic floor to work efficiently and in a coordinated way with all your other musculoskeletal systems. Like a finely tuned orchestra rather than one solo section.

Pelvic floor muscle training
Tailored exercises to strengthen and coordinate the pelvic floor muscles can make a significant difference in reducing both stress and urge symptoms. It’s not just about doing “Kegels”—it’s about doing the right ones, at the right time, in the right way.

Pessary/Incontinence devices
Using silicone pessaries can help support your bladder wall (similar to wearing an ankle brace for sport). Your pelvic health physiotherapist usually manages and offers this.

Bladder retraining
For urge incontinence, we work on gradually increasing the time between toilet visits and teaching techniques to reduce the urgency signals. This helps regain control over your bladder, rather than letting your bladder control you.

Lifestyle and behavioural advice
This includes fluid intake, caffeine management, bowel health, weight considerations, and strategies to support the bladder in daily life.

Musculoskeletal and posture
Whether it is an old back or new hip injury, these conditions contribute significantly to our pelvic floor and therefore bladder and bowel systems. Treating each person as an individual ensures a client centred approach and this is key to success and achieving your outcomes.

For more information, check out the  Continence NZ website HERE.

For more pelvic floor information, see this guide from my colleagues in Wellington.