Almost everything else in this library is about things you can influence yourself. This article is the opposite, and it is the most important one here.

There is a category of symptom that does not respond to sleep, protein, fibre, movement or stress management, because it is not that kind of problem. What it responds to is someone examining you. Working on your habits while one of these is present is not neutral, it costs time, and time is the main thing that determines how these stories end.

None of the lists below mean something is seriously wrong. Most of these symptoms turn out to have ordinary explanations. They are on the list because the small proportion that do not are the ones worth catching early.

Bleeding

Bleeding is where the clearest rules exist, so it is worth knowing them precisely.

Any bleeding after menopause. If it has been a full twelve months since your last period and you bleed at all, even once, even lightly, even if it looks like spotting on tissue, that needs to be checked. Every time.13 16 This is the firmest rule in women’s health, and the reason is that it is the earliest sign of a cancer of the womb lining, which is highly treatable when found early and much less so when found late. Most cases turn out to be something benign. That is exactly why finding out is quick.

Bleeding between periods, or after sex. Both warrant an appointment rather than watching for a few more months.2 16 There is a long list of ordinary causes, and a short list of ones you want excluded.

Heavy bleeding, defined usefully. The clinical definition is vague, so use these instead. Soaking through a pad or tampon every hour for several hours. Needing to double up on protection. Getting up at night to change protection. Passing clots larger than a coin. Bleeding for more than seven days.1 Planning your day around where the bathrooms are.

Pain

Pain has a wide normal range, which is exactly why the boundaries are worth stating.

Sudden, severe pelvic pain that arrives within minutes and is unlike anything you have had is an emergency, particularly with fever, vomiting or faintness. Contact emergency services rather than waiting it out.

Period pain that stops your life is not something to accept. Pain that keeps you off work, that does not respond to standard painkillers, or that has clearly worsened over a few years deserves investigation.4 Endometriosis takes years to diagnose in most women, and much of that delay comes from the symptom being described as normal by everybody involved.

Pain during sex, particularly if it is new, is a symptom rather than a preference or a mood problem. It has physical causes that are identifiable and usually treatable.4

Pain that is not cyclical at all but is persistent and in one place is worth attention precisely because it does not fit the hormonal story.

Bloating and bowel changes

This is the section most often mistaken for a food problem, and it is the one where that mistake costs the most.

Bloating that is there most days, for three weeks or more, and does not come and go with your cycle or your meals, needs an appointment.6 Persistent daily bloating is one of the main early signs of ovarian cancer, and it is routinely treated as a digestive complaint for months.3 Feeling full quickly, needing to urinate more often and pelvic discomfort alongside it make this more urgent, not less.3

A lasting change in your bowel habit of more than three weeks, in either direction, deserves the same attention.7 8

Blood in your stool, whether bright red or dark and tarry, is always worth reporting, including when you have piles, because having one explanation does not exclude another.7

Unintended weight loss that you did not set out to achieve is a symptom in its own right and one that should never be filed as good news.3 8

Breasts

Feeling for lumps monthly matters less than knowing what your own breasts normally feel like, so that a change registers.

Book an appointment for a new lump or thickening that does not go away after a period, a change in the size or shape of one breast, any discharge from a nipple that you did not squeeze out, a nipple that has newly turned inward, skin that has become dimpled or has the texture of orange peel, a rash or crusting on the nipple, or a lump in your armpit or around your collarbone.5

Most breast lumps are not cancer, and lumpiness that changes with your cycle is common.5 What matters is new, persistent and one sided.

Heart symptoms, which look different in women

This deserves its own section because the picture most people carry in their heads is the picture from men.

Women having a heart attack are more likely than men to have no chest pain at all. What they get instead is sudden and unusual breathlessness, pain in the jaw, neck, back or between the shoulder blades, nausea or vomiting, a cold sweat, or an overwhelming and unexplained exhaustion. Often several of these together, and often described afterwards as feeling wrong rather than as pain.

Because it does not look like the film version, women delay calling for help longer than men do, and they are more likely to be sent home from an emergency department. Neither of those facts is your fault, and neither is a reason to wait.

If this comes on suddenly, call emergency services. Do not drive yourself, and do not wait to see whether it settles.

Mood and mind

Low mood that lifts and returns with your cycle is a different thing from low mood that stays.

Contact a doctor if your mood has been low most days for more than two weeks, if things you normally enjoy have stopped registering at all, if you cannot sleep or cannot stop sleeping, if anxiety is stopping you doing ordinary things, or if you feel disconnected from people you love.11 12

If you are having any thoughts of harming yourself, contact a doctor or your local emergency services today. This is a medical situation and it is treated as one. It is not a character problem and it is not something to hold on your own.

Two things are worth knowing. Perimenopause can produce genuine depression and anxiety, sometimes in women with no previous history, and it is frequently missed because the age group is assumed to be simply stressed.13 And low mood is also produced by thyroid problems and by iron deficiency, both of which are simple blood tests, which is a reason to ask for them rather than to assume.10 9

Three more that get quietly normalised

Some symptoms are missed not because they are subtle but because women are told, often for years, that they are simply part of being a woman.

Urinary symptoms. Needing to rush to the toilet, leaking when you cough or run, or repeated urine infections are extremely common after childbirth and around menopause.13 Common is not the same as untreatable. There are effective treatments for all three, and the reason most women never get them is that they never mention it. Blood in your urine is a separate matter and always needs checking.

Vaginal dryness, burning or discomfort. These are physical changes with physical treatments, and they are not something to wait out.13 Any new sore, lump or persistent itch on the vulva should be examined rather than treated with another cream.

Exhaustion that does not match your life. Being tired because you sleep six hours and have small children is not a mystery. Being exhausted while sleeping well, or suddenly rather than gradually, is different, and it is the version worth investigating. Thyroid problems, iron deficiency, sleep apnoea, coeliac disease and depression all present this way and all are identifiable.10 9 8 The trap is that fatigue is so unspecific that it invites a shrug, which is exactly why it should not be the symptom you lead with.

How to be heard

Being dismissed is common enough that preparing for it is practical rather than pessimistic. These things change how an appointment goes.

Take this to the appointment

  • A written timeline with dates, one page, handed over
  • Your most specific symptom stated in the first sentence
  • How the symptom limits what you do, in concrete terms
  • A list of your medicines and supplements
  • The one question you most need answered
  • Someone with you, if you expect it to be difficult

Lead with the discriminating symptom. This is the single highest value change. Fatigue, feeling off and being run down are true but they fit hundreds of conditions, and opening with them steers a consultation towards stress. Open with the thing that narrows the field: the bleeding between periods, the daily bloating for six weeks, the lump. Then add the tiredness.

Bring dates. Since March is dramatically more useful than for a while, and it changes how seriously a description lands.

Say what it stops you doing. I have missed four days of work since April carries information that quite bad does not.

Ask for the actual numbers. If bloods are done, ask for the values and the ranges rather than accepting normal. Normal is a wide band and your position within it can matter.

What else could this be, and how would we rule it out?

The most useful sentence in a difficult appointment

If you have been dismissed

It happens, and to a great many women. What follows is not a complaint strategy, it is a set of things that work.

Ask the question above, plainly and without hostility. It shifts a consultation from reassurance to reasoning, and it often produces the referral on its own.

If you are still not satisfied, ask for your concern and the decision not to investigate to be recorded in your notes. This is a reasonable request, it is normally granted without argument, and it changes the calculation on the other side of the desk more than anything else you can say.

Ask directly for a second opinion or a referral. You are allowed to, and it does not require a justification beyond wanting one.

Go back if it does not settle. Nothing about a first appointment prevents a second. A symptom that persists past the timeframe you were given is new information, and it should be treated as such rather than as the same visit repeated.

Where you can, take someone with you. Not because you cannot speak for yourself, but because a witness changes the room, and because remembering what was said is harder than it should be when you are worried.

What none of this means

It is worth ending honestly, because a list like this can leave you scanning your body for evidence.

Most of these symptoms have dull explanations. Most bloating is food and cycle related. Most breast lumps are benign. Most heavy periods are fibroids or hormonal rather than anything worse.1 The purpose of the list is not to make you afraid of your body, it is to remove the guesswork about which things are worth an appointment, so that you can stop weighing it up privately at eleven at night.

The rule underneath all of it is simple. If something is new, persistent past a few weeks, one sided, or getting steadily worse, it gets looked at. Everything else in this library is for the part of your health that responds to what you do. This part responds to being seen.