Management of menorrhagia in primary care---impact on referral and hysterectomy: data from the Somerset Morbidity Project

Abstract

Objective-To investigate the management of menorrhagia in primary care and its impact on referral and hysterectomy rates. Design-Prospective observational study. Setting-11 general practices from the Somerset Morbidity Project. Subjects-885 women consulting their general practitioner with menorrhagia over four years. Main outcome measures-Proportions of these women investigated and treated with drugs in primary care, referred to a gynaecologist and undergoing operative procedures. The relation between investigation and prescribing in primary care and referral to and surgery in secondary care. Results-Less than half of women had a vaginal examination (42%, 95% CI 39% to 45%), or a full blood count (39%, 95% CI 36% to 43%). Almost a quarter of women, 23% (95% CI 20% to 26%), received no drugs and 37% (95% CI 34% to 40%) received norethisterone. Over a third, 38% (95% CI 34% to 40%), of women were referred, and once referred 43% (95% CI 38% to 48%) of women were operated on. Women referred to a gynaecologist were significantly more likely to have received tranexamic acid and/or mefenamic acid in primary care ( 2 =16.4, df=1, p<0.001). There were substantial between practice variations in management, for example in prescribing of tranexamic acid and/or mefenamic acid (range 16% to 72%) and referral to gynaecology (range 24% to 52%). There was a significant association between high referral and high operative rates (Spearman's correlation coefficient=0.86, p=0.001). Conclusions-Substantial diVerences in management exist between practices when investigating and prescribing for menorrhagia in primary care. Rates of prescribing of eVective medical treatment remain low. The decision to refer a woman impacts markedly on her chances of subsequently being operated on. EVective management in primary care may not reduce referral or hysterectomy rates. (J Epidemiol Community Health 2000;54:709-713) Menorrhagia, defined as excessive menstrual loss of greater than 80 ml per period, 1 has a significant impact on many women's lives, as well as workload in primary and secondary care. Over 5% of women aged 30-49 years consult their general practitioner each year with this complaint.2 Menorrhagia accounts for 12% of gynaecology referrals, 1 and once referred surgical intervention is highly likely. In one study 60% of women underwent a hysterectomy within five years of referral.3 The treatment objective in menorrhagia is to improve quality of life by alleviating heavy menstrual flow. According to recent guidelines, general practitioners should oVer at least one course of eVective drug therapy before referral for gynaecological opinion.

Obesity and menstrual disorders

“…Within the general population, the prevalence of HMB is difficult to estimate; a recent study of women aged 30e49 years consulting their general practitioner (GP) showed a rate of around 3% presenting with HMB [12]. No reference is made to the body mass index (BMI) of the women within this group.…”

Women with congenital factor VII deficiency: clinical phenotype and treatment options from two international studies

“…For menorrhagia, the therapy options have recently changed from more conservative medical approaches, with antifibrinolytics and hormones, to replacement therapy (RT) and prophylaxis [2,15,16]. This shift towards a rational, replacement-based approach is likely to change clinical practice that, until recently, frequently adopted surgical approaches including endometrial ablation [17] or hysterectomy [18].…”

Menstrual discomfort and its influence on daily academic activities and psychosocial relationship among undergraduate female students in Nigeria

“…Furthermore, studies in different cultures have associated it with one of the most common causes of regular absenteeism among young women in schools, work places, sports participation, and other public functions (Banikarim et al, 2000;Grant et al, 2000;Walraven et al 2002;El-Gilany et al, 2005). Dysmenorrhoea, a sharp painful menstrual cramp in the lower abdomen and menorrhagia, heavy and prolonged menstrual bleeding (Grant et al, 2000;KamatemesiMugisha et al, 2007) both of menstrual disorder and discomfort are peculiar health problems that have attracted little or no health concern. Such issues are often omitted in the public health agenda of many low and middle income countries.…”