This is a case study analysis and discussion on a patient who started to have complaints of heavy and painful menstrual bleeding two years ago. To start with the bleeding was lesser than it is now. From both subjective and objective measures, the extent of bleeding has increased progressively in quantity over time. Throughout this assignment, this patient will be named as “the patient” and her identity will remain undisclosed. She had a family history of uterine fibroids.
NICE (2007) has defined heavy menstrual bleeding (HMB) as excessive menstrual blood loss over the limit of normal amount of menstrual blood loss which interferes with a woman’s physical, social, emotional and/or material quality of life. (NICE, 2007). Prevalence of HMB is 4-9 % (Harlow and Campbell, 2004). It has been estimated that one in twenty women seeks medical attention for HMB (NICE, 2007). By definition, thus, it is prolonged or heavy cyclic menstruation. Objectively, menses lasting longer than 7 days or exceeding 80 mL of blood loss qualify HMB (Shapley et al., 2007).
Graph of the rate of women presenting to practice with diagnosis of heavy menstrual bleeding by age range. Incidence rate:
National Costing Report: Heavy menstrual bleeding (January 2007)
The graph above represents the annual rates of heavy menstrual bleeding in different age groups and shows its prevalence in virtually all age groups with the highest incidence in age group 45-49. As indicated in Bonnar and Sheppard (1996), the causes of heavy menstrual bleeding have been tabulated below.
Common causes for HMB include (Bonnar and Sheppard, 1996).
|Local Causes||Fibroids((30%of women), polyps, adenomyosis, endometriosis , infections, pelvic inflammatory disease, carcinoma including endometrial carcinoma and ovarian pathology|
|Intrauterine Contraceptive Devices (IUCD)||Non-medicated and copper releasing IUCD|
|Haemostatic Disorder||Coagulation deficiencies of factor V, IX, X, XI, XII, XIII, von Willebrand’s disease and severe thrombocytopenia.|
|Dysfunctional||No underlying organic disease.10% of women|
|Other Causes||Thyroid gland disorder, Drugs(anticoagulants)|
The Case Description
This patient came to a Women’s Health Clinic via the Choose and Book system. Choose and Book system is a national electronic referral service introduced in England in the summer of 2004. This system gives patients a choice of place, date and time for their first outpatient appointment in a hospital or a clinic (de Kare-Silver, 2005). The Women’s Health Clinic is run by female practitioners with a special interest in Gynaecology. This clinic was set up in 2002 to assist male general practitioners in this area, whose female patients suffer from gynaecological conditions. About 61% of female patients registered with GPs in this area are of South Asian origin (Webb, 2004), and over a third of women have no access to a female GP within their practice. These ladies prefer to come to the Women’s Health Clinic for their initial management.
Before attending this consultation, the patient had an ultrasound done. The General Practitioner wanted to rule out any structural pathology that could contribute to her HMB. Ultrasonography report confirmed the presence of small-sized fibroids. Although information regarding the endometrium was possible to be obtained from the ultrasonogram, unfortunately the sonologist did not comment on the endometrial regularity and thickness, which are important for differentiating the causes of HMB. She had a one-centimetre submucous and two small intramural fibroids. Although sub-mucous fibroids are associated with HMB (RCGP, 2005), it is still possible that in this patient, HMB was not solely due to fibroids. Royal College of Obstetricians and Gynaecologists (RCOG) suggest initial treatment with oral Tranexamic acid and Mefenamic acid for regular painful HMB if contraception is not required for at least three months (Grant et al., 2000). National Institute of Clinical Excellence suggests IUS as first line of treatment if contraception is needed as in this case (NICE, 2007). RCOG recommends that if a woman complaining of HMB has not improved with appropriate drug therapy, only then a further assessment of uterine cavity is needed unless obvious structural or histological abnormality is suspected (RCOG, 1998). This can be accomplished with either transvaginal ultrasound or diagnostic hysteroscopy. A physical examination was not performed as she preferred female practitioner. She had also not received any conservative treatment prior to her scan. The presence of fibroids was mentioned to her at the time of the scan. As a result of this and due to experience and advice of another family member, she felt that a hysterectomy was needed, although it appeared to be a misguided decision.
Fibroids are very common. At least 1 in 4 women develop one or more fibroids in their lifetime. These usually develop in women aged 30-50 years and can sometimes run in families. Fibroids are also more common in women who are overweight. This is thought to be due to the higher levels of circulating oestrogen that occur in heavier women. It is believed that oestrogen exerts an effect on fibroid growth by stimulation of growth factors (Rees, 2000).
Various locations of fibroids:
Other causes contributing to her HMB could be:
- The stress (Critchley, 2005) she was experiencing. Dealing with the stress can help with HMB so she was given a support letter to alleviate some of the anxiety related to this.
- Poorly controlled hypothyroidism (Woeber, 2007) as she mentioned tiredness and weight gain.
Guidelines issued by RCOG and NICE for initial management of HMB suggest only full blood count (FBC) blood investigation in all women complaining of HMB . FBC can give sufficient information about anemia objectively (RCOG, 1998 and NICE, 2007). It allows early recognition and treatment of iron deficiency anemia.
This patient also underwent some further blood test including ferritin, TFT, LFTs and blood sugar. There is no evidence for treating a low serum ferritin concentration unless they are anaemic (Lewis, 1982). TFT was requested as the patient was on treatment for hypothyroidism was also experiencing symptoms of tiredness with weight gain (RCOG, 1998). LFTs and blood sugar were requested in view of her high BMI. Her blood results confirmed low ferritin with anaemia and suboptimal TFT. She was given treatment with ferrous sulphate and the dose of Levothyroxine was increased. It is recognized that the LFTs and blood sugar were perhaps requested inappropriately.
She initially came to discuss a hysterectomy. Although there are several other treatment options available for her, she was only aware of the combined oral contraceptive pill. However, she had unwanted side effects in the past with the pill. During this consultation, she was fully involved in the decision making regarding the future management of fibroids and HMB.
The table given below explains different treatment interventions and potential unwanted outcomes (NICE, 2007):
|Interventions||Potential unwanted outcomes.
(common1:100, un common 1:1, 000, rare 1:10, 000, very rare 1:100,000 cases)
intrauterine system (LNG-IUS)
|Hormone-related symptoms such as breast tenderness, acne or migraine, which if present, are typically mild and intermittent, are frequent bleeding that may continue for over 6 months.
Uterine perforation at the time of IUS
|Tranexamic acid||Less common:||Indigestion; diarrhoea; headaches|
Worsening of asthma, peptic ulcers with potential bleeding, and peritonitis in susceptible people.
|Combined oral contraceptives (COCs)||Common:
|Mood changes, headaches, nausea, fluid retention, breast tenderness.
Deep vein thrombosis, stroke, heart attacks.
|Oral progestogen (norethisterone)
|Weight gain, bloating, tenderness of the breast, headaches, acne (but typically they are both mild and transient)
|Weight gain, intermittent bleeding, amenorrhoea, premenstrual tension-like condition (including bloating, fluid accumulation, breast tenderness)
Small loss of bone mineral density, largely
recovered when treatment is discontinued
|Gonadotrophin-releasing hormone analogue (GnRH-a)
|Menopausal-like symptoms (such as hot flushes, increased sweating, vaginal dryness)
Osteoporosis, particularly trabecular bone with longer than 6 months’ use
|Vaginal discharge, increased period pain or cramping (even if no further bleeding), need for additional surgery
Perforation (but very rare with second generation
|Uterine artery embolisation (UAE)
|Persistent vaginal discharge, postembolisation
syndrome – pain, nausea, vomiting and fever (not involving Hospitalisation)
Need for additional surgery, premature ovarian failure, particularly in women over 45 years old; Haematoma
Haemorrhage, non-target embolisation causing tissue necrosis, infection causing septicaemia
|Adhesions (which may lead to pain and/or impaired fertility), need for additional surgery, recurrence of fibroids, perforation (hysteroscopic route), infection
Intra-operative haemorrhage, damage to other Abdominal organs, such as the urinary tract or bowel, urinary dysfunction –frequent passing of urine and incontinence
Thrombosis (DVT and clot on the lung)
(Complications are more likely when hysterectomy is performed in the presence
|Oophorectomy at the time of hysterectomy
During this consultation different conservative measures for treating her symptoms were discussed as per guidelines issued by RCOG and NICE. The methods discussed were:
- Tranexamic acid and Mefenamic acid: Tranexamic acid is an antifibrinolytic drug. This blocks the enzymes in the endometrial lining that dissolve the blood clots thus reducing symptoms (Cooke, 2000). Mefenamic acid belongs to group of non-steroidal anti-inflammatory drugs. This reduces uterine contraction pain by inhibition of prostagladin synthesis. Tranexamic acid causes on average 54% and Mefenamic acid 20% reduced blood loss (Bonnar and Sheppard, 1996).
- Mirena IUS: Levonorgestrol-releasing IUS originally developed as a contraceptive, has shown 97% reduction in HMB in a study and amenorrhoea in 20-30% of users. This device is now licensed in the UK as treatment for HMB. IUS was offered as this can give her the added benefit of contraception she requires (Anderson,1990 and FSRHC,2006)
- Hysteroscopic: Assessment of endometrial cavity and IUS insertion.
- Oral progestogens: This was declined as she had unwanted side effects from oral combined contraceptive pills.
- Endometrial ablation/resection: It had long been recognised that traumatic destruction of the endometrium leads to amenorrhoea. The devices used are classified into first and second generation. Box below shows types of devices available for endometrial ablation with limitation and selection criteria to the use (Justin et al, 2007)
· Trans-cervical resection of endometrium (TCRE)
| Limitations for first generation.
First generations are used in the operating theatre with women under anaesthesia. Roller ball was found to be safer than other techniques. First generation has limitation of use by expert surgeons.
· Balloon thermal ablation
· Hydrothermal ablation
· Microwave endometrial ablation
· NovaSure (impedance controlled endometrial ablation system)
· Endometrial laser intrauterine thermal therapy(ELITT)
· Photodynamic therapy
· Chemo ablation
|Selection criteria for second generation.
· Family is complete
· Willing to continue contraception if not sterilised
· Failed medical treatment
· Normal sized uterine cavity for most procedures
· Willing to undergo hysterectomy if required
NICE recommends second generation rather than first generation techniques, as they are more cost effective.
She was also made aware that other surgical procedures are normally conducted when all the conservative treatments fail. The options would be myomectomy or hysterectomy. Up to 40,000 hysterectomy operations are carried out by the NHS on women in the UK every year. This figure means that one in five of all women will have a hysterectomy at some point in their life (Hysterectomy Association, 2009). In the early 1990s, it was estimated that at least 60% of women presenting with HMB went on to have hysterectomy but now the trend is decreasing (NICE,2007). Although it gives complete cure of HMB, it is a major operation and associated with significant complications in a minority of patients (NICE, 2007). Fibroids are common and rarely cause mortality and HMB can be treated conservatively or with minimally invasive techniques. The risks associated include anaemia due to excessive bleeding during the operation, fever as a result of infection, dysuria, change in sexual function, decrease in libido, premature ovarian failure, prolonged hospital stay (financial and social implications) and mortality of 0.38/1000 (Kritz-silverstein et al, 2007). She was supplied with a leaflet explaining hysterectomy to ensure her decision was an informed one.
Myomectomy would not be an appropriate option for her as she had completed her family. This is the choice for women who wish to conceive in the future. It can lead to further problems of adhesions and reoccurrence of fibroids. The patient was made aware of the limitation of options that could be provided by a General Practitioner with a special interest and for further information she could be referred to a gynaecologist.
The patient opted to have an outpatient hysteroscopic assessment of endometrial cavity and opted for the Mirena IUS. She received leaflets of IUS and hysteroscopy. She accepted medical treatment with tranexamic acid and mefenamic acid during the days of painful heavy periods. She underwent hysteroscopy only and had insertion of IUS. On review appointment she was significantly better.
On reflection, the patient had some symptoms and signs which mimic fibroids although the ultrasound had confirmed that they were indeed present. However these are not enough reasons to believe that the fibroids are the main causes. The fact that her aunt had a hysterectomy did not necessarily mean that she should have one too, and there were other treatment measures that she needed to be informed about. As a result of this case, I have read up on and updated team. She was managed according to guidelines issued, and it is recognised that primary care practitioners may need updating through local clinical meetings on HMB and its management taking into account local and national guidelines.
- Bonnar,J. and Sheppard,B. (1996).Treatment of menorrhagia during menstruation : Randomised controlled trial of ethamsylate, mefenamic acid and tranexamic acid. British Medical Journal, 313.pp.579-582.
- Choose and Book, available from http://www.chooseandbook.nhs.uk/patients, accessed on June 24, 2009
- de Kare-Silver, N., (2005). Choose and book—whose choice is it anyway? BMJ; 330: 1093.
- D.Kritz-Silverstein, E.Barrett-Connor, and D.L,Wingard,.(2007)Hysterectomy, oophorectomy, and heart disease risk factor.[Online].Available from:www.pubmedcentral.nih.gov/articlerender.fcgi?artid
- Duckitt , K. (2007) Medical management of perimenopausal menorrhagia, an evidence-based approach. Menopause international 13 (1), pp.14-8
- Faculty of Sexual and the reproductive health care (2006) Clinical effectiveness unit UK Medical eligibility criteria for contraceptive use. [Online], Available from: http://www.ffprhc.org.uk/admin/uploads/298_UKMEC_200506.pdf
- Fibroid available from http://www.patient.co.uk/showdoc/23068738/fibroid
- Accessed on June 24, 2009
- Harlow, S.D. and Campbell, O.M.R. (2004) Epidemiology of menstrual disorders in developing countries: a systematic review: BJOG: An International Journal of Obstetrics and Gynaecology , 111 (1) ,pp .6–16.
- Hysterectomy accessed from http://www.hysterectomy-association.org.uk/
- On June 24, 2009
- Huang,P.L (2009),definition of metabolic syndrome .cited in: Disease model and mechanism,2(5-6):231-7.[Online].Availablefrom:http://www.ncbi.nlm.nih.gov/pubmed/19407331?ordinalpos=11&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum http://hcd2.bupa.co.uk/fact_sheets/html/hysterectomy.html
- Justin.W,etal (2007) Current minimal access techniques in the treatment of heavy menstrual bleeding Review in The Obstetrician and Gynaecologist (9),pp. 223-232
- National Collaborating Centre for Women’s and Children’s Health (2007).Heavy menstrual bleeding. London: National institute for health and clinical excellence (NICE).
- Lethaby, A. C, Farquhar. Cooke. (2000) Antifibrinolytics for heavy menstrual bleeding : Cochrane database of systematic review. Available from: http://www.cochrane.org/reviews/en/ab000249.html
- Osei , J. Critchley, H.(2005) Menorrhagia, mechanisms and targeted therapies. Current Opinion in Obstetrics and Gynecology. 17(4), pp. 411-418.
- Rees , M. C. P. (2000) menstrual problems. In: McPherson, A. and Walker Women’s Health fourth edition.Oxford:pp.325-326
- Royal College of obstertricians and Gynaecologists(1998).The initial Management Of Menorrhagia,Evidecce based clinical guidelinesNo.1,p.8-15
- Royal College of obstertricians and Gynaecologists(1999).The Management of Menorrhagia in Secondary Care, Evidence –Based clinical Guidelines No.5,pp.13
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Case history: 38 year old lady requesting hysterectomy for regular heavy menstrual bleeding (HMB).
Presenting complains: A 38 year old lady was referred with a history of HMB and on ultrasound scan she was diagnosed with fibroids. She came for discussion regarding hysterectomy.
History of presenting complains: Her menstrual cycle was 6-8/30 days. This had become increasingly heavy and painful. She was experiencing flooding despite using double protection with tampons and thick pads. She denied any history of inter-menstrual bleeding, post coital bleeding or dysparunia. She was using Ibuprofen and Paracetamol for the pain. Her problem had considerably affected her life in relation to her work and academic studies. She also complained of tiredness, weight gain, feeling stressed and having poor quality sleep. Prior to this she had a normal menstrual cycle since the age of menarche.
Past medical and surgical history: This lady was on treatment for hypothyroidism. She was taking 25 micrograms of Levothyroxine.
Past obstetric history: She had delivered four children by normal vaginal deliveries and had not had any other pregnancies.
Contraceptive history: She currently uses the withdrawal method for contraception. Other methods used in the past included condoms (stopped due to irritation), combined oral contraceptive pills (Tried few but stopped due to unwanted side effects and she was not keen to continue), intrauterine copper contraceptive device (removed due to pelvic pain).
Social history: She was working part time and also taking a part time degree course at a local university. Due to her symptoms of HMB she had to take a lot of time off her university. This had caused conflicts with her tutor. She smoked 5 cigarettes a day and denied drinking alcohol.
Family history: Her aunt had a history of fibroids. She had had the same signs and symptoms as the patient and had had a hysterectomy.
Findings on examination: An obese Asian lady, with a body mass index of 30.2. Her blood pressure was normal. Her pelvic examination revealed a bulky, mobile and anteverted uterus. The rest of the examination was normal.
Trans-vaginal Ultrasound scan was reported as “The uterus has heterogeneous echo texture in keeping with fibroid changes. There are at least two intramural fibroid largest 1 cm, in addition 1cm sub- mucous fibroid. Ovaries are normal in size and appearance.”
This lady presented to the clinic with symptoms and signs of HMB. She was determined to have a hysterectomy due to family pressure, the stress she was experiencing with her course and the fact she was diagnosed with fibroids. She was also expecting a letter of support which would explain to the tutor that HMB was the cause for her absences from the course. Since the combined oral contraceptive pill (COCP) did not help her, she thought that her only option was hysterectomy.
- She was advised to read a leaflet explaining HMB, and fibroids. This was printed from patient.co.uk. It was explained to her that the fibroids were very small and she had a range of options available.
- Blood was taken for full blood count (FBC), liver function tests (LFTS), fasting blood sugar and thyroid function tests (TFT).
- Cyclical Tranexamic acid and Mefenamic acid were prescribed as an interim measure.
- She was encouraged to consider Mirena IUS as it would help her symptoms of HMB and also provide her with a reliable method of contraception. She was supplied with a leaflet.
- She was offered a referral for hysteroscopic assessment of the endometrial cavity with insertion of Mirena IUS.
- Discussion of short term and long-term problems with hysterectomy backed up with a leaflet. It was explained that was still a choice she could opt for.
- A letter of support was given for the university, explaining that she is suffering from HMB.
- Suggested referral to a dietician and prescriptive exercise programme
- Suggested referral to a gynaecologist
The results of investigation revealed the following.
She was given a prescription for ferrous sulphate as per blood results (marginally low HB, low MCV, and a low Ferritin). Her Levothyroxine was increased to 50 micrograms (TSH high). She underwent hysteroscopy with insertion of Mirena coil and no abnormalities were found. On review appointment her symptoms of HMB had improved significantly. Her problem at university was resolved and she has restarted her health studies.