Until 20 years ago about half of the women referred by their GPs with heavy menstrual bleeding would eventually have required a hysterectomy. With up to 30 per cent of women of reproductive age suffering from heavy bleeding, that’s an awful lot of women undergoing major surgery with all the attendant risks at the time of surgery and into the future.
Despite a drop in the number of hysterectomies, a four-year National Heavy Menstrual Bleeding Audit, published this summer by the Royal College of Obstetricians and Gynaecologists (RCOG) in Britain found that nearly one-third of women reported that they hadn't received any treatment for heavy menstrual bleeding at primary care level. It called for this to be examined "as, in a number of cases, immediate referral is an appropriate option, for example for women with extensive fibroids".
The RCOG also found considerable variation in the hospital treatments that women with heavy bleeding received, with surgical treatment ranging from 20 per cent to 60 per cent across NHS hospitals.
We don't have the same research in Ireland but Dr Sharon Cooley, a spokeswoman for the Irish Institute of Obstetricians and Gynaecologists, feels Ireland would compare favourably with the UK. However, she is concerned that there is a significant waiting list for gynaecology in which heavy bleeding is one of the commonest reasons for referral.
She points out that it’s no longer the amount of blood loss that is considered significant, but the impact of that heavy bleeding on a woman’s social, emotional and physical wellbeing, and that women are less likely to suffer in silence than they might previously have done.
Cooley says the biggest change in this area has been the variety of new treatments on offer, such as various ablation techniques and the Mirena IUD, which she says “probably has revolutionised gynaecology”.
In two-thirds of women with heavy bleeding, no cause can be found. Fibroids, the generally benign tumours that grow within or outside the uterus, are often the cause of heavy bleeding.
Up to 40 per cent of women over 35 are thought to have fibroidsm, and less than 1 per cent of those are malignant.
They vary greatly in size from millimetres to tens of centimetres and are commonly described in terms of fruit; compared with, for example, a lime, orange or a cantaloupe. The average size is about 4cm, although many women have several. Many women have no symptoms at all and are unaware of them. The number of hysterectomies being performed here in cases with fibroids has reduced considerably from 635 in 1999 to 375 in 2012.
New procedure
Uterine artery embolisation (UAE) is a relatively new procedure, dating from the early 1990s. It was first used to stop postpartum bleeding at delivery, then used in advance of myomectomy surgery that removes fibroids but leaves the uterus intact.
It was then discovered that many women had no need for the myomectomy after having the UAE. The procedure deprives fibroids of their rich blood supply and they commonly shrink by 40-60 per cent within six months.
As with all interventions, it does have some risks including that of ovarian failure, depending on a woman’s age.
The procedure is available in several hospitals and Dr David Brophy, an interventional radiologist at St Vincent's Hospital in Dublin, estimates that at least 190 uterine artery embolisations were carried out in Ireland last year.
He has performed some 1,200 UAEs for fibroids in Ireland and in the US, and finds that there are still many women who are putting up with heavy bleeding and presenting only when fibroid bulk is causing pressure on other organs, such as the bladder.
The FEMME trial in Britain is comparing UAE with myomectomy for women who want to protect their fertility. One benefit of UAE compared with myomectomy is that there is less risk of a subsequent hysterectomy.
Brophy treated one North American woman in her 20s with a 14cm fibroid who was considered unsuitable for myomectomy given the size of the fibroid and the risk to the uterine wall. She subsequently went on to have a baby.
Guidelines on heavy menstrual bleeding set out by NICE, the National Institute for Health and Care Excellence in the UK, states clearly all the options, from the most conservative to the most invasive, and says that women should be supplied with this information in advance of attending an outpatient department.
See nice.org.uk; femisa.org.uk; britishfibroidtrust.org.uk More women's health issues will be covered in Health+Family on November 11th.
Case study: 'I was having flooding and feeling faint' In my mid-40s, my periods became heavier and when a blood test showed that my ferritin or iron stores were very low, I was told to take iron.
Despite taking it for quite some time there was little improvement. I was having flooding and feeling faint.
Eventually I was referred to the National Maternity Hospital in Dublin where straightaway they found a few fibroids, of which the largest was 9cm. A Mirena coil worked well for a while until it fell out; tranexamic acid was also very effective but it must be taken from the beginning of a period.
Fibroids often shrink when women go through the menopause. I was 53 but my periods were still regular. My mother was still menstruating at 59 and had a hysterectomy because of heavy bleeding, so Dr David Brophy, an interventional radiologist at St Vincent's Hospital in Dublin, agreed to do a UAE a year ago.
Under light sedation a tiny cut is made in one groin and 700 micron particles are silted up in two arteries to block the fibroid's blood supply. I was given a morphine pump to use afterwards; it managed the pain well and quickly. I felt I could have happily left hospital later that day but in practice you stay in one night.
It was only about a day later that I started getting the flu-like symptoms of post-embolisation syndrome, but medication is prescribed to deal with this. Within a week or so I was fine.
As Brophy warned me, it took a few months for my periods to lighten, and after 10 they were completely normal again.
Jill Nesbitt
