27 October 2017

Heavy menstrual bleeding better managed by GPs

Clinical General practice Women

The first national clinical standards have been developed to stem the tide of unnecessary hysterectomies, as less invasive therapies for women with heavy periods are being overlooked.

Australians are more likely to have the major operation, which carries risks of incontinence, prolapse and early menopause, than women in comparable countries, such as the UK and New Zealand, and rates of uptake vary greatly inside the country.

Regional Australia has much higher rates of hysterectomies than metropolitan areas, with some areas sevenfold higher than others, and endometrial ablation varies as much as 21-fold, according to data published in June.

This level of variation indicated women were not being given access to, and perhaps not informed about, less invasive options, Professor Anne Duggan, senior medical adviser for the Australian Commission on Safety and Quality in Health Care, said.

“Since the 1970s there has been such a development in treatments for heavy menstrual bleeding.

“In particular [there is] the intrauterine device that releases hormones, that can manage heavy menstrual bleeding, works for up to 80% of women and protects them from ever needing to have surgery.”

To combat the problem, the commission has released clinical care standards that emphasise most patients are best managed by GPs.

Heavy periods, which affect one in four women of reproductive age, could be distressing, disrupting and painful. But it was becoming apparent that many women did not even know their menstrual bleeding was abnormal, and so might not know to seek help, Professor Duggan said.

“There’s an enormous amount to be gained from getting this right,” she added.

Asking women how many pads or tampons they typically go through, or whether they flood through clothing or are unable to leave the house ever because of their periods, can be useful in gauging whether they may be helped by treatment.

One in two women will have an identifiable cause for the heavy bleeding, such as fibroids, but for the remaining 50% there might be an undue pressure to get invasive interventions such as hysterectomies.

The major message in the online booklet is that first-line treatment for women should be pharmaceutical therapy if appropriate, with the most effective being the levonorgestrel intra-uterine system.

Other options to consider are tranexamic acid, NSAIDs, combined oral contraceptives, cyclic norethisterone or injected long-acting progestogens.

But referring to a specialist can be appropriate when women who don’t respond to six months of medical treatment, or when there is a suspicion of malignancy or other significant pathology.

The recommended first-line imaging test for suspected structural pathology is a transvaginal ultrasound, and the authors stress the importance of timing it during days five to 10 of the woman’s cycle to get the most accurate measure of endometrial thickness and prevent repeated tests.

Professor Duggan said the adoption of the standards would “make a huge difference to many, many women’s lives now and the future”.

“It would be incredibly frustrating to know you may have been one of the 80% of people who could be treated with an IUD.”

Even if a woman is still considering surgical management for their heavy periods, of benign causes, offering another uterine-preserving procedure, such as endometrial ablation or excision of the local pathology, is recommended.

The national standards, which have been endorsed by groups such as Family Planning NSW, Jean Hailes and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, also recommend routinely checking for and, if necessary, treating iron deficiency and anaemia.

To read the Heavy Menstrual Bleeding Clinical Care Standard, visit http://bit.ly/2i475Ph

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Glenn Rosendahl
Glenn Rosendahl
1 year 10 days ago
I am not sure that Professor Duggan understands general practice. Although, since she is a gastroenterologist, she has lived on referrals from general practitioners, before she became an academic and advisor. She she will know of the quality of the referral documents she has picked up and actioned. Certainly, she knows – because it is described in the Heavy Menstrual Bleeding Clinical Care Standard – how she would undertake this task, if she was called on to do it. What the Standard describes is how a specialist would undertake the task. A specialist paid at the specialist MBS rate, with… Read more »