Period peace

Excessive menstrual bleeding - menorrhagia - is a common complaint but because of GPs' ignorance about successful drug treatments, many women are wrongly advised to have hysterectomies. Emma Haughton looks at the options

`It was an awful thing to live with. I'd be out shopping and would suddenly feel the blood squelching in my shoes. At dinner parties or wherever we went, I always had to pad myself up and find out exactly where the loo was. The worst thing was, it was never predictable. You would get a sudden rush and then great blood clots coming down. Each period, I would get through two boxes of tampons, with sanitary towels for the heaviest days. I was always anaemic, which made me tired and depressed and pretty incapacitated, but more than that it was so humiliating and embarrassing. There would be one day in every period when I hated to leave home, but I had to work."

Valerie Davies-Webb, a pattern-cutter for the Theatre Royal, Plymouth, is now 52. She has suffered from menorrhagia, or excessively heavy periods, since the age of 13; the doctor told her mother that it would clear up when Valerie had a baby. "It didn't, it got worse," she recalls. "When I had an operation after my second child was born, they actually had to give me a blood transfusion first."

Mrs Davies-Webb is by no means unusual. Heavy periods are one of the most common female complaints, accounting for about two-thirds of the UK's 70,000 hysterectomies and for some 800,000 prescriptions a year. In severe cases, women may be unable to leave the house for several days every month, and may even have to wear nappies. Anaemia, with the resulting exhaustion and depression, is a common problem. For some, menstruation really is a curse.

Yet despite the misery it can cause, there is growing evidence that excessive menstrual bleeding is not being treated effectively. A recent Department of Health-sponsored review of research has shown that, despite pounds 7.2m a year spent on prescriptions, the most common drug treatment is also one of the least successful, while more effective treatments are hardly ever used.

"Research shows that the most commonly prescribed drug, norethisterone, is no more effective than a placebo at the doses normally prescribed," says Professor Angela Coulter, director of the Kings Fund Centre in London and leader of the team that conducted the review. "A lot of women are going on to have unnecessary hysterectomies because they are not being offered better drug treatment."

Hysterectomy, of course, is a major operation: it renders a woman totally infertile and involves a six-week recovery. In addition, the increasing trend to remove the ovaries as well leads to premature menopause. This increases the risk of developing osteoporosis or heart disease; although long-term hormone replacement therapy can offset that risk, many women only stay on the drugs for a short time.

For many women, excessive bleeding could be controlled by less drastic measures. Another recent study in Ireland, published in the British Medical Journal, showed that tranexamic acid, a drug already used widely in Scandinavia, is a highly safe and effective treatment for excessive bleeding, reducing blood loss by about half and returning periods to normal for most women. Only a few reported side-effects of nausea, headache and stomach disturbance. The paper's co-authors, from the Trinity Centre for Health Sciences at St James Hospital, Dublin, believe it should be offered to all women with heavy periods before any decision is made about surgery. Tranexamic acid is an antifibrinolytic - it works by inhibiting the activity of enzymes that break down blood clots, effectively reducing the menstrual flow. The Dublin researchers also found that another drug, mefenamic acid, could reduce blood loss by up to 25 per cent - often enough to bring it within the normal range.

But GP habits can be difficult to shift. Lingering concerns that tranexamic acid might precipitate thrombosis mean that it is still not widely prescribed, despite a large Scandinavian study that showed no increase in blood clots among women using the drug.

One small comfort is that heavy periods, which tend to afflict women in their late thirties and early forties, are rarely a sign of serious disease. Sometimes they are caused by a physical abnormality in the womb, such as fibroids; occasionally, there may be a general disorder of the blood-clotting system or of the thyroid gland. In around 60 per cent of all cases, however, there is no obvious reason for heavy periods - hence the common diagnostic coverall of dysfunctional uterine bleeding.

Poor treatment is compounded by problems in diagnosis. While the average woman loses around 30ml of blood a month - equivalent to half a cup of tea - up to 80ml is considered normal. But many women who feel worried by blood loss may overestimate the amount they are losing, especially if they have recently come off the Pill, which reduces blood loss.

Many GPs simply inquire about the number of pads and tampons a woman uses, but different absorbencies and levels of fastidiousness make this a highly unreliable measure. As a result, up to 60 per cent of women referred to a gynaecologist with menorrhagia are losing less than 80ml of blood and do not, technically, suffer from any disorder: many will go on to have surgery, when all they may need is reassurance.

Angela Coulter believes there is now enough evidence to force urgent changes in the way menorrhagia is managed, especially at GP level. "Many are staggeringly ignorant and uninterested in menorrhagia; they just think it's boring." Yet, she adds, it can severely affect the quality of a woman's life and is a severe embarrassment, especially for those who are working. "Women are being offered treatments that simply will not work and are rarely given enough information about their treatment options. As a result, most women are not being offered real choices."

For some women, hysterectomy may still be the best option. "If you've had 30 miserable years of flooding and clots and social embarrassment, it is the only treatment that guarantees you will never see another period," says John Foulkes, consultant gynaecologist with South Devon Healthcare Trust. "Some women do get to that point, especially if they are in severe pain every month."

Four years ago, Valerie Davies-Webb's gynaecologist recommended a relatively new surgical procedure, endometrial ablation, which involves removing much of the lining of the womb.

"It has revolutionised my life," she says, "Until this treatment was offered, the only choice I was given was a hysterectomy, and I never felt able to take six weeks off work. In the event I was in overnight. It was easy and I never had any pain, and within three months my periods had stopped completely. I immediately began to feel so much better - it was only then I realised how grotty I'd felt for so long"n

Excessive menstrual bleeding: alternatives to hysterectomy

Norethisterone - a progestogen hormone that helps to regularise periods but has little effect on bleeding in the normally prescribed doses. Higher doses are more effective, but unsuitable for long-term use.

Mefenamic acid - an antiprostaglandin that is good for relieving period pain and can reduce blood loss by 25 per cent. A mild drug with minor side-effects.

Tranexamic acid - works by inhibiting the activity of enzymes that break down blood clots, effectively reducing the menstrual flow. Particularly effective for women with uncontrolled flooding, and recommended as a first- line treatment before surgery is considered.

Endometrial ablation - the latest surgical advance, using a laser, small rollerball electrode or an electrically heated loop to destroy the lining of the womb down to half a centimetre. Around 10,000 of the operations are performed in the UK each year - in 30-40 per cent of women their periods will stop altogether, while a similar percentage will find them effectively reduced. The remainder may need the operation repeated or go on to a hysterectomy.

Mirena - an intra-uterine coil that releases a small quantity of the progestogen levonorgestrel into the womb, which can reduce blood flow by up to 70 per cent. However, it is only as yet licensed as a contraceptive in the UK, and it may cause spotting between periods initially.

Combined contraceptive pill - a treatment that is often overlooked and may bring blood loss down to an acceptable level. Although many women and GPs feel it is unsuitable for those over 40, there is no age-related risk for non-smokers.

Reassurance - a lot of women just need to know that their blood loss is within the normal range and is not a sign of more serious disease such as cancern