Dear Dr Mitchell,

After giving birth to my son at age 21, I was placed on a low dose contraceptive pill. Approximately three years later I started experiencing horrible pain with my period, which would last the entire duration of the cycle. I changed the brand of pill believing this would help, but it got worse - I not only experienced horrific pain but would vomit. I took myself off contraceptives and visited doctors who told me that I probably had fibroids. After coming off the contraceptive and changing my diet by cutting out MSG, I noticed that sometimes I would not have pain during menstruation, if I did experience pain it was mild and lasted only the first or until the second day of my cycle. It has been over two years since experiencing severe pain during my cycle, but now I am 29 and am experiencing a cycle which tends to last up to seven days, compared to previous cycles which lasted three to four days. Not only am I experiencing a prolonged cycle, but having sexual intercourse after my cycle causes bleeding. I also notice that I spot before my cycle begins. I know these things aren't normal. What is causing this?

The painful heavy menstrual period that you experience is significant and definitely needs to be investigated. The most common cause of heavy menstrual bleeding is uterine fibroids. This is a common condition in women in the reproductive age group and tends to be particularly common in black women who also tend to grow much bigger fibroids than women who are white. Other causes of painful heavy menstrual flow include endometriosis, adenomyosis (endometriosis in the muscles of the uterus) and pelvic inflammatory disease.

The combined low dose oral contraceptive pill and other hormonal contraceptives including depo provera usually work very well in significantly reducing the menstrual flow and the severe pains that some women normally experience. In your case unfortunately this did not work. The bleeding that you experience after intercourse first after your menses needs to be further evaluated as this is abnormal. This may be due to cervical polyps; submucosal fibroids (fibroids in the cavity of the uterus), inflammation of the cervix, precancerous changes or even cancer of the cervix.

You need to go to your doctor for a detailed physical examination and a cervical smear (Pap test). A pelvic ultrasound should definitely be done to check on the ovaries, the size of the uterus and also the lining of the uterus. This will definitely help to identify uterine fibroids. Unfortunately, ultrasound is really not good for diagnosing endometriosis so you will need to have a diagnostic laparoscopy done to look at your pelvic organs if your doctor suspects that you have endometriosis. This is a simple outpatient procedure and with the information obtained will certainly help in your subsequent management.

The prolonged menstruation and painful periods really has very little to do with getting older and the exact cause needs to be determined so that the appropriate treatment may be undertaken to improve your quality of life.

Consult your doctor and follow his recommendations by doing the investigations ordered.

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