This introduction discusses the aetiology of menstrual problems, their presentation and investigation as well as medical and surgical management. Specific problems such as fibroid-associated bleeding, adolescent and perimenopausal bleeding and breakthrough bleeding are covered, as are other critically important problems such as premenstrual disorders, pelvic pain and dysmenorrhoea. The most common presenting menstrual problem is heavy menstrual bleeding (HMB). A woman's approach to her periods will vary through her reproductive life. After childbearing is completed, the view of the menses will alter dramatically. The longest intermenstrual interval occurs at the menarche. Menstrual irregularity is most likely to occur at the extremes of reproductive life, the incidence of anovulation increasing as the menopause approaches. Classical primary spasmodic dysmenorrhoea occurs at the onset of the menses and gets better after 1 or 2 days, whereas secondary dysmenorrhoea tends to start prior to the menses and worsens as it proceeds.

Excessive menstrual bleeding describes the clinical problems of heavy menstrual blood loss together with frequent or irregular menstruation. This chapter addresses endometrial morphology, the mechanism of menstruation and the aetiology and management of menstrual problems. A very common cause relates to ovulatory dysfunction, which typically leads to a combination of irregular bleeding and a variable volume of menstrual flow, which can lead to heavy menstrual bleeding (HMB). Clotting disorders such as von Willebrand's disease are another cause of HMB. Reduced clotting is a known feature at the time of menstruation. Pelvic pathologies such as fibroids are common, affecting between 20 and 25% of women. It is reported that around a third of women with fibroids complain of heavy menstrual blood loss. There are a number of terminologies to describe menstrual complaints such as menorrhagia, polymenorrhoea, oligomenorrhoea, polymenorrhagia and metrorrhagia.

The purpose of uterine cavity evaluation is to make an accurate diagnosis of the cause of abnormal uterine bleeding, in order that therapy can be appropriately tailored to the woman. This chapter reviews the accuracy and efficacy of currently available tests used to evaluate the uterine cavity. Uterine size can be assessed on bimanual examination; if the uterus is greater in size than 12 weeks of gestation, it may be palpable abdominally. Women with amenorrhoea (no menstrual bleeding for 6 months) should have a full history and examination. Dilatation and curettage (D&C) used to be the method of choice for assessing the uterine cavity. Other methods for assessing the uterine cavity include hysteroscopy, ultrasound, Doppler ultrasound, and outpatient endometrial biopsy. Women presenting with postmenopausal bleeding require urgent referral for pelvic ultrasound and further testing, with endometrial biopsy and/or hysteroscopy undertaken depending on the initial ultrasound result.

Management of excessive menstrual bleeding has changed over the past two decades with the promotion of effective medical treatments and in particular the use of the levonorgestrel-releasing intrauterine device. The aims of therapy are to reduce blood loss, reduce the risk of anaemia and improve quality of life. Non-hormonal treatment options for excessive menstrual bleeding are non-steroidal anti-inflammatory drugs, antifibrinolytics, and etamsylate. Intrauterine administration of levonorgestrel, oral and intramuscular progestogens, oestrogen/progestogen combinations, and antiprogestogens are used as hormonal treatments for excessive menstrual bleeding. Plasminogen activator inhibitors have been promoted as a treatment for excessive menstrual bleeding because of increased endometrial fibrinolytic activity in women. The use of progestogens is based on the erroneous concept that women with excessive menstrual bleeding principally have anovulatory cycles and require progestogen supplementation. From clinical experience, combined oral contraceptives (COCs) are generally considered to be effective in the management of dysfunctional menstrual bleeding.

The surgical options for the management of menstrual problems are chiefly endometrial ablation as a uterine conserving procedure and either total or subtotal hysterectomy, which can be performed by a number of routes. Endometrial ablation represents the most thoroughly evaluated surgical treatment to date. Endometrial techniques are divided into first generation and second generation techniques. First generation techniques include transcervical resection of the endometrium (TCRE), rollerball endometrial ablation (RBEA), and endometrial laser ablation (ELA). They offer the benefit of direct vision and require a fluid distension media. Second generation techniques are: thermal balloon ablation, microwave endometrial ablation (MEA), NovaSure, Hydro ThermAblator, and cryosurgical ablation. Second-generation ablative techniques have been evolved to simplify the technique and ideally place endometrial ablation safely in the hands of all gynaecologists. Total hysterectomy is the only surgical treatment for menstrual problems that guarantees amenorrhoea. Satisfaction with hysterectomy is higher than that with ablation.