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AI can help you make sense of health information, but when it comes to your symptoms, a convincing answer isn’t necessarily the right one.

Have you ever typed your symptoms into an AI chatbot because you weren’t sure whether they were worth discussing with a doctor?

Perhaps you’ve asked whether your fatigue could be hormonal, whether irregular periods are normal during perimenopause, or why sex has suddenly become uncomfortable. You might simply want a clearer explanation before deciding what to do next.

AI tools can make information easier to understand, and it’s understandable that people turn to them for quick answers about their health. They can explain unfamiliar medical terms, summarise general information and help you prepare questions for an appointment.

But there is an important distinction between understanding possible explanations for a symptom and knowing what’s causing it.

Over the last year, I have seen an increasing number of women who have delayed seeking medical advice because AI had reassured them that their symptoms were common for their stage of life. In some cases, these symptoms were red flags that, as a gynaecologist, I recognised as requiring further investigation sooner rather than later.

AI can be a useful starting point, but it cannot diagnose you or replace an individual medical assessment.

Here are five things worth knowing before you rely on an AI-generated answer about your health.

1. A confident answer doesn’t necessarily mean a correct answer

One of the reasons AI-generated health advice can be persuasive is that it often sounds clear, detailed and reassuring. It may explain your symptoms in straightforward language and suggest a plausible reason for what you’re experiencing.

The difficulty is that AI can produce inaccurate, incomplete or misleading information while presenting it convincingly. Research reviews have identified concerns about the reliability, consistency and safety of AI-generated medical information, particularly when questions require complex clinical judgement.

For example, if you describe fatigue, poor sleep and changes in your mood, an AI chatbot might suggest perimenopause. That may be one possibility, but these symptoms can also have other explanations.

The same applies to pelvic pain, changes in your periods or discomfort during sex. Recognising a possible cause is not the same as establishing a diagnosis.

Treat an AI response as information to explore, not confirmation of what’s wrong.

2. AI doesn’t have the full picture of your health

When a healthcare professional assesses your symptoms, they consider more than the symptoms themselves. Your medical history, medication, age, examination findings, previous investigations and the way your symptoms have changed can all influence the assessment.

An AI chatbot only has the information available to it in the conversation and any other information you have chosen and are able to share. It cannot independently carry out a physical examination, order investigations or reliably establish what’s happening inside your body.

This is particularly important in women’s health, where different conditions can cause similar symptoms.

Consider menopause, for example

Changes in sleep, mood, periods and concentration may be associated with perimenopause. However, they aren’t exclusive to the menopause transition.

Similarly, pelvic pain might be associated with endometriosis, but other gynaecological and non-gynaecological conditions may cause similar symptoms.

A chatbot may help you understand these possibilities, but it cannot reliably determine which explanation applies to you.

Your symptoms need to be considered in the context of your individual health, rather than matched to a list of possible conditions.

3. Reassurance from AI shouldn’t delay seeking medical advice

Sometimes, people use AI because they want reassurance. They may be worried about a symptom, embarrassed to discuss it or unsure whether it warrants an appointment.

An AI response might suggest that a symptom is common or potentially harmless. However, this doesn’t establish that it is safe to ignore.

Take changes in vaginal bleeding, for example. Changes in bleeding can occur during the menopause transition or after starting HRT, but unexpected or persistent bleeding should be medically assessed.

Likewise, persistent pelvic pain or pain during sex shouldn’t automatically be attributed to hormonal changes.

It’s important to seek appropriate medical advice if symptoms are persistent, recurrent, worsening or concerning. Some symptoms need more urgent assessment.

Don’t wait for an AI chatbot to confirm that something is wrong before seeking help. Equally, don’t let an AI-generated answer convince you that a symptom can safely be ignored.

4. AI can help you prepare for an appointment, and that’s where it can be useful

The answer isn’t necessarily to avoid AI altogether. Used thoughtfully, it can help you feel more informed and confident when discussing your health.

For example, you could use it to:

• Understand medical terminology: Ask for a plain-English explanation of a term you’ve encountered in a letter or article.
• Organise your symptoms: Create a list of when symptoms started, how often they occur and how they affect your everyday life.
• Prepare questions: Think about what you’d like to ask a healthcare professional about possible causes, investigations or treatment options.
• Understand general information: Ask for an explanation of the differences between perimenopause and menopause, or between different types of HRT.

You can also ask an AI tool to identify reputable sources, but check those sources yourself rather than assuming the references or summaries it provides are accurate.

For UK health information, the NHS and NICE are useful starting points.

The key is to use AI to help you prepare for a conversation with a healthcare professional, rather than using it as a substitute for that conversation.

5. Think carefully about what personal health information you share

Health information can be sensitive, and it’s worth considering privacy before entering personal details into an AI platform.

Before sharing information, check the tool’s privacy policy and settings to understand how your information may be stored or used. Avoid entering identifying details, such as your full name, address, NHS number or other information that isn’t necessary for your question.

You can usually ask a general health question without providing information that identifies you.

For example, rather than sharing your complete medical history, you might ask: “What are some possible causes of vaginal dryness during perimenopause, and what should I discuss with a healthcare professional?”

This allows you to explore general information while sharing less personal detail.

So, when should you seek professional advice?

If you’re experiencing symptoms that concern you, you don’t need to work out the cause yourself before asking for help.

Speak to your GP or an appropriate healthcare professional if:

• Your symptoms persist, worsen or keep returning.
• Your period pattern has changed.
• You’re experiencing pelvic pain, painful intercourse or unusual vaginal bleeding.
• Menopause symptoms are affecting your sleep, relationships, work or quality of life.
• You’re unsure whether your symptoms could be related to menopause or another condition.

The bottom line: AI can inform you, but it can’t assess you

AI is changing the way people access health information, and it can be helpful when used carefully. It can make medical language easier to understand, help you organise your thoughts and give you a starting point for further questions.

But there is a difference between an explanation that sounds right and an assessment that takes your individual circumstances into account.

You don’t need to arrive at an appointment with a diagnosis. You simply need to be able to explain what you’ve noticed and ask for help understanding it.

If you have questions about your symptoms, don’t have to rely on an online answer alone, speak to a healthcare professional.

Somewhere along the way, the conversation about hormone replacement therapy (HRT) seems to have become a little like choosing a side.

You’re either pro-HRT or anti-HRT.

You believe women have been unnecessarily frightened away from treatment, or you’re concerned about the risks. You champion the benefits, or you question whether it is being prescribed too readily.

And if you spend any time on social media, you could be forgiven for thinking you need to arrive at a firm opinion before you’ve even worked out whether HRT might help you.

But here’s the thing.

You don’t have to be for it or against it.

You can be pleased that effective treatments are available while wanting to understand their risks. You can decide to take HRT, decide not to take it, or feel unsure and want to explore your options.

You can even change your mind.

What matters is not which camp you belong to. It’s whether you have the information, support and individualised advice you need to make a decision that feels right for you.

First, let’s take a step back

HRT is an effective treatment for many symptoms associated with perimenopause and menopause. It can help with hot flushes, night sweats and sleep disturbance, as well as other symptoms that can affect everyday life.

For some women, the difference can be substantial. Better sleep, fewer hot flushes and relief from troublesome symptoms can have a real impact on quality of life.

But menopause isn’t experienced in the same way by everyone.

Some women have relatively mild symptoms. Others find their symptoms affect their work, relationships, confidence, sleep and ability to get through an ordinary day.

Some want to explore HRT as soon as symptoms begin. Others prefer to try non-hormonal approaches first. Some have medical conditions that make the decision more complex.

There isn’t one experience of menopause, so it makes little sense to expect one universal answer to HRT.

NICE guidance reflects this. Management should be tailored to the individual, and treatment options should be discussed in the context of personal circumstances, potential risk factors, preferences and the benefits and risks of each approach.

That’s a rather different proposition from deciding that HRT is either wonderful or terrible.

Why has HRT become such a controversial subject?

Part of the answer lies in history.

Older research raised concerns about the risks associated with HRT, particularly breast cancer, blood clots and cardiovascular disease. The findings had a significant impact on how HRT was viewed, both by healthcare professionals and by the public.

The consequences are still felt today.

Some women remain understandably worried about taking hormones. Others feel that they were denied treatment, or that their symptoms were dismissed, because of concerns about HRT.

More recently, increased awareness of menopause has helped many women seek information and support. That is a positive change.

But social media can turn complicated evidence into simple, confident statements. A personal success story can become a recommendation for everyone. A frightening experience can become a warning against all hormone treatment.

Neither tells the whole story.

The evidence has developed, and guidance has been updated. The right response isn’t to dismiss historical concerns, nor is it to assume that every concern remains equally applicable to every woman today.

It is to look at what the evidence says now, understand the limitations, and apply it to the person sitting in front of you.

So, is HRT safe?

This is usually the question behind the debate, and it deserves a proper answer.

HRT has benefits and risks. The balance between them depends on factors including the person’s age, medical history, family history, symptoms, type of HRT and how it is taken.

For many otherwise healthy women experiencing troublesome menopausal symptoms, the benefits of HRT are likely to outweigh the risks, particularly when treatment is started before the age of 60. But that is not a blanket statement that every preparation is suitable for every person.

Different formulations have different risk profiles.

For example, NICE advises that oral HRT increases the risk of venous thromboembolism (blood clots), whereas this risk is not increased with transdermal HRT, such as patches or gel. The route of administration can therefore be an important consideration for someone with particular risk factors.

Breast cancer risk also needs a more nuanced explanation than a simple yes or no. NICE advises that combined HRT is associated with an increased risk of breast cancer, and that this risk rises with duration of use. The evidence and risk profile differ between combined HRT and oestrogen-only HRT.

This is one reason why it matters which treatment is being discussed, rather than treating all HRT as one identical medication. It also matters who you discuss it with. When discussing risks in relationship to your personal medical history be sure you are getting advice from a recognised menopause specialist, you can check this on the British Menopause Society website to ensure the person advising you is qualified to do so.

It is also important to distinguish between treating menopausal symptoms and using HRT to prevent disease. For example, HRT isn’t recommended specifically for the primary or secondary prevention of cardiovascular disease, or for dementia prevention .

Good advice isn’t about promising that HRT is risk-free. It’s about explaining the relevant risks in context, alongside the potential benefits, so that you can make an informed decision.

For further information, NICE’s Menopause: identification and management guideline and the British Menopause Society’s resources on HRT benefits and risks provide evidence-based guidance.

Your medical history matters

Two women can be the same age, experience similar symptoms and still receive different advice about HRT.

That isn’t inconsistency. It is individualised care.

Your personal and family medical history may affect which options are suitable, the type of HRT considered and whether specialist advice is needed.

Previous breast cancer, a history of blood clots, certain cardiovascular conditions and other medical circumstances may need particular consideration. Sometimes HRT may not be suitable; sometimes a different preparation or route of administration may be considered following an appropriate assessment.

Other factors matter, too.

Do you have a uterus? Are your symptoms mainly hot flushes and night sweats, or are vaginal dryness and discomfort your biggest concerns? Are you still having periods? Have you had a hysterectomy? Have you experienced an early or premature menopause?

These questions can influence the treatment options available.

The point is not that you need to know all of this before seeking help.

It is that HRT is not one single treatment, and choosing it is not a simple yes-or-no decision.

What if you don’t want HRT?

That is absolutely a valid choice.

You do not have to take HRT because your symptoms are troublesome, because a friend has benefited from it, or because you feel you ought to be doing something about menopause.

Your preferences matter.

Depending on your symptoms and circumstances, there may be other options worth considering. These can include menopause-specific cognitive behavioural therapy (CBT), lifestyle measures and other treatments for particular symptoms.

Vaginal moisturisers and lubricants may help with vaginal dryness and discomfort, while other treatments may be appropriate for specific symptoms.

The important distinction is that different options do different things. A treatment that helps with one symptom may not help with another, and not every alternative has the same level of evidence behind it.

Choosing not to take HRT should not mean being left to struggle without support.

You deserve to understand what else may help, what the evidence says and when it might be worth reviewing your decision.

What if you do want HRT, but you’re worried about the risks?

You don’t have to ignore those concerns to access treatment.

In fact, asking questions about the risks is an important part of making an informed decision.

Perhaps you’ve read about breast cancer. Perhaps someone in your family has had a blood clot. Perhaps you’ve heard conflicting advice about body-identical hormones, patches, gels or how long HRT can be taken.

These are all reasonable things to want to discuss with a healthcare professional.

A good consultation should give you space to explain what worries you, understand which risks are relevant to your circumstances and explore the available options.

It should also make clear where evidence is strong, where uncertainty remains and what follow-up is needed.

You shouldn’t have to choose between having your symptoms taken seriously and having your concerns about treatment taken seriously.

You can have both.

You don’t have to make a decision for the rest of your life

Another misconception is that starting HRT means committing to it indefinitely, or that reaching a particular age means you must stop.

Neither reflects the approach recommended.

Treatment should be reviewed, with the benefits and risks of continuing considered in the context of your circumstances and symptoms. There should not be an arbitrary time limit applied to everyone.

Some women use HRT for a relatively short period. Others continue for longer because their symptoms persist and the benefits continue to outweigh the risks for them.

The right approach can change over time.

Your symptoms may change. Your health may change. Your priorities may change.

You may decide to adjust your dose, change your preparation, explore another treatment or stop HRT. If you stop, symptoms may return, and it is worth discussing how best to manage that possibility.

The important thing is that the decision remains informed and individualised, with appropriate review.

You do not need to predict today exactly what you will want or need in five or ten years.

The role of a good menopause consultation

If the online conversation leaves you feeling that you need to arrive with a decision already made, it is worth remembering that this is not your responsibility.

You don’t need to walk into a consultation demanding HRT.

You don’t need to arrive determined to avoid it.

You don’t need to have researched every possible preparation or memorised the latest discussion about breast cancer risk.

Your starting point can simply be: These are my symptoms, this is how they are affecting me, and I would like to understand my options.

A useful consultation should explore:

• Which symptoms you are experiencing and how they affect your daily life.
• Your medical and family history, including any factors that may influence treatment choices.
• The potential benefits and risks of HRT in your individual circumstances.
• The different preparations and routes of administration that may be suitable.
• Non-hormonal options and other treatments where appropriate.
• Your preferences, concerns and priorities.
• How treatment will be reviewed and what to do if it isn’t helping.

This is the principle of shared decision-making: a healthcare professional contributes clinical knowledge and evidence, while you contribute your experience, values and preferences.

The decision is made together.

And if the most appropriate next step is further assessment or specialist advice, that should be part of the conversation, too.

A more useful conversation about HRT

We don’t need to replace an anti-HRT message with an equally absolute pro-HRT message.

We need to move beyond the idea that there is one correct position to hold.

Some women will benefit from taking it; others will choose different options. For some, the decision will be more complex and require specialist input.

None of those choices makes someone better informed, more committed to women’s health or more sensible than someone else.

And no one should feel that they have to defend their treatment choice to strangers on the internet.

The question is not whether you are for or against HRT.

It is whether your symptoms have been properly assessed, whether you understand the options available to you, and whether you have the support to make a decision that reflects your own health and circumstances.

You need care that is individual to you.

Do you want to talk about it?

If menopausal symptoms are affecting your quality of life, a consultation with a suitably qualified healthcare professional can help you understand your options, discuss the benefits and risks, and decide what may be appropriate for you.

At West Wales Women’s Wellbeing, our consultant-led approach puts your symptoms, medical history and individual circumstances at the centre of the conversation. Whether you’re considering HRT, have questions about treatment you’re already taking, or would prefer to explore alternatives, the aim is to help you make an informed decision — without pressure to choose a particular side.

Because your menopause care should be about you.

Trusted sources and further reading

• NICE: Menopause — identification and management (NG23)
• British Menopause Society: What are the benefits and risks of HRT?
• British Menopause Society: Recommendations on hormone replacement therapy in menopausal women
• NHS: Benefits and risks of HRT

This article provides general information and is not a substitute for individual medical advice. The suitability of HRT and the balance of benefits and risks should be discussed with a healthcare professional who can take your circumstances into account.

Blog Guest Author: Laura Price. BSc Hons. PG Cert. HCPC. MCSP. MPOGP

Women’s Health Physiotherapist

What is Pelvic Floor Dysfunction (PFD)?

Pelvic floor dysfunction (PFD) is a condition in which the pelvic floor muscles around the bladder, anal canal, and vagina do not work properly.

Symptoms include: 

• Urinary Incontinence. 
• Difficulty emptying the bladder. 
• Faecal incontinence.
• Difficulty emptying the bowels. 
• Pelvic organ prolapse. 
• Sexual dysfunction (pain/ lack of sensation/ inability to climax) 
• Chronic pelvic pain. 

What increases your risk of developing PFD? 

Risks can be divided into things that can be changed (modifiable) and things that cannot be changed (non- modifiable) and risks related to the birth of your baby (obstetric risk):

Modifiable	Non-Modifiable	Obstetric
A body mass index (BMI) above 25	Age	Being over 30 years of age when having a baby
Smoking	Family history of urinary incontinence, overactive bladder, faecal incontinence or prolapse	Having had one or more babies prior to current pregnancy
Lack of exercise	Gynaecological cancers and treatments related to this	Having an assisted birth (Forceps or ventouse)
Constipation	Gynaecological surgery e.g. hysterectomy	Having a birth where the baby is lying face up – back to back birth. (occipito-posterior)
Diabetes	Fibromyalgia	An active second stage of labour that lasts longer than 1 hour
	Chronic respiratory disease.	Injury to the anal sphincter during birth (OASI)

Identifying if you have an increased risk can help to prevent symptoms from developing or manage them early. 

Below are some useful resources to help manage some of these risk factors:

https://www.nhs.uk/health-assessment-tools/calculate-your-body-mass-index

https://helpmequit.wales/

https://www.gov.uk/government/publications/physical-activity-guidelines-adults-and-older-adults

https://masic.org.uk/

https://www.asthmaandlung.org.uk

https://www.nhs.uk/conditions/constipation

What are the pelvic floor muscles?

The pelvic floor muscles are a collection of muscles that form the “floor” of the pelvis. The main role of these muscles is to support the pelvic organs and the fascia and to maintain continence. 

Pelvic floor muscles can become weak due to the risk factors above and are unable to provide support or manage pressure in the abdomen which may result in symptoms of incontinence and prolapse. 

These muscles can also cause symptoms of pain and difficulty emptying if they do not lengthen and relax fully.

All women and girls aged 12 and above should complete regular pelvic floor exercises to prevent PFD. This is particularly important in pregnancy and after childbirth.

What is supervised pelvic floor exercise?

Those who have been identified at risk of developing pelvic floor dysfunction or have developed symptoms can benefit from supervised pelvic floor muscle training. 

This is considered the first line treatment for urinary incontinence and prolapse. 

Following a full assessment of your symptoms, a pelvic health physiotherapist will undertake an assessment of the function of the pelvic floor, including strength, endurance, co-ordination, and technique. This can also include assessment of the abdomen, ribs, hips, lower back and supporting muscle function. 

An individualised training programme can then be advised with support for progressing strength training for the individual women’s needs and goals. 

Training should be undertaken for at least 3 months and should include 3 sets per day.

Where someone is unable to undertake this kind of training, symptoms and strengthening can be supported with intravaginal supports, biofeedback and neuromuscular electrical stimulation.

For more information on pelvic health physiotherapy:

Email: wwpelvicphysio@gmail.com

Instagram: @wwpelvicphysio

Facebook: http://www.facebook.com/share/1LXFdym3CL/

References:

NICE (2021) Pelvic floor dysfunction: prevention and non surgical management. NG210. https://www.nice.org.uk/guidance/ng210

NICE (2019) Urinary incontinence and pelvic organ prolapse in women: management. NG123. https://www.nice.org.uk/guidance/ng123

The POGP Why choose a POGP registered physiotherapist. https://thepogp.co.uk/patient_information/why_choose_a_pogp_registered_physiotherapist.aspx

Let’s start with a slightly awkward question.

Have you ever actually looked at your vulva?

Not because something was hurting.

Not because you were checking for thrush.

Not because your doctor or nurse was examining you.

Just… looked.

If the answer is no, you are certainly not alone.

For many women, the vulva is one of those parts of the body that we don’t really look at. We wash it, we deal with periods, we have sex, we notice when something is uncomfortable but we don’t necessarily know what our own vulva actually looks like.

And that can make it surprisingly difficult to notice when something has changed.

The vulva comes in all different shapes, sizes, colours and textures. There isn’t one “normal” appearance.

The important thing is knowing what is normal for you.

That way, if something changes, you are more likely to notice it.

Your vulva isn’t your vagina

Let’s clear up one thing first.

The vulva is the external genital area. It includes the labia, clitoris and the skin around the vaginal opening.

The vagina is the internal passage leading from the vaginal opening towards the cervix.

We often use the word “vagina” to describe the whole area, but when we’re talking about changes to the skin, itching, soreness, lumps, colour changes or skin conditions, we’re often talking about the vulva.

And vulval skin can develop a surprisingly wide range of conditions.

Itching doesn’t always mean thrush

This is something I think is really important.

If you’ve ever had vulval itching or soreness, your first thought may well have been:

“I’ve got thrush.”

Sometimes you might be right.

But not every itchy or sore vulva is caused by thrush.

Vulval symptoms can have many different causes, including irritation or dermatitis, eczema, psoriasis, lichen sclerosus, lichen planus, hormonal changes and infections.

And sometimes, several things can be going on at once.

This is why repeatedly treating yourself for thrush when things aren’t improving isn’t necessarily the answer.

If symptoms keep coming back, don’t settle for the assumption that you are simply someone who “gets thrush a lot”.

It is worth finding out what is actually causing the problem.

So, what should you look out for?

Just as there is a lot of awareness around checking your breasts, checking your vulva is equally as important. 

This is about becoming familiar with your own body,

When you look at your vulva, you might notice:

• a new lump or area of swelling
• a change in the colour of the skin
• a new white, pale, red or darker patch
• an area of skin that has become thicker or raised
• cracks or small splits in the skin
• sores or ulcers that don’t heal
• bleeding that isn’t expected
• a change in the shape or appearance of the vulva
• persistent itching, burning or soreness
• pain during sex
• changes in sensation
• discomfort when passing urine or opening your bowels.

Many of these symptoms can be caused by conditions that are not cancer. In fact, vulval symptoms are common and have many possible causes. But that doesn’t mean you should ignore a change that is new, persistent or unusual for you.

One condition worth knowing about: lichen sclerosus

Lichen sclerosus is a long-term inflammatory skin condition that commonly affects the vulval and anal areas.

It can occur at any age, although it is more common after the menopause.

It can cause itching, soreness and irritation, but there can also be visible changes to the skin.

You may notice white or pale patches, crinkled or thickened skin, small cracks or fissures, bruising or bleeding. Over time, untreated lichen sclerosus can cause scarring and changes to the structure of the vulva.

Some people have very obvious symptoms.

Others don’t.

And this is one of the reasons that knowing what your vulva normally looks and feels like can be helpful.

Lichen sclerosus is not an infection, is not contagious and isn’t caused by poor hygiene. It can usually be managed effectively with treatment, but it is a condition that needs proper diagnosis and ongoing management.

Why does lichen sclerosus matter?

There are two reasons.

The first is that treatment can make a significant difference to symptoms and help protect the vulval skin.

The second is that lichen sclerosus is associated with a small increased risk of vulval cancer.

That sounds frightening, but it is important to put it into perspective.

Having lichen sclerosus does not mean you are going to develop vulval cancer.

It does mean that changes in the vulval skin shouldn’t simply be ignored.

Regular checks, appropriate treatment and speaking to your healthcare professional if something changes are important parts of looking after the condition.

How do you actually check your vulva?

If you’ve never done this before, it might feel a little strange.

You don’t need anything complicated.

A mirror and a good light are enough.

Find somewhere private where you feel comfortable. You could stand with one leg raised, sit down or find another position that gives you a good view.

Have a look at the different areas of your vulva and around the vaginal opening.

You can gently part the folds of skin so you can see areas that aren’t normally visible.

You’re not looking for a textbook-perfect vulva.

You’re getting to know yours.

We recommend regular vulval checks, particularly for people with lichen sclerosus, and suggests looking for changes in colour or texture, lumps, thickened areas, sores, ulcers, cracks or changes to the structure of the vulva.

You might even find yourself thinking:

“Oh. That’s what I actually look like.”

And that’s exactly the point.

What if something looks different?

Don’t panic.

There are lots of reasons why the vulval skin might look different.

Hormonal changes, irritation, eczema, infections and other skin conditions can all cause changes.

But if you notice something new, persistent or unusual for you, get it checked.

That might mean speaking to your GP, practice nurse, sexual health service or another healthcare professional who is familiar with assessing vulval conditions.

Vulval symptoms should be assessed to establish what is causing them, and that if the diagnosis is unclear or the skin doesn’t improve with treatment, further assessment sometimes, including a small biopsy may be needed.

And although it’s easy to say, please don’t feel embarrassed.

Your vulva isn’t shocking, unusual or inappropriate.

It’s a body part.

When should you definitely get it checked?

It’s particularly important to seek medical advice if you notice:

A lump that is new or unexplained.

An ulcer or sore that doesn’t heal.

Unexplained vulval bleeding.

A persistent change in the colour or texture of the skin.

An area that becomes thickened, raised or changes in appearance.

Persistent itching, burning or soreness that isn’t settling.

Symptoms that keep returning despite treatment.

And please don’t keep treating yourself for thrush if it’s not getting better

This is another common situation.

You feel itchy.

You buy a thrush treatment.

It gets a little better.

Then it comes back.

So you treat it again.

And again.

At some point, it is worth stopping and asking:

Is this actually thrush?

Some over-the-counter preparations can themselves irritate sensitive vulval skin, particularly if they are used repeatedly when they aren’t needed. I advise caution with some over-the-counter preparations because they can aggravate allergies or prolong symptoms.

If something isn’t settling, getting the diagnosis right is much more useful than simply adding another cream.

Your vulva doesn’t need lots of products

Another misconception worth clearing up is that the vulva needs to be scrubbed, scented, exfoliated or “freshened”.

It doesn’t.

Vulval skin is sensitive, and products such as perfumed soaps, shower gels, bubble baths, deodorants, wipes and douches can irritate it. I recommend a gentle approach to vulval care.

In other words, when it comes to your vulva:

Clean doesn’t have to mean squeaky.

And you certainly don’t need to make it smell like a tropical shower gel.

The bigger message

There is a bigger reason I want women to feel more comfortable talking about their vulva.

We are generally much better at talking about breast awareness.

We know that breasts come in different shapes and sizes. We know to notice a new lump or change. We know that something unusual should be checked.

We should be just as comfortable knowing our own vulva.

Not because we should be constantly looking for something wrong.

But because you can’t recognise a change if you don’t know what is normal for you.

That might be particularly important if you have a condition such as lichen sclerosus, but it applies more generally too.

Your vulva is part of your body.

It deserves the same attention and care as the rest of you.

So, when was the last time you looked?

If the answer is “I honestly can’t remember”, don’t worry.

You don’t need to turn it into a daily ritual.

But finding a comfortable, private moment to have a look can be a useful way of becoming more familiar with your own body.

And if you notice something that doesn’t look or feel right?

Don’t ignore it.

It doesn’t mean something serious is wrong.

It simply means it is worth finding out what is going on.

Because when it comes to vulval health, knowing your normal can make it much easier to spot when something has changed.

A final reminder

Vulval itching, soreness, skin changes and other symptoms can have many different causes. This article is intended to help you recognise changes and understand when to seek advice; it is not a substitute for an examination or diagnosis.

If you have a new or persistent vulval symptom, or a change that concerns you, speak to your GP or another appropriate healthcare professional.

Useful resources

The Labia Library – The models in this gallery span a wide range of ages and genders it can be helpful to view what the spectrum of normal looks like.

The LS Guide – A fantastic website covering a wealth of helpful information about Lichen Sclerosus.

There is a particular kind of frustration that comes with endometriosis.

You can spend years trying to understand your pelvic pain, your periods, your fatigue and everything else that comes with it.

And then there is your stomach.

The bloating.

The constipation.

The diarrhoea.

The feeling that you look several months pregnant by the end of the day.

The abdominal pain that seems to appear from nowhere.

And perhaps the most frustrating part is not knowing what belongs to what.

Is this my endometriosis?

Is it IBS?

Is it something I have eaten?

Or have I somehow reached the point where I am supposed to remove half the contents of my kitchen just to get through the week?

It is a question I am asked increasingly often.

And the honest answer is that the relationship between endometriosis, the bowel and food is complicated.

But there is some genuinely interesting research emerging, particularly around women who have endometriosis alongside IBS-type gastrointestinal symptoms.

So, rather than giving you another list of foods you apparently must never eat again, let’s look at what we actually know.

First things first: endometriosis and IBS can coexist

Endometriosis and irritable bowel syndrome are different conditions.

That sounds obvious, but the symptoms can overlap considerably.

Endometriosis can cause pelvic and abdominal pain, painful bowel movements and gastrointestinal symptoms, particularly around menstruation.

IBS can cause abdominal pain, bloating, constipation, diarrhoea or changes in bowel habit.

And, unfortunately, it is entirely possible to have both.

In fact, the association appears to be quite strong.

A 2022 systematic review and meta-analysis found that people with endometriosis had almost three times the odds of having IBS compared with people without endometriosis. Across the studies that looked specifically at prevalence, around 23% of people with endometriosis also had IBS.

That does not mean that endometriosis causes IBS.

It also doesn’t mean that every episode of bloating or constipation in somebody with endometriosis is IBS.

It does mean that if you have endometriosis and significant gastrointestinal symptoms, it is worth considering that there may be more than one thing going on.

And that distinction becomes important when we start talking about diet.

So, what exactly is a FODMAP?

FODMAP is one of those words that sounds considerably more complicated than it needs to be.

It stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols.

These are types of short-chain carbohydrates found in a wide variety of foods.

For some people, particularly those with IBS, certain FODMAPs are poorly absorbed in the small intestine and can draw water into the bowel and be fermented by gut bacteria.

The result can be bloating, abdominal discomfort, wind, diarrhoea or other gastrointestinal symptoms.

And this is where the low-FODMAP diet comes in.

The important word is low.

It is not supposed to mean no FODMAPs forever.

A proper low-FODMAP approach is generally a short-term process involving an initial period of reducing high-FODMAP foods, followed by systematic reintroduction and personalisation.

The aim is not to end up with the smallest possible diet.

It is to work out what your individual gut actually tolerates.

That distinction matters enormously.

But does low-FODMAP actually help endometriosis?

This is where things have become particularly interesting.

For years, there has been a lot of discussion about diet and endometriosis, but relatively little high-quality evidence behind many of the claims made online.

There is certainly no single diet that has been shown to cure endometriosis.

However, researchers have started looking more specifically at women with endometriosis who also have significant gastrointestinal symptoms.

And the results are beginning to suggest that low-FODMAP may help some of these women.

A particularly interesting study published in 2025 was the EndoFOD trial.

It was a randomised controlled crossover study involving 35 women with endometriosis and poorly controlled gastrointestinal symptoms.

Participants followed either a low-FODMAP diet or a nutritionally matched control diet for 28 days before crossing over to the other diet.

After four weeks, 60% responded to the low-FODMAP diet compared with 26% during the control diet.

There were also improvements in abdominal pain, bloating, stool consistency and quality of life.

That is interesting.

But it needs interpreting carefully.

It was a relatively small study.

It lasted four weeks.

And it looked specifically at women with endometriosis who already had significant gastrointestinal symptoms.

It does not show that a low-FODMAP diet treats the underlying endometriosis.

What it does suggest is that reducing FODMAPs may be a useful way of managing gastrointestinal symptoms in some women with endometriosis.

And that is a much more sensible conclusion.

Think symptoms, not cure

This is probably the most important distinction I would make.

If somebody with endometriosis tells me that changing their diet has made their bloating, bowel symptoms or abdominal discomfort considerably better, I absolutely believe that experience.

But symptom improvement does not necessarily mean that the endometriosis itself has disappeared or become less extensive.

You can improve a symptom without treating the underlying disease.

We do this in medicine all the time.

Painkillers can reduce pain without removing its cause.

Treating constipation can improve abdominal discomfort without changing the underlying condition.

And, in the same way, dietary intervention may improve gastrointestinal symptoms without treating endometriosis itself.

That doesn’t make the improvement unimportant.

Quite the opposite.

If your bowel symptoms are affecting your work, sleep, relationships, social life or simply your ability to wear trousers comfortably by 4pm, improving them matters.

This is where IBS becomes particularly relevant

The overlap between endometriosis and IBS is one reason I think the low-FODMAP conversation needs to be handled carefully.

If you have endometriosis and IBS, a low-FODMAP diet may be addressing the IBS component of your symptoms rather than the endometriosis itself.

And that could still make a very significant difference to how you feel.

It is also one reason why I would be cautious about assuming that every bowel symptom in someone with endometriosis is simply “part of the endometriosis”.

Persistent or troublesome bowel symptoms deserve proper assessment.

Sometimes there is endometriosis affecting the bowel.

Sometimes there is IBS.

Sometimes there is constipation.

Sometimes there is more than one thing happening at once.

And sometimes the answer is not related to endometriosis at all.

Good medicine starts with working out which problem we are actually trying to solve.

Don’t assume every bowel symptom is IBS

There is one important point I would add here.

If you have endometriosis, it can be very tempting to put every new abdominal or bowel symptom down to the endometriosis itself, or to IBS if you have already been given that diagnosis.

But a new or persistent change in your bowel habits should not simply be written off as part of your endometriosis or managed through diet without speaking to a doctor.

That might mean a change in how often you open your bowels, persistent diarrhoea or constipation, a change in the consistency of your stools, or symptoms that are noticeably different from your usual pattern.

You should also seek medical advice if you notice blood in your stool, unexplained weight loss, persistent abdominal pain or bloating, or other symptoms that are unusual for you.

These symptoms are very often caused by conditions other than bowel cancer, and having them does not mean that something serious is wrong. But they are symptoms that deserve proper assessment rather than simply being attributed to IBS or endometriosis.

This is particularly important if symptoms are new, persistent or changing.

Diet can be part of symptom management. It shouldn’t become a substitute for finding out what is causing the symptoms in the first place.

And that is an important distinction throughout this whole conversation.

And no, you don’t need to stop eating everything

This is the part I worry about most when I see social media discussions about endometriosis and diet.

There are an enormous number of lists telling women to avoid gluten.

Or dairy.

Or sugar.

Or meat.

Or soya.

Or nightshade vegetables.

Or processed foods.

Or carbohydrates.

Or practically anything enjoyable.

Some of these approaches may make an individual person feel better.

But that is not the same as having good evidence that they should be recommended to everybody with endometriosis.

Endometriosis UK is very clear that there is currently limited high-quality evidence for a specific diet for endometriosis. Their guidance on low-FODMAP specifically distinguishes between using it for IBS or IBS-type gastrointestinal symptoms and treating endometriosis itself.

And this matters because restrictive diets are not completely harmless.

They can make eating socially difficult.

They can make meals unnecessarily complicated.

They can increase anxiety around food.

And if enough foods are removed, there is a genuine risk of nutritional inadequacy.

The aim should not be to see how little you can eat.

It should be to work out what helps you feel better while keeping your diet as varied and nutritionally adequate as possible.

Low-FODMAP isn’t supposed to be forever

This is perhaps the biggest misconception about the diet.

The elimination phase is not meant to become your permanent diet.

The whole point is to identify which foods or groups of foods are actually contributing to your symptoms and then gradually reintroduce foods to establish your own level of tolerance.

That is why professional guidance is important.

NICE recommends that formal dietary exclusion and reintroduction approaches for IBS, including low-FODMAP diets, should be supported by a healthcare professional with expertise in dietary management.

Endometriosis UK also recommends working with a registered dietitian if you are considering a low-FODMAP approach.

In other words, this shouldn’t be a case of downloading a food list from Instagram on Monday and deciding that onions, apples, bread and milk are permanently banned by Friday.

There is a process.

And there is a reason for that process.

What about all the other “endometriosis diets”?

This is where I think a healthy dose of scepticism is useful.

There are diets described online as anti-inflammatory, endometriosis-specific, hormone-balancing, autoimmune, gluten-free, dairy-free and many other variations.

Some are based around generally healthy principles.

Others are extremely restrictive.

But at the moment, there isn’t good-quality evidence to support one particular diet as a treatment for endometriosis itself.

That doesn’t mean nutrition is irrelevant.

Far from it.

Eating a varied diet, getting enough fibre and protein, staying hydrated and maintaining good general nutrition are all important for health.

But there is a big difference between:

“A healthy diet is good for you.”

and

“This particular diet will treat your endometriosis.”

The first is sensible.

The second needs evidence.

And unfortunately, there is a lot more certainty about the second claim on social media than there is in the scientific literature.

What I would actually suggest

If you have endometriosis and significant gastrointestinal symptoms, I wouldn’t start by trying to eliminate everything.

I’d start by asking a few questions.

What symptoms are you actually trying to improve?

When do they occur?

Are they linked to your menstrual cycle?

Are you constipated, having diarrhoea, or alternating between the two?

Is bloating your main problem?

Have you been diagnosed with IBS as well as endometriosis?

Are there symptoms that need investigating rather than simply managing through diet?

And what is your diet currently like?

Sometimes a few straightforward changes can make a difference.

Sometimes IBS is part of the picture and a structured low-FODMAP approach may be worth considering.

And sometimes the most useful thing you can do is stop trying to solve everything with food.

Because not every symptom is caused by something you ate.

The bigger picture

One of the things I find particularly interesting about endometriosis is that it rarely behaves like a single-organ problem.

Pain, bowel symptoms, bladder symptoms, fertility, fatigue and quality of life can all become part of the picture.

That means treatment often needs to be broader than simply asking, “What can we do about the endometriosis?”

Sometimes the question is also:

“What else is contributing to how this woman feels?”

For some women, that may include IBS.

For some, constipation.

For some, pelvic-floor dysfunction.

For some, other gastrointestinal conditions.

And for some, diet may genuinely be one part of managing their symptoms.

That is very different from saying that food is the cause of endometriosis.

Or that removing the right food will cure it.

So, can changing your diet help?

Possibly.

And increasingly, we have evidence that for women with endometriosis and significant gastrointestinal symptoms, a carefully managed low-FODMAP approach can improve some of those symptoms.

The 2025 EndoFOD trial is interesting because it gives us more evidence than we had previously. But as I mentioned it is still a small study, and we need more research, particularly looking at longer-term outcomes and what happens after foods are reintroduced.

So I think the sensible position is somewhere between the two extremes.

You don’t need to believe that diet has nothing to do with your symptoms.

And you don’t need to believe that there is a secret “endometriosis diet” that somebody on Instagram has discovered and your doctor hasn’t told you about.

There is a middle ground.

Understand your symptoms.

Work out whether IBS or another gastrointestinal problem might also be present.

If appropriate, consider dietary intervention with someone properly trained to deliver it.

And, most importantly, don’t let managing endometriosis turn eating into another source of stress.

Food should still be food.

Not another thing to be frightened of.

And if changing what you eat makes your bowel symptoms better, that is useful information.

It is just not the same thing as saying that you have treated the endometriosis.

That distinction matters.

Because good healthcare isn’t about finding one perfect answer.

It is about understanding the whole picture and working out what might actually help you feel better.

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If you are experiencing pelvic pain, bowel symptoms, painful periods or other symptoms that you think may be related to endometriosis, a proper clinical assessment can help work out what may be contributing to your symptoms and whether further investigation is appropriate.

Dietary management is individual, and a low-FODMAP diet should be undertaken with guidance from a registered dietitian. If you develop new or persistent changes in your bowel habit, it is important to have these assessed by a Doctor.

“The coil.”

It is a phrase most of us have heard, but it can actually mean two quite different types of contraception: the copper IUD, which is non-hormonal, and the hormonal IUS, which releases a small amount of progestogen into the womb.

And while contraception is one of their most familiar uses, that is not the whole story.

A hormonal IUS can also be used to help manage heavy menstrual bleeding, provide protection for the lining of the womb alongside oestrogen HRT, and play an important role in the treatment of some forms of endometrial hyperplasia.

At the same time, it is not suitable for everyone, and there are other contraceptive and treatment options available.

So, if you have ever wondered whether a coil might be right for you, it is worth looking beyond the word “coil” and understanding what the different options actually do.

First, what is the difference between an IUD and an IUS?

Although the terms are sometimes used interchangeably, they are not the same.

The copper IUD – the non-hormonal coil

The copper IUD is a small device placed inside the womb. It does not contain hormones.

Instead, copper creates an environment that is hostile to sperm and prevents fertilisation.

For someone who wants highly effective contraception but does not want hormones, it can be an excellent option.

But there is an important consideration.

Copper coils can make periods heavier, longer or more painful, particularly in the first few months.

That can be a significant disadvantage if you already have heavy or painful periods.

The hormonal IUS – the hormonal coil

The hormonal IUS releases levonorgestrel, a type of progestogen, predominantly within the womb.

It provides highly effective contraception and, for many women, has the added benefit of making periods much lighter. Some women eventually have no bleeding at all.

The hormonal IUS is therefore quite different from the copper IUD.

It is not simply a choice between “a coil with hormones” and “a coil without hormones”. The two devices have different effects and may suit very different circumstances.

How effective is a coil as contraception?

Both the hormonal IUS and copper IUD are among the most effective forms of reversible contraception available.

They are over 99% effective at preventing pregnancy. One of their advantages is that, unlike the pill, you do not have to remember to take something every day or use something every time you have sex.

A hormonal IUS is long-acting but reversible. Once it is removed, fertility returns to previous levels.

Other devices are available

When we talk about a hormonal IUS, it is also worth remembering that there are different devices available, with different hormone doses and licensed durations.

As well as the 52 mg levonorgestrel IUS, there are lower-dose hormonal IUS options containing 19.5 mg and 13.5 mg of levonorgestrel, which are licensed for contraception for 5 years and 3 years respectively.

These lower-dose devices may be suitable for some women, depending on their individual circumstances and what they are hoping to achieve.

It is important to remember, however, that the different devices are not interchangeable for every indication. For example, the 52 mg IUS is the device generally used when endometrial protection is required alongside oestrogen HRT.

The choice of device should therefore take into account not just contraception, but also your bleeding pattern, whether you need endometrial protection, your preferences and how long you want contraception for.

What about the hormonal side of the IUS?

This is one of the questions I am often asked.

The hormonal IUS contains a progestogen, so technically it is a hormonal contraceptive.

However, the levonorgestrel is released directly into the womb, meaning the amount of hormone entering the bloodstream is much lower than with many systemic hormonal contraceptives.

That does not mean that nobody experiences hormonal side effects.

Some women do notice changes such as acne, breast tenderness, headaches or mood changes, particularly around the time of insertion or in the early months.

Others find that they tolerate it extremely well.

As with many treatments, there is a real difference between what can happen and what will happen to you.

One of its biggest advantages: heavy periods

This is where the hormonal IUS becomes more than simply a contraceptive.

For women with heavy menstrual bleeding, NICE recommends considering a levonorgestrel-releasing IUS as a first treatment in a number of circumstances, including when there is no identified pathology, with smaller fibroids that do not distort the womb cavity, or with suspected or diagnosed adenomyosis.

The reason is fairly straightforward.

The progestogen acts on the lining of the womb and can make it much thinner. As a result, menstrual bleeding can become considerably lighter.

For some women, this can make a huge difference to everyday life.

Less bleeding can mean fewer days worrying about leaks, less disruption to work and exercise, fewer restrictions on what you wear, and potentially an improvement in iron deficiency caused by heavy periods.

But there is an important part of this conversation that sometimes gets missed.

It may get worse before it gets better

The first few months after fitting can involve irregular bleeding, spotting or unpredictable bleeding.

For some women, this settles considerably with time. NICE advises women to be aware of these expected bleeding changes and that it may take several cycles to see the full benefit.

This is one reason I think it is important to have realistic expectations before having an IUS fitted.

If you are expecting perfect periods from the first month, you may be disappointed.

If you understand that the first few months can be unsettled and that the aim is often a gradual improvement, the experience can be very different.

And, of course, not everyone will have the same experience.

The IUS and HRT – an important combination

This is an area that is sometimes confusing.

If you have a womb and are using systemic oestrogen HRT, you need adequate progestogen to protect the lining of the womb.

Oestrogen on its own can stimulate the endometrium and increase the risk of endometrial hyperplasia.

A 52 mg levonorgestrel IUS can provide the progestogen component needed for endometrial protection alongside oestrogen HRT.

This means that, for some women, an IUS can effectively provide contraception and endometrial protection, while allowing the oestrogen component of HRT to be tailored separately to their menopause symptoms.

The British Menopause Society recognises the 52 mg levonorgestrel IUS as an effective method of providing endometrial protection with oestrogen therapy, with the added potential benefits of contraception and control of heavy menstrual bleeding.

There is an important distinction around how long it can be used for HRT compared with contraception.

The licensed duration can differ between products and indications. For example, Mirena has an extended contraceptive licence, but that does not mean that the duration of its licence for endometrial protection alongside HRT has automatically changed.

Current BMS guidance supports five years of endometrial protection from a 52 mg levonorgestrel IUS within HRT regimens based on the available evidence, although this is outside the manufacturer’s four-year licence for that particular indication.

This is a good example of why it is important to look at why the IUS is being used, rather than simply asking how many years a coil “lasts”.

Can a hormonal coil treat endometrial hyperplasia?

It can be an important part of treatment for some women with endometrial hyperplasia, but this needs to be discussed in the context of the specific type of hyperplasia and individual circumstances.

Endometrial hyperplasia means that the lining of the womb has become thicker or more disordered than expected. It can cause heavy, irregular or unexpected bleeding and, depending on the type, can increase the risk of developing endometrial cancer.

For hyperplasia without atypia, progesterone treatment can increase the chance that the hyperplasia will regress. RCOG patient guidance explains that progesterone can be given as tablets or through an IUS, and that the IUS is more likely to make the hyperplasia go away and may have fewer side effects than oral treatment.

The IUS may also be used in some women with atypical hyperplasia who are not having a hysterectomy, but this is a much more closely monitored situation because atypical hyperplasia carries a greater risk of progression. Regular biopsies and specialist follow-up are important.

So this is not simply a case of “having a coil to treat a thick womb lining”.

The diagnosis needs to be established properly, and the treatment and follow-up need to be tailored to the individual.

But what if I don’t want hormones?

That is completely reasonable.

There are very good reasons why someone may prefer a non-hormonal approach.

The copper IUD is an option for highly effective, long-acting contraception without hormonal contraception.

And if you are looking for treatment for heavy periods rather than contraception, there are also non-hormonal options such as tranexamic acid and non-steroidal anti-inflammatory drugs (NSAIDs), depending on your circumstances.

There are also other hormonal options, as well as procedures and surgery where appropriate.

It’s important to have the opportunity to discuss all the available treatment options, including their benefits and risks, the best treatment is not necessarily the one that works best on paper.

It is the one that works for you.

And what if I’ve heard some really bad stories about coils?

This is worth talking about.

If you search online for experiences of coil fitting or talked with friends who’ve had a bad experience, it’s understandably worrying to hear those difficult stories.

Pain during insertion. Difficult fittings. Persistent bleeding. Mood changes. Acne. The coil moving or coming out. People who simply hated how they felt with it.

Those experiences are real and should not be dismissed.

But there is another side to the story.

People who have a completely uneventful fitting, lighter periods and a contraceptive method they barely have to think about are perhaps less likely to write a post online about it.

Negative experiences can therefore become disproportionately visible.

That does not mean you should ignore them.

Quite the opposite.

They are useful things to know about before making a decision.

But they should sit alongside the experiences of women who have found an IUS life-changing, particularly those who have struggled with heavy bleeding, anaemia or difficult periods.

The important question isn’t:

“Are coils good or bad?”

It is:

“What are the potential benefits and downsides for me?”

Is a coil right for everyone?

No.

And I think it is important to say that clearly.

An IUS may not be suitable because of certain medical conditions, problems with the shape of the womb, unexplained bleeding or previous experiences with hormonal contraception.

Some women simply do not want something inserted into the womb.

Some do not want hormones.

Some would rather use tablets, patches, condoms or another form of contraception.

And some women may be looking for treatment of heavy bleeding where a coil is not appropriate because of the underlying cause.

Your reproductive plans, age, symptoms, medical history, bleeding pattern and personal preferences all matter.

A coil should never be presented as the only answer.

What about having it fitted?

For some women, the idea of the fitting is the biggest barrier.

An IUD or IUS is inserted through the cervix into the womb. The procedure is usually relatively quick, but it can be uncomfortable and some women experience significant pain.

Pain relief and individual circumstances should be discussed beforehand.

If you have previously had a difficult experience with cervical examinations, smear tests, coil fitting or childbirth, tell the person fitting your IUS.

That information matters.

Good contraceptive care should include a discussion about the procedure itself, what you can expect, and what options are available to make it as comfortable as possible.

So, is the coil a good option?

For some women, absolutely.

A hormonal IUS can provide highly effective reversible contraception, reduce heavy menstrual bleeding, and provide endometrial protection when used alongside oestrogen HRT.

For some women with endometrial hyperplasia, it can also form an important part of treatment.

A copper IUD offers highly effective contraception without hormones, but may not be the best choice if heavy or painful periods are already a problem.

And for other women, neither option will be right.

There are always alternatives to discuss.

The important thing is not to make a decision based solely on a friend’s experience, a social media post, or the assumption that because something is popular it must be right for you.

Equally, don’t rule something out simply because of someone else’s experience.

Ask questions.

Understand the potential benefits and risks.

Consider what matters most to you.

And make the decision with a healthcare professional who can take your individual circumstances into account.

The bottom line

There is no universally “best” contraception or treatment for heavy bleeding.

The hormonal IUS is an incredibly useful option for some women, particularly when contraception, bleeding control and endometrial protection are all important.

But it is only one option.

Whether you are considering a coil for contraception, heavy periods, as part of your HRT, or because you have been diagnosed with endometrial hyperplasia, the most useful conversation is an individual one.

What are you hoping to achieve?

What are you worried about?

What other options are available?

And most importantly:

What feels like the right choice for you?

“Should I be taking progesterone this time?”

It is a very understandable question after a miscarriage.

When you have been through the heartbreak of losing a pregnancy, finding out you are pregnant again can bring a mixture of emotions that are difficult to put into words.

There can be excitement, but also fear.

You may find yourself analysing every symptom, worrying about every twinge and wondering whether there is anything — anything at all — that you can do differently this time.

That is where progesterone often comes into the conversation.

You may have read that progesterone can help prevent miscarriage. You may have been offered it before. Or perhaps you have been told by someone else that you “should” be taking it from the moment you get a positive pregnancy test.

But the evidence is a little more nuanced than that.

Progesterone can be helpful in some circumstances, but it isn’t recommended for everyone who has experienced a miscarriage.

So let’s talk about what progesterone actually does, what the research tells us and where it may have a role.

What does progesterone do in early pregnancy?

Progesterone is one of the hormones that plays an important role in supporting an early pregnancy.

After ovulation, progesterone helps prepare and maintain the lining of the womb so that an embryo can implant and continue to develop.

In early pregnancy, progesterone continues to support the pregnancy while the placenta develops. Later in the first trimester, the placenta becomes the main source of progesterone.

So it is an important hormone.

But that doesn’t mean that every miscarriage happens because there isn’t enough progesterone.

And this distinction is really important.

Although progesterone is important in supporting early pregnancy, miscarriage is not usually as simple as having “too little progesterone”.

Many early miscarriages occur because the pregnancy itself has a chromosomal abnormality that means it cannot continue developing normally.

Taking progesterone cannot correct that.

This is one reason why progesterone isn’t simply prescribed to everyone who has experienced a previous miscarriage.

So why might progesterone help some women?

This is where the evidence becomes particularly interesting.

Research has looked at women who experience vaginal bleeding in early pregnancy — particularly before 12 weeks — and who have also had a previous miscarriage.

The theory is that progesterone may provide additional support to the pregnancy at a time when the pregnancy is vulnerable.

The large PRISM trial looked at women with early pregnancy bleeding and investigated whether vaginal micronised progesterone could improve the chance of having a live baby.

Overall, the difference between progesterone and placebo was relatively small.

But when researchers looked more closely at women who had previously miscarried, there appeared to be a benefit.

And the benefit became more apparent as the number of previous miscarriages increased.

This is why the current UK guidance is much more specific than simply saying “progesterone prevents miscarriage”.

What does the evidence actually show?

There are three groups worth separating.

1. Previous miscarriage AND bleeding in the current pregnancy

This is the group where the evidence is strongest.

If you have had at least one previous miscarriage and then develop vaginal bleeding in an early pregnancy, vaginal micronised progesterone may increase the chance of the pregnancy resulting in a live birth.

This is the situation in which NICE recommends offering progesterone.

Tommy’s summarises the evidence as suggesting that, among women who are bleeding in early pregnancy, progesterone may increase the chance of a successful pregnancy by around 5% for those who have had one or two previous miscarriages, and by around 15% for those who have had three or more previous miscarriages. These are estimates of the additional benefit seen in the research rather than a guarantee for an individual pregnancy.

2. Bleeding in early pregnancy, but no previous miscarriage

This is different.

The evidence has not shown the same clear benefit from progesterone for women who have bleeding in early pregnancy but have never previously miscarried.

That doesn’t mean the bleeding should be ignored — it absolutely needs appropriate assessment — but progesterone isn’t routinely recommended simply because bleeding has occurred.

3. Previous miscarriage, but no bleeding in the current pregnancy

This is another important distinction.

You might reasonably think:

“I’ve had a miscarriage before, so surely taking progesterone from the moment I get pregnant again would reduce my risk?”

It sounds logical.

Unfortunately, the evidence doesn’t currently support routine progesterone treatment simply because you have had a previous miscarriage.

The PROMISE trial looked at progesterone in women with previous unexplained miscarriages and did not demonstrate a significant improvement in live birth rates when progesterone was given routinely in the next pregnancy.

So at the moment, a previous miscarriage alone isn’t an indication for progesterone.

What does NICE recommend?

This is where the UK guidance is particularly helpful.

NICE recommends offering vaginal micronised progesterone 400 mg twice daily to women who have:

• vaginal bleeding in early pregnancy
• a history of at least one previous miscarriage
• and an ultrasound confirming that the pregnancy is in the womb.

If a fetal heartbeat is confirmed, NICE recommends continuing progesterone until 16 completed weeks of pregnancy.

One important point is sometimes missed here.

You do not necessarily have to wait until a heartbeat can be seen before progesterone can be started.

If it is very early in the pregnancy, an ultrasound may confirm that the pregnancy is in the womb while it is still too early to see a heartbeat. Current guidance allows progesterone to be started in this situation if the other criteria are met.

There is an important reason for establishing the location of the pregnancy.

Progesterone is not a treatment for an ectopic pregnancy, and bleeding in early pregnancy can have several causes. An ultrasound assessment is therefore an important part of deciding what is happening and what treatment, if any, is appropriate.

What if I’ve had more than one miscarriage?

This is an area where conversations can become particularly difficult.

If you have experienced recurrent miscarriage, it is completely understandable to want to try anything that might improve your chances next time.

The evidence suggests that progesterone is particularly helpful when recurrent miscarriage is accompanied by bleeding in an early pregnancy.

However, progesterone hasn’t been shown to reliably prevent recurrent miscarriage when there is no bleeding in the current pregnancy.

That can feel frustrating when what you really want is something proactive that you can do.

But sometimes good medical care involves being honest about where the evidence stops.

Does progesterone guarantee that the pregnancy will continue?

No.

And this is important to understand before starting treatment.

Progesterone may increase the chance of a live birth in the particular group of women where the evidence supports its use, but it cannot prevent every miscarriage.

Some pregnancies will unfortunately miscarry despite progesterone because the underlying reason for the miscarriage is unrelated to progesterone.

It is also important not to interpret a miscarriage as meaning that you “didn’t have enough progesterone” or that you should have taken it sooner.

Pregnancy loss is rarely that simple.

Is progesterone safe?

The research so far has not identified evidence of harm to the mother or baby from progesterone when used for this purpose.

NICE considers the potential benefits and risks when making its recommendations. Tommy’s also explains that, while current evidence is reassuring, there is not enough evidence to completely rule out very rare events or every possible long-term outcome.

As with any treatment in pregnancy, it is sensible to have a conversation with your healthcare professional about your individual circumstances.

Why is an early pregnancy scan important?

If you have previously experienced miscarriage, another pregnancy can feel very different from the first.

You may want to know as soon as possible that the pregnancy is in the womb and developing as expected.

An ultrasound scan can help establish the location of the pregnancy and, depending on how far along you are, whether a fetal pole and heartbeat can be seen.

It can also help guide decisions about progesterone if you are experiencing bleeding.

And sometimes it is simply too early to see everything clearly.

That doesn’t necessarily mean something is wrong. Early pregnancy changes very quickly, which is why a repeat scan may sometimes be recommended if the first scan is inconclusive.

But I think there is another side to this that is sometimes overlooked.

After miscarriage, reassurance matters too.

A scan cannot guarantee that a pregnancy will continue, but for some women it can provide an important point of reassurance and help make sense of what is happening.

What if I feel I need a little more reassurance this time?

This is where individualised care matters.

You may have had one previous miscarriage, or several.

You may have had bleeding in a previous pregnancy.

You may have used progesterone successfully during fertility treatment.

Or perhaps you have been given progesterone in a previous pregnancy and are wondering whether the same approach should be used again.

These circumstances aren’t necessarily interchangeable.

The right question isn’t simply:

“Does progesterone work?”

It is:

“Does the evidence suggest progesterone is likely to help someone in my particular situation?”

That is a much more useful conversation.

And what about progesterone after a miscarriage itself?

It is worth making another distinction here.

Progesterone is not a treatment for a miscarriage that has already occurred.

Once a pregnancy has unfortunately ended, progesterone cannot reverse the miscarriage.

The role we are talking about is supporting a subsequent pregnancy in particular circumstances — especially when there is bleeding in early pregnancy and a previous miscarriage.

That distinction can easily become blurred online.

The emotional side matters too

There is something else I think is important to say.

After a miscarriage, it is very easy to feel that you should have done something differently.

A miscarriage is not usually something you caused, and taking progesterone is not a guarantee that a pregnancy will continue.

When you become pregnant again, it is entirely understandable to want more monitoring, more information and more reassurance.

That doesn’t make you anxious or difficult.

It means you’ve been through something difficult.

So, could progesterone be right for you?

The answer depends on your circumstances.

The strongest UK evidence is for women who have had a previous miscarriage and develop vaginal bleeding in a subsequent early pregnancy, particularly before 12 weeks, once an intrauterine pregnancy has been confirmed by ultrasound.

For women who have had a previous miscarriage but have no bleeding, routine progesterone is not currently supported by the evidence.

And for women experiencing bleeding who have never previously miscarried, progesterone has not been shown to provide the same benefit.

That doesn’t mean there is nothing that can be done.

It means the focus should be on assessing the pregnancy properly, understanding your individual history and deciding what is appropriate for you.

At West Wales Women’s Wellbeing, we offer early pregnancy ultrasound scans and can talk through what is happening in your pregnancy, including whether progesterone may be appropriate in light of your previous pregnancy history and current symptoms.

The aim isn’t to prescribe progesterone simply because you’ve had a miscarriage.

It is to help you understand whether there is good evidence that it could benefit you.

The bottom line

Progesterone is an important hormone in early pregnancy, but the evidence for giving additional progesterone is quite specific.

It isn’t a universal treatment after miscarriage.

For women with a previous miscarriage who experience bleeding in an early pregnancy, there is good evidence that vaginal micronised progesterone can increase the chance of a live birth, and this is reflected in current NICE guidance.

For women with a previous miscarriage but no bleeding, the evidence does not currently support routine progesterone treatment.

And perhaps most importantly, having a miscarriage does not mean that your next pregnancy is destined to end in the same way.

Sometimes what women need most is not simply another medication.

It is careful assessment, honest information, appropriate monitoring and someone who understands why the next pregnancy can feel so frightening.

You don’t have to navigate that uncertainty alone.

Further support after miscarriage

If you’ve experienced miscarriage and would like further information or support, Tommy’s has a wealth of evidence-based information about miscarriage, pregnancy after miscarriage and progesterone in early pregnancy.

They also have a specialist midwife team who can offer support and answer questions about pregnancy loss.

You can find their information and support through Tommy’s website.

Recently, I’ve had a number of conversations with women who have been told that they have an ovarian cyst or an adnexal mass.

Understandably, this can cause anxiety.

The questions are often very similar:

“Could this be cancer?”

“My CA125 is raised. Should I be worried?”

“Should I have an HE4 test?”

“What are RMI and ROMA?”

Because I’ve found myself having these conversations increasingly often, I wanted to explain some of the things I look at when assessing an ovarian cyst or adnexal mass.

The first thing to say is reassuring:

Most ovarian cysts and adnexal masses are benign.

However, identifying which masses are reassuring, which need surveillance and which require further investigation or specialist referral is extremely important.

At West Wales Women’s Wellbeing, our approach is based on a simple principle:

We don’t rely on one thing.

A blood test, an ultrasound feature or a risk score should not be considered in isolation.

Instead, we bring together your clinical history, menopausal status, specialist in-house ultrasound, recognised ultrasound terminology, risk models, pattern recognition and blood biomarkers where appropriate.

The aim is to build a holistic assessment of your individual risk and, importantly, decide what should happen next.

What is an adnexal mass?

The term adnexal mass can sound worrying, but it simply describes an abnormality arising from the ovary, fallopian tube or surrounding tissues.

There are many possible causes.

These include simple ovarian cysts, haemorrhagic cysts, endometriomas associated with endometriosis, dermoid cysts and many other benign conditions.

A much smaller proportion will represent borderline or malignant disease.

So finding an ovarian mass does not mean that you have ovarian cancer.

The important question is what that particular mass represents and how confident we can be about its nature.

It starts with the ultrasound

A specialist gynaecological ultrasound is at the heart of our assessment.

Modern ultrasound can tell us considerably more than simply whether a cyst is present or how large it is.

We assess the morphology, or architecture, of the mass in detail.

For example:

• Is it a simple fluid-filled cyst?
• Is it unilocular or multilocular?
• Are there solid components?
• Are papillary projections present?
• What does the cyst wall look like?
• What pattern of blood flow is present?
• Is there free fluid?
• What does the other ovary look like?
• Are there other findings within the pelvis?

Just as importantly, we consider how these findings fit together.

Ultrasound terminology and pattern recognition

We use standardised ultrasound terminology, including internationally recognised approaches developed by the International Ovarian Tumor Analysis (IOTA) group.

Why does terminology matter?

Because describing an ovarian mass consistently allows us to move beyond vague terms such as “complex ovarian cyst”.

A detailed description of the morphology of a mass helps us understand what it is likely to represent and enables meaningful risk assessment.

Alongside this structured assessment, specialist ultrasound also involves pattern recognition.

Certain ovarian masses can have characteristic ultrasound appearances. The combination of their shape, internal structure, echogenicity and vascular pattern can provide important clues about their likely pathology.

Pattern recognition is therefore an important part of specialist gynaecological ultrasound, particularly when combined with validated assessment models.

The IOTA ADNEX model

Where appropriate, we can use the IOTA ADNEX model, which stands for Assessment of Different NEoplasias in the adneXa.

ADNEX combines specific clinical and ultrasound features to estimate the probability that an adnexal mass is benign or malignant.

One of its strengths is that it goes beyond a simple “low risk/high risk” answer. The model can provide estimates across different categories of disease, helping add further structure to the ultrasound assessment.

But the same principle applies here as it does to blood tests:

ADNEX is a tool to support clinical assessment, not replace it.

We interpret the result alongside the actual ultrasound images, pattern recognition, your history and other relevant investigations.

What about CA125?

CA125 is probably the blood test most commonly associated with ovarian cancer.

It can be extremely useful, but it is also frequently misunderstood.

CA125 is not, by itself, a test for ovarian cancer.

Some ovarian cancers produce increased amounts of CA125, but many benign conditions can also cause it to rise.

These include conditions such as endometriosis, fibroids, menstruation and pelvic inflammation.

This is particularly important in premenopausal women.

Conversely, a normal CA125 does not completely exclude ovarian malignancy.

So when somebody comes to clinic concerned about an abnormal CA125, we don’t simply look at whether the number is inside or outside the laboratory reference range.

We ask a much more useful question:

What does this CA125 result mean in the context of this woman’s ultrasound, symptoms, menopausal status and overall clinical picture?

What is the RMI?

The Risk of Malignancy Index (RMI) is an established method of estimating the risk associated with an ovarian mass.

It combines three pieces of information:

RMI = Ultrasound score × Menopausal status × CA125

This is important because the RMI does not rely on the CA125 result alone. It incorporates specific ultrasound features and whether a woman is pre- or postmenopausal.

The resulting score can help determine whether further investigation or referral into a specialist pathway is appropriate.

However, an RMI remains a risk assessment, not a diagnosis.

A high RMI does not mean that someone definitely has ovarian cancer, and a low RMI cannot provide an absolute guarantee that a mass is benign.

It is another piece of the overall picture.

What is HE4?

HE4 stands for Human Epididymis Protein 4.

Like CA125, HE4 is a biomarker that can be measured in the blood. Levels may be increased in some epithelial ovarian cancers.

HE4 behaves somewhat differently from CA125, which means that in selected situations it can provide additional information.

This can be particularly useful when CA125 is difficult to interpret in isolation.

But HE4 has limitations too.

Its level can be affected by factors including age and kidney function, and an elevated HE4 does not diagnose ovarian cancer.

It needs context.

What is ROMA?

This brings us to another acronym that women are increasingly encountering: ROMA.

ROMA stands for the Risk of Ovarian Malignancy Algorithm.

It combines:

CA125 + HE4 + menopausal status

These factors are used within an algorithm to classify the risk associated with an adnexal mass.

This is quite different from the RMI.

RMI uses:

Ultrasound + CA125 + menopausal status

ROMA uses:

HE4 + CA125 + menopausal status

ROMA therefore adds information from a second biomarker, HE4, but does not directly incorporate the detailed ultrasound appearance of the mass.

ROMA is also not an ovarian cancer screening test for women who do not have an adnexal mass.

And, importantly, a higher-risk ROMA result does not mean that ovarian cancer has been diagnosed.

It tells us something about risk.

RMI, ROMA or ADNEX: which is best?

This is perhaps the wrong question.

Each looks at the problem from a slightly different angle.

RMI combines a relatively simple ultrasound score with CA125 and menopausal status.

ROMA combines two biomarkers, CA125 and HE4, with menopausal status.

ADNEX uses much more detailed information about the ultrasound appearance of the mass alongside clinical information, with CA125 incorporated where appropriate.

And then there is the clinician’s pattern recognition, interpreting what the mass actually looks like in real time.

Rather than placing all our confidence in one number, at WWWW we prefer to ask:

Do all the different pieces of information tell a consistent story?

That is a much more useful clinical question.

Putting the pieces together

Our comprehensive adnexal mass assessment therefore brings together several different layers of information.

Your story

Your symptoms, age, menstrual or menopausal status, medical and family history, previous imaging and how the mass was discovered.

Specialist ultrasound

A detailed in-house gynaecological ultrasound assessing the morphology and vascularity of the mass and the remainder of the pelvis.

Standardised terminology

Using recognised ultrasound terminology so that the features of the mass are described systematically rather than simply labelling it a “complex cyst”.

Pattern recognition

Considering whether the combination of ultrasound appearances suggests a recognisable benign or malignant pattern.

Validated risk assessment

Using models such as IOTA ADNEX or RMI where appropriate.

Biomarkers

Interpreting CA125 and, in selected circumstances, additional markers such as HE4 and ROMA within the wider clinical picture.

It is the combination that matters.

What happens after the assessment?

The purpose of all of this is not simply to generate another score.

It is to answer the question that actually matters:

What should we do next?

For some women, the ultrasound appearances are reassuring and no further investigation may be required.

For others, repeating an ultrasound after an appropriate interval may be recommended.

Sometimes additional blood tests, further imaging or another specialist opinion is helpful.

And occasionally the safest recommendation is referral into an NHS specialist gynaecology or gynaecological oncology pathway.

A good assessment should therefore provide more than a description of an ovarian cyst.

It should provide a clear clinical plan.

“So, should I worry about my ovarian cyst?”

In most cases, an ovarian cyst will ultimately prove to be benign.

But understandably, being told that you have an ovarian mass can create considerable uncertainty, particularly if you have also received an abnormal blood result.

Our approach is not to provide reassurance based on one number alone.

Nor do we believe that simply ordering more blood tests necessarily provides a better answer.

Instead, we bring together specialist ultrasound, recognised ultrasound terminology, pattern recognition, validated risk models such as ADNEX and RMI, and biomarkers including CA125 and, where appropriate, HE4 and ROMA.

This allows us to develop a more complete, individualised assessment of risk.

Because ultimately the most useful question isn’t:

“Is my CA125 normal?”

or:

“What is my ROMA score?”

It is:

“When we put everything together, what does my ovarian mass most likely represent, what is my individual risk, and what should happen next?”

That is the question a comprehensive adnexal mass assessment should help answer.