Program: You don't have to put up with heavy periods

Norman Swan: So this next story is a really important one for women's health.

Shelby Traynor: Yeah, a lot of women might not be aware that they're dealing with heavy menstrual bleeding. 

Norman Swan: Why not? 

Shelby Traynor: Well, if you're not talking to your friends about it, chances are you may not be talking to your doctor about it, but it's so normalised to just deal with it and not question it.

Norman Swan: So, compared to others, you might be dealing with heavy bleeding, but for you it feels normal. 

Shelby Traynor: Yeah, there's no comparison, you only know your own body. But there are actually treatments available to deal with this, to make it easier and more comfortable.

Norman Swan: I mean, the whole thing about heavy menstrual bleeding, it's sometimes called menorrhagia, is that there are lots of different causes. IUDs can cause bleeding, but IUDs are also a treatment for menorrhagia in older women, but never to be ignored, even in younger women, particularly with the increase in cancers in younger people, it can be a tumour. It could be a benign tumour, like a fibroid, unusual in younger women. Infections, I mean, dengue fever rarely can cause menorrhagia. So, not an issue for most of Australia, but Northern Queensland. Pelvic inflammatory disease, problems with the cervix. You could actually have nothing wrong with your uterus at all and you've got a bleeding disorder, or it could be iatrogenic (in other words, doctor caused); you could be on aspirin or a blood thinner, and that's causing it. So it's a complicated story where you should be recognising whether you've got it, but it requires the GP to do quite a lot of investigating.

Shelby Traynor: But even if it's not caused by any of these things, even if it's just something that your body does and it's affecting your life, you should be able to get help to deal with it. And that's what Liz Marles is saying. She's a GP, and also Clinical Director of the Australian Commission on Safety and Quality in Healthcare.

Norman Swan: Former President of the College of GPs. 

Shelby Traynor: Yes. She's played a part in developing new guidelines around heavy periods so more people have received the right treatment. 

Liz Marles: It's really about the impact that it's having on that woman's life. If she is having to restrict what she does, you know, take time off work, restrict her social activities or her dress choices, there's a lot that we can do to help her so that it's not such a difficult time of the month.

Shelby Traynor: And so is this a separate classification to if you're experiencing very bad cramps or back pain or headaches?

Liz Marles: No, I think bad cramping and passing clots is often associated with heavy menstrual bleeding. We know that 60% of the women who have heavy menstrual bleeding are actually iron deficient as well, and they may be experiencing fatigue, and that could go on beyond the time of their period as well. 

Shelby Traynor: Do we know anything about the amount of people who do come forward and seek help for this? Is it a large percentage, or is it in the minority?

Liz Marles: Yes, so we actually think that it's less than half of women who are experiencing heavy menstrual bleeding actually seek help. These women are missing out on treatment that could be life changing for them. One of the things that we really want to encourage is for women to feel comfortable to raise this, knowing that there are actually lots of treatment options available, it's not just about having a hysterectomy. We can do a lot to make life better without going to a major operation as the only treatment. 

Shelby Traynor: So you mentioned a hysterectomy, is that the most extreme treatment option? And if we can just give an overview of what else there is out there for people. 

Liz Marles: So there are lots of treatment options available for heavy menstrual bleeding, and it starts with really simple treatments like taking anti-inflammatories or tranexamic acid around the time of the period, through to hormonal treatments like the contraceptive pill. The hormonal IUD is a really effective treatment for heavy menstrual bleeding and will probably manage the problem for the vast majority of women. If those treatments don't work, then we can move to other, more procedural treatments, minor surgical procedures, to get rid of polyps, maybe deal with fibroids. And there is a treatment called an endometrial ablation, which removes the lining of the uterus, and again, for most women that will solve the problem. It's just a day procedure, it does involve an anaesthetic, but it's much less invasive than actually having a hysterectomy. In this clinical care standard we've also talked a little bit about a new procedure, which is not widely available, so we haven't put a lot of emphasis on it, but that's a uterine artery embolization, where they reduce the blood flow to fibroids, for instance, which will reduce bleeding. 

Shelby Traynor: You've looked at rates of hysterectomies versus ablations over quite an extensive period of time. What did you see?

Liz Marles: Since I think 2013 we first started monitoring this, and we've seen that over an eight-year period there's been a 20% reduction in hysterectomy rates, and at the same time we've probably seen a 10% rise in endometrial ablation. Both of those things are positive. We're very happy to see the decrease, but it still leaves us with substantially higher rates of hysterectomy than comparable countries like the UK and New Zealand. And whilst we've seen that 10% increase in endometrial ablation, we know that there's a huge variation across the country in endometrial ablation rates. There's a 20-fold difference from the area with the highest rates of endometrial ablation and the areas with the lowest rates, so we know that that procedure is not being offered equally across the country. All of this is speculation because we don't actually know the reasons why, but it is possible that a lot of the women in rural areas have to travel, and maybe that means that they're more inclined to get a more definitive treatment. We've also seen that there's a 9% higher rate of hysterectomy in First Nations women compared to other Australian women in this latest data, and we know that a lot of First Nations women will be accessing the public system, and so, again, it's whether that full spectrum of treatment options is available.

Shelby Traynor: And there's new clinical care standards that came out last week. How are you hoping that will guide these interactions with patients?

Liz Marles: So the clinical care standards have got a big focus on women making an informed choice, and really emphasise the need to have discussions with women that highlight the range of treatment options. They also emphasise that we should start treatment the first time a woman presents, so not wait for all the investigations to be completed. We can start with some of those simple treatments, like using anti-inflammatory medications around the time of the period. There's a lot of guidance around cultural safety and equity, noting that there are some particular groups who may find talking about this quite difficult, and that includes women who come from culturally and linguistically diverse backgrounds, women who maybe have a disability, trans and non-binary people who are still menstruating who might find it difficult to discuss those issues or even have a clinical examination, and First Nations women. So we're really trying to broaden the horizons of the clinician in terms of thinking about all the people who may be experiencing heavy menstrual bleeding.

Shelby Traynor: Thank you so much, Liz.

Liz Marles: That's a pleasure. 

Shelby Traynor: That was Associate Professor Liz Marles from the Commission on Safety and Quality in Healthcare.