Kent, DA3 8ND
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If I could only spend 10 minutes with a patient presenting with:
NICE has recently produced guidance on the management of heavy menstrual bleeding. For the most part, this guidance is sensible and reflects the practice of modern gynaecologists. Some women with heavy periods have identifiable diseases and on rare occasions these can be serious in nature. As well as other gynaecological symptoms, their management will often depend on their age, contraceptive needs, concerns and prejudices.
I find it helpful to start with a full list of available treatments in my mind and, as the consultation progresses, place these in order of suitability for the patient. Thus, as well as looking for indicators of the need for further investigation, I am constantly checking the appropriateness of the wide range of treatments that are available.
I would divide my consultation into:
Establish the nature and range of symptoms
- Establish the nature and range of symptoms.
- Investigations, if necessary.
- Make a diagnosis if possible.
- Discussion of a short-list of treatment options with the patient.
There have been studies which have measured the volume of menstrual blood loss which show that around 50% of women complaining of heavy periods actually have normal periods. Outside of a research setting, the quantification of menstrual loss is not very accurate and NICE advise that women should be treated according to their perception of their periods.
Go through the following:
- When did symptoms start?
- Duration of period and how many days are heavy?
- Length of menstrual cycle? - many women only count from the end of one period to the beginning of the next, so clarify this carefully if they say they have a short cycle.
- Menstrual pain and severity? - clearly subjective but I find that women who take time off work often have a significant cause.
- If the periods are painful, ask about pain between periods and dyspareunia. Cyclical premenstrual pain suggests endometriosis, as does deep dyspareunia especially when it persists after intercourse.
- Intermenstrual bleeding? In younger women think (and check for) Chlamydia. A few days postmenstrual or premenstrual spotting may be an inconvenience but does not suggest disease. Persistent IMB without a pattern may have a benign cause such as a cervical/endometrial polyp, chlamydia or minipill usage, but should be regarded as a very significant symptom warranting careful assessment and, especially in women over 30, referral.
- Postcoital bleeding? Although PCB can be a symptom of cervical cancer, it is not a good indicator of such and is not an indication for referral to a Rapid Access Clinic. Remember that cervical cancer does not occur before the age of 25 and is very rare before the age of 30. In younger women think (and check for) Chlamydia. A vaginal examination is clearly necessary. Persistent PCB warrants referral to a colposcopy clinic.
- Date of last smear? This is a good opportunity to check.
- Age? This has a huge effect on the likely causes and also the treatments that I recommend.
- Parity and mode of deliveries? I can fit a Mirena in a nulliparous women, but you may struggle.
- Current contraception? If contraception is needed then try to find a method which will also lighten the periods. If she has a copper coil, then change it to a Mirena.
- Make sure she is not currently trying to get pregnant.
- Establish which treatments (including doses) have been tried in the past.
- Ask about concerns. She may have a friend with similar symptoms who was later diagnosed with cancer. There may be concerns about future fertility.
- Ask about expectations. Some women simply want reassurance, others want treatment and some are quite adamant that they need a hysterectomy (often like their mother and sister had).
In the absence of other symptoms that may suggest significant disease (IMB, PCB, prolonged bleeding), women who just have heavy periods do not need to be examined according to NICE guidelines. Other women, and those who do not respond to simple treatments should have an abdominal and pelvic examination. Obviously, a smear should be taken if it is due. Take an endocervical swab for Chlamydia if there is IMB, pelvic pain or fertility issues especially in the under 25s.
A vaginal examination in a relaxed thin woman reliably excludes an enlarged uterus. Don't place so much faith in a VE if the woman is overweight.
All women with heavy periods should have a full blood count. There is no need to check thyroid function (unless other symptoms suggest a problem) or female hormones.
Ultrasound scanning is now the first-line tool for investigating for structural abnormalities of the uterus. Indications for requesting an ultrasound scan are:
Indications for an endometrial biopsy (to exclude atypical hyperplasia and endometrial cancer) include:
- The uterus is palpable abdominally.
- Vaginal examination reveals a pelvic mass of uncertain origin.
- Pharmaceutical treatment fails.
- Significant IMB.
NICE does not give guidance on when a woman should be referred for specialist care and presumably this reflects a wide variation in service provision within Primary Care. Most GPs will refer when a woman needs further investigation or when the woman requests a treatment that is only available in secondary care.
- Ineffective treatment in women aged 45 years or more. This guidance is different from the previous prevailing opinion.
- Persistent IMB, especially in women over 40 years and when there is no pattern to the loss.
- In women over 40 years -prolonged periods, especially with a shortened cycle. (This is not NICE guidance but bleeding for 10 days out of every 20 causes me some concern.)
NICE recommends that it women in whom pharmaceutical treatment is appropriate (those with no or only small fibroids), and both hormonal and non-hormonal treatments are acceptable, treatments should be considered in the following order:
- Mirena - provided use for more than 12 months is anticipated. The Mirena device has revolutionised gynaecological practice in recent years, leading to a large reduction in hysterectomy rates. It is ideal for women who have had one or more vaginal births and whose uterus is not too enlarged - the cavity length (<10cm ideally) is more important than the size of any subserosal fibroids - if in doubt, refer to a gynaecologist
- Tranexamic acid (1g tds during period) or NSAIDS or the Combined Pill. NSAIDs are preferred to Tranexamic acid in women with dysmenorrhoea, but they can be combined. If effective, these non-hormonal treatments can be used long-term. However, if no benefit has been seen after 3 cycles they should be stopped. The Combined Pill will almost always be the treatment of first choice in young women.
- Norethisterone 15mg daily from day 5-26 of the cycle or Depo-Provera. The use of progestogens only in the luteal phase of the cycle is not effective.
These are suitable for women who do not want the pharmaceutical treatments, in whom they are ineffective / not appropriate, and in women with certain histological abnormalities of the endometrium.
NICE feels that Endometrial Ablation (but not hysterectomy) can be offered to women as initial treatment for menorrhagia. It is only appropriate for women who have completed their family, but reliable contraception must be used afterwards. It is not suitable for women with a large uterus.
There are several different methods of endometrial ablation and the colleagues I speak to cannot reproduce the excellent results that have been achieved in the trials that have been funded by the device manufacturers (surprise, surprise). Ask your gynaecologist what his/her medium or long-term success rate is. If they don't know, find another gynaecologist!
NICE say that hysterectomy should not be used as first-line treatment solely for heavy periods unless all other treatments are contra-indicated or refused by the woman. In practice, many women request hysterectomy because they are unaware of other treatments or have misconceptions about them. NICE guidance says that women referred for specialist care should be given written information about all the treatment options prior to their appointment. This is a key priority for implementation and will be welcomed by most gynaecologists. There are many types of hysterectomy nowadays and a good surgeon will match the right operation with the right patient.
Uterine fibroid embolisation
Most gynaecologists think that this new and still experimental treatment has received undue prominence in the NICE guidelines. It clearly has a role which I do not think has been properly defined as yet.