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Heavy Menstrual Bleeding CCS interview


[Music] Today you’re going to hear from a family planning
clinician and a consumer about an important health issue, heavy menstrual bleeding. Figures suggest many Australian women are
having hysterectomies for this condition rather than less invasive treatments. The Australian Commission on Safety and Quality
in Health Care has developed the first nationally agreed standard of care for women with this
condition. I’d like to introduce Clinical Associate Professor
Deborah Bateson the Medical Director of Family Planning New South Wales. Deborah was also a member of an expert working
group which developed this clinical care standard. So why do we need a heavy menstrual bleeding
clinical standard? So, a clinical care standard is a user-friendly
resource. It’s made up of a small number of high-level
nationally agreed quality statements which are based on best available evidence and what
they do is describe the care that health professionals and health services should be providing to
their patients for particular conditions and actually also the care that patients can expect
to receive. Now these are not full clinical guidelines
they don’t take you through every step of the management pathway, what they do do is
address the priority areas. So, appropriateness of care is really at the
centre of quality improvement, how we improve quality of health care across Australia and
that means giving the right patient, the right care, at the right time and that includes
heavy menstrual bleeding. Now the Commission’s Atlas of Healthcare
Variation is a really important document because what it does is it maps where healthcare is
being provided with where people live. So one of the procedures that the Atlas looked
at was hysterectomy. So what the Atlas found was that there was
quite considerable variation, in fact a 6.6 fold variation between the highest rates which
were in the inner and outer regional areas and the lowest rates which are in the big
cities the metropolitan areas and the remote areas and there was actually an even higher
variation when it came to the less invasive endometrial ablation, so what this suggests
is that maybe you know women and not actually being necessarily offered or being aware of
these less invasive options. I’d now like to introduce Dr. Karina Lim,
a GP who has experienced heavy menstrual bleeding. So Karina tell us a little bit about your
experience with this condition? So, for me heavy menstrual bleeding started
after I turned about 30 and it was a gradual thing so I had my first child when I was 31
and then I had my second at 33 and then my third at 36. So in between each pregnancy my periods got
heavier and heavier and then shorter and shorter till after my third, things started to get
quite bad. I was looking to where the toilet was, I was
glad that my office was right next door because I’d have to get up and change super tampons
every two hours. Then I actually took two wearing pads as well
just to be on the safe side, in case I couldn’t make it to the toilet in time. I’d watch where I would take the kids out,
so if we were going out to a park I’d make sure I knew where the toilet was. So, it’s really quite difficult each time
of month. From your point of view what’s the most important
part of this new clinical care standard for patients? I think the most important thing is bringing
awareness about heavy menstrual bleeding to women and to GPs and that it’s something
that’s often undiagnosed and untreated because women, either it happens gradually where they
don’t realise that it’s getting to a point that it’s really affecting their lifestyle,
until it becomes completely unbearable, or it’s something that they’ve always lived
with so they don’t realise that it’s, I guess, considered abnormal. The next thing I think is really important
that women be able to feel comfortable to have that conversation with their GP about
their periods and that GPs are open to having that discussion, asking the right questions,
giving them advice and giving them all the options about the treatments that are available,
whether it be medication or other less invasive things before a woman gets to a point where
they just would like to have a hysterectomy. So, I think the most important part really
is that statement around shared decision making and that affects every single part of the
management pathways. But the other one I’d like to highlight
is the statement that says about initial management, being pharmaceutical. That highlights that a lot of heavy menstrual
bleeding, once we have excluded malignancy and serious causes, can be managed in the
primary care setting, but the other thing is to make sure that when a woman, when you
are actually identified that a woman’s got heavy menstrual bleeding making sure that
her next period it’s not going as heavy, even while you’re waiting for an ultrasound or
waiting for a referral, if that’s going to happen, start tranexamic acid or a non-steroidal
anti-inflammatory or even the contraceptive pill just to make sure that you provide that
symptomatic relief. Hysterectomy used to be really the only option
for women with this condition but there are now some new less invasive treatments, what
can you take us through those? One of the main ones is the hormonal IUD. It’s inserted into the uterus and they’ve
a very low dose of levonorgestrel hormone thins out the lining of the uterus and many
women become amenorrheic. The other procedure is called endometrial
ablation, it’s been around for a long time but we’ve got new generation techniques now
which are minimally invasive and what that does is remove the lining of the uterus. We know that many women think that hysterectomy
is actually the only option for them. Often they’ve been you know told that by their
friends perhaps, they’ve read about it, other people have said oh that’s the way to
go and they’re just unaware of these other options. So how relevant is the clinical care standard
to primary care? GPs are at the frontline of detecting heavy
menstrual bleeding, taking that history when someone comes for a cervical screening test
for instance, obviously carrying out an appropriate assessment, organising the investigations. But then a key thing of course is once you’ve
excluded malignancy and serious pathology, then the vast majority actually of heavy menstrual
bleeding can be managed within the primary care setting. It’s really useful to know that each of
these standards comes with a companion factsheet one for clinicians and one for consumers,
and are really helpful and what we know is that many of the primary healthcare networks,
the PHNs are actually incorporating these resources into their health pathways. So, at what point should GPs be thinking about
referring their patients on to a specialist? So, I think there’s two points, so the first
is when you’ve done your initial investigations if you’ve got any suspicion of malignancy
in particular, or serious pathology, in that’s particularly for women over the age of 45,
we know that there’s an increased risk then of uterine cancer but otherwise if you’re
managing the heavy menstrual bleeding in primary care, maybe with a contraceptive pill, maybe
with a hormonal IUD, it’s incredibly important to review them at six months or earlier if
they you know if things are not settling down and if there’s no improvement in their symptoms
and that’s the time that referral is warranted. So, for GPs assessing a patient who might
have this condition what are the important investigations that they should be doing? So, it’s important always to exclude pregnancy
but then it’s about it thinking about blood tests, importantly we need to assess for iron
deficiency, and anaemia, we might want to do thyroid tests if indicated by the history
or coagulation profile, as well then as a good quality transvaginal ultrasound. Why is it so important to get the timing of
the ultrasound right? We do know that optimally we need to organise
that pelvic ultrasound, a good quality transvaginal ultrasound, between day five and ten of the
cycle. It’s when the endometrium is thinnest, so
we’re going to be able to pick up structural problems like polyps and what we do know from
our gynaecology colleagues is that sometimes you know women end up having to go back for
a second, and I should say sometimes even more ultrasounds because that timing hasn’t
occurred. So, the standard says that IUDs are the most
effective option for managing this condition. How important is it that doctors feel they’re
well trained enough to insert the device themselves? We’re certainly getting lot more GPs wanting
to learn this skill and a lot of new GPs coming through GP training are taking that up, which
is fantastic. So, I think the key thing is to ensure that
within your practice obviously take up training or provide them yourself. But if you’re not providing them yourself
have a rapid referral pathway, have someone else in your practice who can do it, and if
there’s no one in the practice ensure you know someone locally, a family planning organisation,
a local GP, and nurse practitioners who can actually insert that IUD in a timely manner. So, Dr. Lim how is it having this condition
yourself changed how you approach patients? Since the clinical care standards came out
and I was asked to be involved I’ve actually noticed that I now routinely ask women about
their periods in more detail, with general screening things like pap smears, cervical
screening, so normally I would have just asked are you having a regular cycle, are you getting
any extra bleeding in between or after sex, but now I actually ask, what and how your
periods going, are they heavy, are they painful and then I actually find that there’s quite
a few women that I pick up that are now saying, yeah but you know they’ve always been like
that, and then that then prompts me to ask further questions like how often are you changing,
how’s it affecting your life and those kind of things so it’s been an eye-opener.

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