Red flags and referrals
Red flags and referrals
While many menstrual symptoms can be managed conservatively, certain features should prompt referral. These include very heavy or prolonged bleeding, bleeding between periods, bleeding after sexual intercourse, and any bleeding after menopause (see Table 2 below).
Severe pelvic pain, particularly where it affects daily functioning or is associated with other events or symptoms such as intercourse or bowel problems, should also prompt medical assessment.
Anaemia symptoms, including fatigue, pallor or breathlessness, may indicate significant blood loss and should not be managed in isolation. Early recognition and referral can help reduce diagnostic delays, support earlier treatment and improve long-term outcomes. Pharmacists should feel confident in advising GP assessment when symptoms fall outside expected patterns.
| Symptom or sign | Why it matters |
|---|---|
| Very heavy menstrual bleeding | Possible fibroids or other pathology; risk of anaemia |
| Bleeding lasting longer than 7-8 days | May indicate underlying pathology |
| Bleeding between periods | Possible hormonal or structural cause |
| Bleeding after sexual intercourse | Possible cervical pathology |
| Bleeding after menopause | Potential sign of endometrial cancer |
| Severe pelvic pain affecting daily life | Possible endometriosis |
| Pelvic pain outside menstruation | Possible chronic pelvic pathology |
| Pain during sexual intercourse | May suggest endometriosis |
| Persistent pelvic pressure or abdominal swelling | Possible fibroids |
| Anaemia | Suggests significant blood loss |
Self-care and supportive advice
Not all menstrual discomfort indicates underlying pathology. Many women benefit from simple supportive measures such as non-steroidal anti-inflammatory drugs for pain relief, heat therapy, regular physical activity and maintaining adequate dietary iron intake.
It is important to balance reassurance with awareness of when symptoms require further assessment. Patients should be encouraged to seek medical advice if symptoms are severe, persistent, or impacting their quality of life. Framing this advice appropriately is key. Rather than implying that symptoms are abnormal, it can be helpful to emphasise that effective treatments are available and that further assessment may help improve symptoms.