HOPE

Advice on starting a new treatment if you are struggling with symptoms or because your surgery has been cancelled/postponed

If you are not using any medical treatment currently but would like to start something new, either because you are struggling with symptoms or because your surgery has been cancelled/postponed.

1. Iron tablets

If your bleeding is very heavy, this may result in low iron levels (anaemia). Your GP may advise iron tablets and can prescribe these electronically for you to pick up at a pharmacy. It is important to keep hydrated and eat a healthy diet to prevent constipation while taking these tablets.

2. Tranexamic acid

These are non-hormonal tablets that lessen the amount of blood lost during a period. They are recommended on days 1-5 of your period and may be taken three times per day.

Important: Tranexamic acid is not suitable for people who have had previous blood clots in their legs or lungs. These medications do NOT work as a contraceptive.

3. Progestogen only pill (POP):

The desogestrel containing POP (e.g. Cerazette, Cerelle, Feanolla) is currently recommended for people who want to start a hormonal contraceptive during the pandemic. This is because it is safe for the majority of people and does not require any checks of blood pressure or weight before starting it.

Important: remember that you should not stop the POP if you get some bleeding, it is designed to be taken every day. Stopping and starting the POP is likely to result in irregular bleeding and it won’t work as a contraceptive. It can often take a number of months for bleeding to settle down, so it’s worth persevering for 3 months at least.

4. Provera (Medroxyprogesterone acetate; MPA) tablets:

If you have tried a double dose of a desogestrel POP previously and it didn’t work for you or even a single dose gave you unacceptable side-effects (it suits most people very well, so please don’t expect side-effects...) then our next recommendation would be Provera tablets. These need to be taken three times a day and we would suggest starting at a dose of 10mg, though this can be reduced to 5mg if it is working for your symptoms but you don’t like the side effects (although again it is usually very well tolerated).       

Important: Provera is not a licensed contraceptive and therefore you should use condoms as well if contraception is required. If the tablets work for you and you need contraception, you could consider asking your GP whether they are giving Depo-Provera injections currently, however, we are aware that many are not. We usually recommend at least a month’s trial before switching to ensure you don’t have side-effects as the injectable form can’t be taken out after it is given.

5. ‘Menopause injections’:

If you are really struggling with symptoms, it might be worth discussing with your GP whether you could start on a ‘menopause injection’ such as Decapeptyl or Prostap. Although these drugs are only licensed for 6 months, there are many people who use them “off-licence” for a number of years in combination with a low dose of Hormone Replacement Therapy (HRT) to protect their bones and heart/blood vessels and to reduce the associated menopausal symptoms. They can be very effective at controlling bleeding. If you are going to start this treatment we would suggest having 1-2 months of treatment without HRT and then adding HRT in, there is some evidence that this achieves better pain relief than starting them at the same time. It is worth noting that the way the drug works means that you will often get a flare in your symptoms (pain and bleeding) in the first couple of weeks of treatment, however beyond that you are likely to notice menopausal side effects (hot flushes, mood changes and sometimes joint pain) but your bleeding should stop. If after 3 months there has been no improvement, we would suggest stopping the treatment. However, if it has been effective then we recommend starting some HRT to remove/reduce the side effects and protect your bones, blood vessels and heart. This HRT should be a low-dose continuous combined preparation (i.e. it contains a low dose of both oestrogen and progestogen and the same dose is taken every day), however, it doesn’t matter whether this is a tablet or a patch. Some preparations that are commonly used include Kliovance, Tibolone [Livial] and Evorel Conti. If you have a Mirena coil (that was inserted less than 5 years ago) then you can use this as the progestogen part of the HRT and therefore only need an oestrogen. Oestrogen-only preparations commonly used include Elleste Solo (1mg), Evorel and Sandrena. Your GP will be able to discuss these options over the phone as they are very familiar with prescribing low dose HRT to those who are post-menopausal. Please note that the risks of HRT you may have heard about in the media, apply to people of menopausal age. If you are using these drugs to replace hormones taken away by the menopause injections but would not otherwise be menopausal the benefits far outweigh the risks.

Important: Menopause injections are not contraceptive. Although it is unlikely that you would conceive on them, we have seen this occur, and the effect of these injections on a developing baby are not known. Therefore, you should use condoms if you require contraception and are using this treatment.

If your surgery has been postponed

We can only imagine how disappointing it must be to have had your surgery postponed due to the pandemic, especially if you had been waiting a long time for it. Whilst there is nothing we can do to alter that situation, we would like to suggest alternative strategies to get you through the coming weeks to months as best as possible:

Current recommendations are that problematic bleeding can be managed with either medical treatment or surgical treatment as a first line. Therefore, if this was to be your first operation and you have not tried hormonal treatments before, we would strongly suggest that you read the section above on medical treatment and then discuss with your GP about starting one of the treatments that are currently available. Even if you have tried hormones before it would still be worth reading this information, as there may be different options to consider or different ways of taking a treatment that may work better for you.

Regular exercise can help regulate your hormones and have a positive impact on your menstrual bleeding. If possible, do regular exercise like walking or running or one of the many free online exercise sessions. Please listen to your body and start slowly, building up gradually as your body allows. Make sure you get outside for some daily exercise as long as you stick within current Government recommendations for social distancing/isolation.

Taking care of your diet. The current restrictions on access to shopping and limited availability of supermarket home deliveries means many people’s diets may have changed considerably. It is very important to maintain a diet rich in iron (e.g. meat, green leafy vegetables) if your menstrual blood loss is heavy. It might be worth exploring whether there are local farms or shops who are delivering some of your more familiar foods to help with this.

Trying to reduce stress and anxiety. Whilst we understand how difficult this is currently, destressing can have beneficial effects on the hormones that control your periods. We offer some suggestions for how to go about this in the section on “Emotional well-being and managing stress” below.