Menstrual Disorder Treatment — Cost, Top Hospitals & Success Rates | MyMedicPlus

Menstrual disorders represent one of the most common reasons women seek gynaecological care, affecting an estimated 30–50% of women of reproductive age at some point in their lives. The International Federation of Gynaecology and Obstetrics (FIGO) PALM-COEIN classification system, introduced in 2011 and refined in 2018, provides a structured framework for diagnosing and treating abnormal uterine bleeding (AUB).

The PALM-COEIN acronym encompasses both structural and non-structural causes: PALM — Polyp, Adenomyosis, Leiomyoma (fibroid), Malignancy/hyperplasia; COEIN — Coagulopathy, Ovulatory dysfunction, Endometrial (primary endometrial disorder), Iatrogenic, Not yet classified. Treatment is directed at the underlying cause identified through systematic workup, which typically includes menstrual history (PBAC score for HMB quantification), pelvic ultrasound, and targeted investigations such as haematological screening for coagulopathy, hormonal profiles, and endometrial biopsy when indicated.

The main clinical categories addressed in this guide are: heavy menstrual bleeding (HMB, formerly menorrhagia), dysmenorrhoea (primary and secondary), amenorrhoea (primary and secondary), and irregular bleeding patterns including intermenstrual and postcoital bleeding.

Heavy Menstrual Bleeding (HMB)

Defined clinically as menstrual blood loss that interferes with physical, emotional, social, or material quality of life, regardless of measured volume (>80 mL/cycle historically). Affects 20–30% of women of reproductive age. Common PALM-COEIN causes include:

• Leiomyoma (fibroids, AUB-L): Submucosal fibroids most significantly cause HMB by distorting the uterine cavity. Intramural fibroids >3 cm may also contribute.
• Adenomyosis (AUB-A): Ectopic endometrial glands within the myometrium; causes HMB and dysmenorrhoea. Increasingly diagnosed on transvaginal ultrasound using morphological MUSA criteria.
• Coagulopathy (AUB-C): Inherited bleeding disorders (von Willebrand disease — present in 13–20% of women with HMB) or acquired (anticoagulant therapy).
• Ovulatory dysfunction (AUB-O): Irregular or absent ovulation leading to unopposed oestrogen stimulation; causes irregular, often heavy bleeding. Includes PCOS, thyroid disorders, hyperprolactinaemia, and perimenopause.
• Endometrial disorder (AUB-E): Impaired local haemostatic mechanisms without structural pathology.
• Polyp (AUB-P): Endometrial or endocervical polyps causing irregular and/or heavy bleeding.

Dysmenorrhoea

• Primary dysmenorrhoea: Painful periods without pelvic pathology; caused by excess prostaglandin F2-alpha-driven uterine contractions and ischaemia. Onset typically within 1–2 years of menarche.
• Secondary dysmenorrhoea: Pelvic pain associated with an identifiable cause — most commonly endometriosis, adenomyosis, uterine fibroids, or pelvic inflammatory disease. Onset usually later; pain may not correspond to menstruation.

Amenorrhoea

• Primary amenorrhoea: No menstrual period by age 15 (with secondary sex characteristics) or by age 13 (without). Causes include Turner syndrome, androgen insensitivity, Mullerian agenesis.
• Secondary amenorrhoea: Cessation of menstruation for >3 months in a woman with previously regular cycles, or >6 months in a woman with irregular cycles. Workup follows a hypothalamic-pituitary-ovarian-uterine axis approach: hypothalamic (functional hypothalamic amenorrhoea — low GnRH from stress, low weight, over-exercise), pituitary (hyperprolactinaemia, Sheehan syndrome), ovarian (PCOS, POI), uterine (Asherman syndrome).

PCOS (Polycystic Ovary Syndrome)

The most common endocrine disorder in reproductive-age women (5–15%), causing oligomenorrhoea/amenorrhoea, hyperandrogenism, and polycystic ovarian morphology on ultrasound. Diagnosed using Rotterdam criteria (2 of 3 criteria required). Associated with insulin resistance, metabolic syndrome, and endometrial cancer risk from unopposed oestrogen.

Any woman whose menstrual disorder significantly impairs quality of life, causes anaemia, or suggests an underlying pathology warrants assessment and treatment. Key assessment steps:

• Menstrual history: Frequency, duration, regularity, blood loss (PBAC score, pad/tampon usage, flooding, clots), pain severity (VAS score), and impact on daily functioning.
• NICE NG88 (Heavy Menstrual Bleeding): Women with HMB should have a full blood count. Pelvic and transvaginal ultrasound is first-line imaging to identify structural pathology. Endometrial biopsy is indicated in women >45 with intermenstrual bleeding, failed medical treatment, or risk factors for endometrial cancer.
• Coagulopathy screening: Recommended for women with HMB since menarche, strong family history of bleeding disorders, or prior significant bleeding events — screen with FVIII, vWF antigen and activity.
• Hormonal profiling: FSH, LH, oestradiol, testosterone, DHEAS, TSH, prolactin for amenorrhoea and suspected ovulatory dysfunction.
• Fertility considerations: Treatment strategy must account for desire for future fertility — uterine-preserving options preferred; LNG-IUS, endometrial ablation, and hysteroscopic myomectomy are suitable fertility-sparing choices.

Heavy Menstrual Bleeding (HMB) — NICE NG88 Treatment Pathway

• LNG-IUS (Mirena 52 mg) — First-line: Levonorgestrel intrauterine system reduces menstrual blood loss by 90–95% at 12 months in most women. It is the most effective medical treatment for HMB, superior to oral progestogens and tranexamic acid. Also treats adenomyosis-related HMB. NICE NG88 recommends offering the LNG-IUS as first-line treatment in women with HMB without underlying structural pathology when long-term contraception is acceptable.
• Tranexamic acid: Antifibrinolytic — 1 g three times daily from day 1 of bleeding for up to 4 days per cycle. Reduces blood loss by 40–60%. Non-hormonal; suitable for women seeking pregnancy. Can be combined with NSAIDs.
• NSAIDs (e.g., mefenamic acid 500 mg, ibuprofen 400–800 mg): Reduce blood loss by 25–35% and treat concurrent dysmenorrhoea. Most effective when started 1–2 days before menstruation.
• Combined oral contraceptive pill (COC): Reduces blood loss by 40–50% and provides cycle regulation; also treats primary dysmenorrhoea and manages PCOS-related irregular bleeding.
• Oral progestogens (norethisterone 5 mg, medroxyprogesterone acetate): Effective for cycle control and HMB management; used in anovulatory cycles. Long-term norethisterone is less effective than LNG-IUS. Depot medroxyprogesterone acetate (DMPA, Depo-Provera) induces amenorrhoea in ~50% of women at 1 year.
• GnRH analogues (goserelin, leuprorelin): Induce medical menopause; highly effective for HMB and fibroids as pre-surgical down-regulation (up to 3–6 months). Add-back hormone therapy required for courses beyond 3 months to prevent bone density loss.

Surgical Treatment for HMB

• Endometrial ablation: Destruction of the endometrium using second-generation devices — NovaSure (bipolar radiofrequency impedance-controlled ablation, 90-second procedure), ThermaChoice (thermal balloon), Microwave Endometrial Ablation (MEA). Patient satisfaction ~80% at 5 years; 20–30% of women achieve amenorrhoea. Requires exclusion of uterine malignancy and is contraindicated in women desiring future fertility. Outpatient/day-case procedure.
• Hysteroscopic myomectomy: Resection of submucosal fibroids (FIGO type 0, 1, 2) using a resectoscope; fertility-preserving. Success rate 80–95% for symptom control in eligible lesions.
• Uterine fibroid embolisation (UFE): Radiological occlusion of uterine artery branches; reduces fibroid volume 40–60%, HMB improvement in 85–90%. Preserves uterus; fertility outcomes variable — not recommended as a primary fertility-preserving procedure.
• Hysterectomy: Definitive treatment for HMB; 100% amenorrhoea rate. Reserved for cases where medical and conservative surgical treatments have failed or are declined, or when there is concurrent pathology (e.g., large fibroids, severe adenomyosis). Laparoscopic approach preferred when feasible.

Dysmenorrhoea — Treatment

• Primary dysmenorrhoea: NSAIDs (ibuprofen, naproxen, mefenamic acid) are first-line — start 1–2 days before expected menstruation; effective in 70–80% of women. COC is highly effective for women also requiring contraception. Transcutaneous electrical nerve stimulation (TENS) and heat therapy are non-pharmacological options.
• Secondary dysmenorrhoea (endometriosis/adenomyosis): Hormonal suppression is central — COC, progestin-only pill, LNG-IUS (Mirena), depot medroxyprogesterone, etonogestrel implant. Dienogest 2 mg daily is a highly effective progestogen with specificity for endometrial tissue. GnRH analogues (with add-back) for severe cases. Surgical laparoscopic excision of endometriosis remains the gold standard for confirmed moderate-to-severe disease.

Amenorrhoea — Treatment by Cause

• Functional hypothalamic amenorrhoea (FHA): Nutritional rehabilitation, weight restoration, stress reduction, and management of excessive exercise. CBT is effective. Once energy balance is restored, spontaneous menstrual recovery occurs in the majority.
• Hyperprolactinaemia: Dopamine agonist (cabergoline preferred over bromocriptine for tolerability) normalises prolactin and restores ovulation in 80–90% of cases.
• PCOS-related amenorrhoea/oligomenorrhoea: Lifestyle modification (weight loss, exercise) is first-line for overweight women — 5–10% body weight loss restores ovulation in many. COC for cycle regulation and endometrial protection. Metformin improves insulin sensitivity and cycle regularity. Clomiphene/letrozole for ovulation induction in women seeking fertility.
• Asherman syndrome (intrauterine adhesions): Hysteroscopic adhesiolysis under direct visualisation, followed by oestrogen therapy to promote endometrial regeneration and balloon/intrauterine device stenting to prevent re-adhesion. Recurrence rate 20–60% depending on severity (AFS score).

• Quality of life: Effective HMB treatment resolves iron-deficiency anaemia, reduces fatigue, and allows women to participate fully in work, education, and social activities.
• Pain relief: Treatment of dysmenorrhoea — particularly with NSAIDs or hormonal suppression — significantly reduces abdominal and pelvic pain, decreasing analgesic use and sick days.
• Fertility preservation: Treating underlying causes (fibroids, endometriosis, Asherman syndrome, PCOS, FHA) restores fertility potential in many women.
• Endometrial cancer prevention: Hormonal treatment of anovulatory cycles (particularly in PCOS) prevents endometrial hyperplasia from unopposed oestrogen exposure. Regular withdrawal bleeds or progestogen therapy reduces long-term cancer risk.
• Avoiding surgery: Effective medical management (LNG-IUS, tranexamic acid, hormonal therapy) avoids hysterectomy in the majority of women with HMB.
• Minimal invasive surgical options: Endometrial ablation and hysteroscopic myomectomy are day-case procedures with rapid recovery (1–2 days), far less morbidity than hysterectomy.

• LNG-IUS: Irregular spotting or amenorrhoea (welcomed by most, unwelcome by some). Insertion discomfort — paracervical block or misoprostol may help in nulliparous women. Rare risk of perforation (1–2/1,000) and expulsion (3–5% within 5 years). Does not protect against STIs.
• Combined oral contraceptive: Small absolute increase in VTE risk (particularly in the first 3 months); contraindicated in women with migraines with aura, uncontrolled hypertension, current VTE, or over 35 years of age who smoke. Cervical cancer: modest risk increase with long-term use.
• GnRH analogues: Menopausal side effects (VMS, bone loss) if used beyond 3–6 months without add-back therapy. Not for long-term use without add-back.
• Endometrial ablation: Post-ablation tubal sterilisation syndrome (haematometra in women who have been sterilised). Ongoing symptoms requiring reoperation in 15–20% of women. Hysterectomy rate at 5 years approximately 15–20%. Subsequent endometrial biopsy is more difficult, masking future pathology — important in women at elevated endometrial cancer risk.
• Hysteroscopic myomectomy: Risk of uterine perforation, fluid overload (from distension medium), haemorrhage; recurrence of fibroids in 20–50% at 5 years.
• Hysterectomy: Major surgery with risks of haemorrhage, infection, bladder/ureter injury, VTE, prolonged recovery. Laparoscopic route reduces complications vs. abdominal approach. Vaginal vault dehiscence is a rare but serious complication of laparoscopic hysterectomy.
• Asherman syndrome treatment: Recurrence of adhesions in 20–60% (higher with severe initial disease); risk of placenta accreta in subsequent pregnancies.

• Medical treatment review: Reassess at 3 months after initiating therapy (LNG-IUS, tranexamic acid, hormonal treatment) to assess symptom control, side effects, and tolerability. LNG-IUS review at 6 weeks post-insertion for threads check; then annually.
• Full blood count: Repeat at 3–6 months after treatment initiation to confirm resolution of iron-deficiency anaemia; continue iron supplementation as needed.
• Ultrasound surveillance: Fibroids should be monitored 6–12 monthly with ultrasound, especially in perimenopausal women (high-grade suspicion for leiomyosarcoma if rapid growth — rare, 1/500 fibroids).
• Endometrial surveillance: Women on unopposed oestrogen (PCOS, FHA treated with oestrogen-only, tamoxifen) require endometrial surveillance if amenorrhoeic for >12 months — endometrial biopsy or ultrasound for endometrial thickness.
• Post-ablation: Review at 3 months post-procedure for symptom assessment. PBAC score to document improvement. Annual cervical screening remains necessary.
• PCOS: Annual metabolic screening (fasting glucose/HbA1c, lipid profile, blood pressure, BMI) given the elevated risk of type 2 diabetes and cardiovascular disease.
• Fertility outcomes: Women treated for Asherman syndrome or endometriosis who wish to conceive should have fertility review 6–12 months after treatment if natural conception has not occurred.

Treatment costs vary significantly by setting and modality:

• Medical management (India): LNG-IUS (Mirena) costs approximately INR 8,000–12,000 (device cost) plus INR 500–2,000 for insertion; lasts 5–8 years, making the annual cost very affordable. Tranexamic acid tablets cost INR 10–30/day. NSAIDs are widely available and inexpensive (<INR 5–15/tablet). COC pills cost INR 100–300/month.
• Medical management (UK/NHS): All first-line treatments (LNG-IUS, tranexamic acid, mefenamic acid, COC) are available on NHS prescription at standard prescription charge (~£9.90/item as of 2026, free with PPC). GnRH analogues (goserelin implants) are significantly more expensive (~£150–300/month) but available on NHS with appropriate indication.
• Endometrial ablation (India): NovaSure ablation: INR 40,000–80,000 in private hospitals; may be available in government hospitals at subsidised or no cost. Day-case procedure.
• Endometrial ablation (UK): Available on NHS as a day-case procedure when NICE criteria are met. Private: £1,500–3,500.
• Hysterectomy (India): INR 50,000–2,00,000 in private hospitals depending on approach (laparoscopic vs. abdominal) and hospital tier. Covered under government insurance schemes (Ayushman Bharat) for eligible patients.
• Hysteroscopy (India): Diagnostic: INR 5,000–15,000; operative (myomectomy, polyp resection): INR 20,000–50,000 in private settings.

• Iron supplementation: Oral ferrous sulfate (200 mg twice daily) or intravenous iron (ferric carboxymaltose) for iron-deficiency anaemia secondary to HMB. Treats anaemia but not the underlying bleeding disorder.
• Dietary and lifestyle modification: Weight loss of 5–10% in overweight women with PCOS restores ovulation in ~55% of cases and reduces HMB. Low-GI diet and regular aerobic exercise improve insulin sensitivity.
• TENS (transcutaneous electrical nerve stimulation): High-frequency TENS reduces primary dysmenorrhoea pain in clinical trials; non-pharmacological option with no systemic side effects.
• Heat therapy: Continuous low-level topical heat (heat patches, heating pads at 38.9°C) as effective as ibuprofen for primary dysmenorrhoea pain in some studies.
• Acupuncture: Some systematic reviews suggest benefit for primary dysmenorrhoea; evidence is limited by methodological heterogeneity. May be considered as an adjunct.
• Cognitive behavioural therapy (CBT): Effective for chronic pelvic pain associated with endometriosis and secondary dysmenorrhoea, particularly for pain catastrophising and pelvic floor muscle dysfunction component.
• For women seeking uterus-preserving fibroid treatment: Uterine fibroid embolisation (UFE), MRI-guided focused ultrasound (MRgFUS), and laparoscopic myomectomy are alternatives to hysterectomy where fibroids are the primary cause of HMB.