{"paper_id":"03174d3b-208a-496f-82f4-29c5dc856c29","body_text":"Introduction\nHeavy menstrual bleeding or menorrhagia, defined\nas excessive menstrual loss of greater than 80 ml per\nperiod, is a common reason for a woman to consult\nher general practitioner (GP), with over 5% of\nwomen aged 30–49 consulting their GP each year \nin the UK (Coulter et al., 1995; Tudor Hart, 1997).\nMenstrual loss is self-reported and subjective, as it is\nimpractical to measure it routinely, an ‘unequivocal’\ndiagnosis of menorrhagia is unlikely in either pri-\nmary or secondary care. Many women are sub-\nsequently referred to gynaecologists which often\nresults in surgical treatment (Coulter et al ., 1991;\nGrant et al., 2000). Research looking at the associ-\nation between reported heavy loss and objective\nmeasurement of heavy blood loss reports that fewer\nthan half of the women referred to the gynaecolo-\ngist have losses greater than 80 ml (Higham, 1999).\nIn the great majority of these cases of menorrhagia\nthere is no underlying pathology (Stirrat, 1999).\nThe aims of treatment for menorrhagia are to\nreduce menstrual flow, improve the quality of \nlife and reduce the likelihood of iron deficiency\nanaemia (Effective Health Care, 1995). The \nRoyal College of Obstetrics and Gynaecologists\n(RCOG) have produced guidelines that outline\neffective treatments of menorrhagia.These suggest\nthat at least one option should be tried, for a min-\nimum of three months, before referral for a gynaeco-\nlogical opinion (Royal College of Obstetricians and\nGynaecologists, 1998). A recent study investigating\nPrimary Health Care Research and Development 2005; 6: 217–223\n© 2005 Edward Arnold (Publishers) Ltd 10.1191/1463423605pc251oa\nThe role of primary care in the diagnosis and\nmanagement of menorrhagia: a qualitative\nstudy of women with menorrhagia\nJoanne Protheroe National Primary Care Research and Development Centre, Williamson Building, University of\nManchester, Manchester, UK and Carolyn Chew-Graham Division of Primary Care, Rusholme Academic Unit,\nUniversity of Manchester, Rusholme Health Centre, Manchester, UK\nThere is increasing emphasis on including patients in decision making about treat-\nment. In order to do this, they need to have access to appropriate information about\ntreatment options. The study reported here reports initial work carried out in the devel-\nopment of a decision analysis tool to assist women about treatment for menorrhagia.\nWomen referred to secondary care with a diagnosis of heavy menstrual bleeding were\ninterviewed. Our study shows that women had limited and often inaccurate knowledge\nof most treatment options. They expressed feelings of diagnostic uncertainty, the need\nfor a ‘label’ for their symptoms and a perception of the failure of the general practi-\ntioner (GP) to provide this. The women in our study referred to secondary care with a\ndiagnosis of menorrhagia do not seem to have had their concerns about their men-\nstrual symptoms addressed prior to the referral. In addition, the women in this study\ndo not feel that their GP has communicated a diagnosis to them. Women must be able\nto feel that they have been diagnosed in order that treatment options can then be prop-\nerly discussed, and a shared management decision reached. Reasons for the apparent\nlack of adherence to guidelines are discussed. There is a need for a decision aid for use\nin primary care to assist women and their doctors in the management of menorrhagia.\nKey words: menorrhagia; patient information; treatment options\nAddress for correspondence: Dr Joanne Protheroe MRes,\nMRCGP , MRC Research Training Fellow, National Primary\nCare Research and Development Centre,Williamson Building,\nUniversity of Manchester, Oxford Road, Manchester M13 9PL,\nUK. Email: j.protheroe@man.ac.uk\nPC-251oa-5.qxd  03-06-2005  14:01  Page 217\nhttps://doi.org/10.1191/1463423605pc251oa Published online by Cambridge University Press\n\n218 Joanne Protheroe and Carolyn Chew-Graham\nPrimary Health Care Research and Development 2005; 6: 217–223\nthe management of menorrhagia in primary care\nreported that of 885 women from 11 GPs, almost \na quarter received no medical treatment (23%)\nand over a third received norethisterone (37%),\ndescribed as ineffective by both the Effective Health\nCare Bulletin, and the RCOG (Grant et al., 2000).\nShared decision making has been widely accepted\nas the goal for effective clinical management, partic-\nularly in the treatment of menorrhagia, which has\nmany equally effective treatments (Department of\nHealth, 1996; Royal College of Obstetricians and\nGynaecologists, 1998). For a patient to take part in\ndecision making about treatments, he/she needs to\nknow, or be given information about the various\ntreatment options in order to make an informed\nchoice (Coulter, 1997). Indeed a recent randomized\ntrial of an information booklet for women with \nmenorrhagia did show a positive impact on active\ndecision making (Vuorma et al., 2003). The study\nreported here was undertaken as a prelude to a\nlarge randomized controlled trial of treatment infor-\nmation provision and decision analysis in menorrha-\ngia (the MENTIP trial, Medical Research Council,\nfunded study of the place of a decision aid in the\nmanagement of menorrhagia, started 2003). The\nstudy was necessary because there is little previous\nliterature looking specifically at what patients cur-\nrently know about the treatment options for men-\norrhagia and the place of a decision aid in the\nmanagement of menorrhagia.\nThe aim of this research was to examine women’s\nknowledge and attitudes towards treatment for\nmenorrhagia, to explore where they obtain their\ninformation from, and to determine how accurate\n(according to current best evidence) is this informa-\ntion. In particular, women’s experience of primary\ncare as a source of information about the manage-\nment of menorrhagia was explored.\nMethods\nSampling\nPurposive (systematic, non-probabilistic) sam-\npling was used to ensure that women of a variety of\nages, socio-economic groups, and ethnic groups were\nsampled for the study. Fifteen women at the point of\nentry to secondary care, attending for their first\ngynaecology outpatient appointment for excessive\nmenstrual loss (in the absence of identified signifi-\ncant medical pathology) were recruited to the study.\nContacting patients at the point of referral to sec-\nondary care was a pragmatic choice, based on the\nfollowing theoretical assumption: The study aimed\nto answer questions about what women know, and\nunderstand, about treatment for menorrhagia from\ntheir experience in primary care. The assumption\nbeing made is that prior to being referred to a spe-\ncialist, the women will have had some experience of\nthe different treatments available in primary care.\nInterviews\nThe patients were invited to attend for a semi-\nstructured qualitative interview prior to their\nappointment with the gynaecologist.The interviews\nwere conducted by the first author, and audio-\ntaped, with the patient’s consent. Each interview\nlasted between 30 minutes and one hour.\nData analysis\nThe typed transcripts of the audiotapes, in con-\njunction with the reflexive notes and the fieldwork\ndiary, were analysed by constant comparison,\nusing an interpretive stance most closely allied to\nthat of Layder’s ‘adaptive theory’ (Layder, 1998).\nThe analysis was enhanced by the use of computer\nassisted data analysis, using Atlas Ti. The inter-\nviews were continued until category saturation\nwas achieved. In this study, although the respond-\nents were offered the opportunity to receive a\ncopy of the research findings, only one actually\nasked for a copy, so member checking in this way\nwas not possible. However throughout the inter-\nview the researcher’s interpretations of what was\nbeing said was checked with the respondent.\nDisconfirming cases, those that do not appear to\nfollow the emerging explanatory theory, were\nactively sought through sampling of women and\nmodification of the interview schedule, as well as\nthrough careful analysis of the data, and used to\nmodify themes in order to increase validity and\nreliability.The first and second author coded separ-\nately then discussed the analysis, and agreed upon\nsalient themes.\nResults\nFifteen women, seven Caucasian, three Pakistani,\ntwo Black-African, one Black-Caribbean, one\nPC-251oa-5.qxd  03-06-2005  14:01  Page 218\nhttps://doi.org/10.1191/1463423605pc251oa Published online by Cambridge University Press\n\nThe role of primary care in the management of menorrhagia 219\nPrimary Health Care Research and Development 2005; 6: 217–223\nEast-African Asian and one mixed race, aged\n21–49 (median 38 yr) of mixed socio-economic\nstatus and mixed educational background were\ninterviewed.\nIn common with previous studies (Marshall,\n1998), the women were more concerned about the\nchange in their periods than about the amount of\nblood loss per se.They reported presenting to their\nGP for an explanation of their symptoms and a\ndiagnosis, or a ‘label’, for their condition. The\nwomen did not consider that their GP was in a\nposition to fulfil this need, and were looking to the\nspecialist to answer their questions.\nWhat the women knew about the treatment of\nmenorrhagia\nThe women had limited, and sometimes inaccur-\nate, knowledge of most treatment options, but they\nall were aware of hysterectomy as a potential\ntreatment option. Respondents’ attitudes varied\nbetween the women but the strongest attitudes\nand beliefs were regarding hysterectomy:\n… I’d have a hysterectomy, you know. I\nwould. But do people say you still get period\npains when you’ve had a hysterectomy? ‘Cos\nMary O’R (friend) had one, but they left her\novaries in, I think, so she says she still suffers\nwith pains, even though she’s had a hysterec-\ntomy.… (ID 11)\nSome women reported not liking the possibility of\nsurgery, but felt that it was inevitable:\nWell I’ve been thinking about it ( hysterec-\ntomy) for twelve months really and obvi-\nously the reason I’ve been thinking about it\nfor so long is that I didn’t want to have it\ndone…you know, I’m quite terrified about\nhaving it done really but I’ve been so poorly,\nyou know, in the last few months that I’ve\ndecided, you know, I thought that would be\nthe best thing to do.… (ID 04)\nTwo women had been prescribed medication, but\ndenied having tried any ‘treatment’ for their heavy\nmenstrual bleeding:\nQ: Did you try any treatment at all over the last\ntwelve years?\nA: No.… They’ve just been giving me tablets to\nlike, slow my periods down … (ID 12)\nIt is not clear why these women did not consider\ntaking tablets to be a ‘treatment’, but it is possible\nthat some women may only see something done to\nthem to be ‘treatment’, rather than something they\ncan do for themselves such as taking tablets. Other\nwomen who had been prescribed hormonal treat-\nments within primary care raised concerns about\nthe use of such medication. Three women, dis-\ncussing the combined oral contraceptive pill, were\nconcerned about the side effects of taking hor-\nmone tablets, and one woman was concerned\nabout the prospect of taking hormone tablets\nwhen the cause of her heavy bleeding had not\nbeen found:\nIts just I didn’t understand why I was being\nput on hormones without being tested were\nmy hormones wrong. You know, I might be\ncompletely wrong on that, but I felt as if,\nwell, why give me a medication when is it\nthat? … (ID 12)\nThus of all the possible treatment options available,\nthe only one that all the respondents knew about\nwas hysterectomy, a major surgical procedure.This\nmight be linked to the high rates of hysterectomy\nundertaken in the UK for menorrhagia (Box 1).\nMEDICAL TREATMENT OPTIONS\nNon Hormonal:\nNon Steroidal Anti-Inflammatory Drugs: e.g.,\nMefenamic acid, Ibuprofen\nAnti-Fibrinolytics: e.g., Tranexamic acid\nHormonal:\nOral Cyclical Progestogens: e.g., Norethisterone\nCombined Oral Contraceptive Pill\nAndrogens: e.g., Danazol\nIntra-uterine Progestogens: e.g., Levonorgestrel\nIntra-uterine System (Mirena coil)\nSURGICAL TREATMENT OPTIONS\nEndometrial Ablation\nHysterectomy\nNote: This is a list of possible treatments, and as such does\nnot contain prescribing instructions.\nBox 1 Treatment options for menorrhagia\nPC-251oa-5.qxd  03-06-2005  14:01  Page 219\nhttps://doi.org/10.1191/1463423605pc251oa Published online by Cambridge University Press\n\nWhere the women obtained their information\nOne of the aims of the study was to explore where\nwomen were getting their information from about\ntreatment for menorrhagia.As might be predicted,\nthe woman described a variety of sources of infor-\nmation.A couple of women described reading news-\npapers and magazines; one read about endometrial\nablation in a newspaper, and one had read about the\nMirena intrauterine device. Interestingly both of\nthese women had queries about what they had read\nwhich they did not address with their GP . Most\nwomen described discussing their condition and\ntreatment with their family, friends or colleagues.\nQ: But you want to get that ( information about\nthe Mirena coil ) from here ( Gynaecologist),\nnot your own GP?\nA: Yeah.… I don’t think they ( GPs) know\nenough…. (ID 08)\nOnly three women mentioned the internet as a\nsource of information, one woman said that she\nwould like to use it, if she had access to a com-\nputer, another said that she would consider it, and\nanother had used it, but only for information about\nher husbands’ heart complaint. Other sources of\ninformation mentioned were family planning clin-\nics and health food shops.\nNo one had seen any written information, or\npatient information leaflets, specifically relating to\nheavy menstrual bleeding and its treatment. None\nof the women reported having received a leaflet\nabout their condition from the GP . Respondents\nfelt that such leaflets may well be useful, except \nby one woman who admitted that she ‘wouldn’t\nwant to be bothered’ (ID 15), yet she had been \n‘bothered’ to attend an outpatient appointment.\nThe biggest theme emerging from the data was\nthe apparent failure by these women to consider\nthe GP as a source of information on either the\ncondition or its treatment.The reasons for this war-\nranted further analysis, and are described below.\nWhy not from the GP?\nThe Royal College of Obstetricians and\nGynaecologists considers menorrhagia should be\nprimarily managed in primary care.\nThe reasons described by the women in this\nstudy for not seeking information on treatment\noptions from the GP are divided into three main\ncategories: (i) women not feeling that they have a\ndiagnosis because they do not consider that the\nGP has the specialist knowledge to make the diag-\nnosis; (ii) women not feeling able to bother the GP\nwho is short of time, or being too embarrassed to\ntrouble the GP; and (iii) women expressing dissat-\nisfaction with their GP .\n(i) No diagnosis yet: Women who do not consider\ntheir symptoms to have been diagnosed and a\nlabel applied will not feel in a position to dis-\ncuss treatments with their GP . Some respond-\nents implied that the GP was not in a position\nto make the diagnosis, even though they were\n‘diagnosed’ as having menorrhagia in the GP’s\nreferral letter to the consultant.\nQ: Have you ever been given a label for your\nperiod problems, a name or something?\nA: No cos my doctor didn’t know, more or\nless probably think I’ll just find out today\nwhat’s the cause or why…. (ID 07)\nThat the women were expecting their appoint-\nment with the gynaecologist to provide this\nexplanation could be viewed as a failure of the\ngeneral practice consultation. It must also have\nan impact on what the women knew and felt\nabout possible treatments for menorrhagia.\nI just think that a gynaecologist probably\nhas a lot more experience in that field and\nthey’ll see a lot more patients perhaps with\nsimilar problems, and know the sort treat-\nments that have worked in one case that\ndid not work for another patient…. (ID 09)\nAnd if they say ‘Well, its age’ and ‘tough’\nthat’s fine. I can cope with that … (ID 12)\nQ: Right. What about if your GP had\nsaid to you, ‘well its age’ and ‘tough’?\nA: Well I wouldn’t have believed that\ncos how would she know without hav-\ning taken a look?\nQ: Right. So what way would you take a\nlook?\nA: I don’t know what they do, just scan,\nlook…. (ID 12)\nI think they are GPs, as the title implies, and\nthat they’re not specialists in every field,\nand I think it’s perhaps better that they\nrefer people on to the specialists. (ID 09)\n220 Joanne Protheroe and Carolyn Chew-Graham\nPrimary Health Care Research and Development 2005; 6: 217–223\nPC-251oa-5.qxd  03-06-2005  14:01  Page 220\nhttps://doi.org/10.1191/1463423605pc251oa Published online by Cambridge University Press\n\nMore disturbingly perhaps, some women con-\nsidered their GPs had not bothered to try to\nmake a diagnosis and were ‘fobbing them off’\n(ID 13 & 15) with different treatments.\n… You know, because of my initial experi-\nence with going to the doctor’s and ‘Try\nthis and try that.’ And not really trying to\nfind out what’s really wrong with you. You\nknow, they didn’t have the time like, ‘Oh,\nthat’s Mrs (…) coming in with a back\nache.’… (ID 13)\nThey say … ‘Well, what do you want to do,\nwe can stop your periods if that’s what\nyou want, we can give you the injection\nand that will stop your periods for three\nmonths. Or we can put you on the pill.’\nAnd that’s just really like, you know, its\njust always upset me, cos I thought, I’m\nnot asking you to stop me periods, I’m just\nasking you to find out why I’m suffering\nlike this.…Cos its just like ‘okay, well have\nthe pill’.You know,‘Run along’…. (ID 14)\nWell, the thing is, sometimes they are rush-\ning and you’ve got to say what you want,\nyou know, and then get out. And when\nmaybe you want.…I just don’t bother, in\ncase I get fobbed off or something like\nthat. So I just don’t bother…. (ID 15)\nThis data demonstrates that these women felt\nthat their GPs did not have the necessary\nexpertise, or did not appear to be interested,\nto identify the cause of their symptoms. The\nrespondents emphasise that their condition,\nmenorrhagia, is similar to other problems in\nprimary care which GPs may find difficult to\nmanage.\n(ii) Not bothering the GP: several women felt that\nthe GPs were too busy to discuss treatments,\nor that a busy surgery wasn’t the right place\nfor such a discussion:\nIt’s just not the right place, it is not, I’ve\nalways got children with me anyway, so\nyou know its hard to talk, so…. (ID 08)\nI think it’s just the system, I think it’s just\nthe time. It’s much easier to refer us in\nfive minutes, say ‘I’m going to refer you to\nsomebody’ than talk to you about what\nother things you can take…. (ID 08)\nMm. No. I think that’s what the real\nproblem is, because you don’t have\nenough time with the doctor. You know,\nyou know you go there and within five\nminutes you’re out. You know, he just\nprescribes you quickly and out you go.\nSo … I think that’s also one of the rea-\nsons why you don’t tend to confide in\ntelling what’s your problem, you think\nyou’re wasting his time…. (ID 13)\nSome women reported that they were embar-\nrassed to talk about periods, particularly if\ntheir GP was male. One woman said she was\nreluctant to talk about periods in general, and\nhad brought her mother to the consultation\nwith the gynaecologist because of this reluc-\ntance to speak. Other women said they found\nit easier to talk to a female GP as they ‘under-\nstand the symptoms’, but the majority of the\ninterviewees did not feel that the gender of\nthe GP was an issue,‘particularly after having\nchildren’ (ID 9). Other women also felt that\nthey should not be bothering the GP with\nwhat was essentially part of a ‘woman’s lot’,\nyet they were prepared to subject themselves\nto referral to secondary care.\nYeah. She’s gotta have periods, she’s\ngotta bear children, she’s gotta cook,\nshe’s gotta clean (laughter). Look after\nthe family. That sort of thing, you\nknow…. (ID 13)\nThese women felt that they could not discuss\ntheir menstrual problems in any depth with\ntheir GP because there wasn’t enough time in\nsurgery, or they were too embarrassed to\nbring the subject up, or the subject was not a\n‘medical’ problem; yet they were happy to be\nreferred to hospital to discuss them.\n(iii) Dissatisfied with their GP: four women sug-\ngested that they didn’t discuss things with\ntheir GP because they were ‘unhappy with\ntheir GP’. We have already described how a\nfew women appear to feel ‘fobbed off’ by\ntheir GPs, another woman told how her GP\ndid not listen to her, and had suggested to her\nthat she could always change her GP . One\nwoman had resorted to just this when her GP\nrefused to do a blood test at her request to\nThe role of primary care in the management of menorrhagia 221\nPrimary Health Care Research and Development 2005; 6: 217–223\nPC-251oa-5.qxd  03-06-2005  14:01  Page 221\nhttps://doi.org/10.1191/1463423605pc251oa Published online by Cambridge University Press\n\nsee if she was menopausal, and another again\nfelt that her GP did not listen to her:\nHe really doesn’t, and I’ve been with him a\nlong time and he doesn’t listen to me. Cos\nI’ve had the complaint for twelve years\nand I’m still suffering now, so obviously\nsummat’s wrong somewhere…. (ID 11)\nThis was the most important and significant\ntheme, to emerge from this study: the\nwomen’s feelings of diagnostic uncertainty,\nthe lack of an explanation and need for a\n‘label’ for symptoms, and, most significantly,\nthe women’s perception that it is not the role\nof the GP to provide this.\nDiscussion\nThe data in this study represent the views of a heter-\nogenous group of women, all of whom had been\nreferred by their GP , to the gynaecologist, with\nexcessive menstrual loss in the absence of already\nidentified significant medical pathology; in other\nwords, a diagnosis of menorrhagia. No conclusions\ncan be drawn about those women who do not\npresent to their GP in the first place, which the lit-\nerature suggests may be a sizeable proportion of\nwomen with menorrhagia (Chapple, 1999; Shapley\net al., 2000), or about those women who are suc-\ncessfully managed in primary care, without recourse\nto referral to secondary care. Obviously the women\nin the study represent a select group of women,\nhowever, we shall see that some of the emergent\nthemes from this data, particularly in reference to\nthe women’s perception of the role of the GP , have\nimportant implications for primary care.\nOne of the main aims of this study was to deter-\nmine women’s knowledge of and attitudes towards\nthe various different treatment options for menor-\nrhagia. Sufficient knowledge would be vital in order\nto fully participate in shared decision making\nabout the management of their menstrual symp-\ntoms. The data show that a proportion of women\nreferred from primary care reported not receiving\nenough information about treatment options but\nalso insufficient information about the causes and\nmeanings of their symptoms.\nThe data show that the only treatment that all\nthe women were aware of was hysterectomy.Their\nknowledge regarding other treatment options was\nlimited and often misleading.The information that\nthese women did have on treatment options was\nlay information obtained from family, friends and\nmagazines articles, not from their GP , nor any\nmedical patient information leaflets. The issue of\nwhat was considered to be a ‘treatment’ by these\nwomen was interesting, as treatments suggested \nby the management guidelines (Royal College of\nObstetricians and Gynaecologists, 1998) such as\n‘watchful waiting’ or the combined oral contracep-\ntive pill, were not considered to be ‘treatment’ by\nthese women. This may result in entirely clinically\ncorrect treatment leading to dissatisfaction in\nsome women.\nThe literature has suggested that many hysterec-\ntomies are performed in this country with no under-\nlying organic pathology, and that women have high\nexpectations of surgery compared with their expec-\ntations of other treatments (Marchant-Haycox \net al., 1998; Stirrat, 1999). This data would suggest\nthat women have high expectations of surgery in\nthe absence of adequate knowledge of other treat-\nment options. They are relying on secondary care\nto provide both diagnosis and management, and\nprevious studies have found that once a woman is\nreferred to a gynaecologist, the likelihood of sur-\ngery can be as high as 60%, even in the absence of\nunderlying pathology (Coulter et al., 1991; Grant\net al., 2000). The reasons given for not considering\nthis information to be a part of the GP’s role\nincluded: not feeling the GP had the specialist\nknowledge to make the diagnosis; not feeling able\nto broach the subject with the GP for reasons of\nlack of time or embarrassment and feeling that\ntheir GP simply did not listen to them. It is plain\nfrom the guidelines issued by the RCOG on the\nmanagement of menorrhagia (1998) that diagnosis\nand initial medical management of menorrhagia is\nfirmly placed in primary care and is the role of the\nGP . That this is not perceived to be the case is\neither a failure of the guidelines, or a failure of pri-\nmary care itself. There is evidence that guidelines\nimposed on primary care are not successful (Little\nand Williamson, 1996). There may well be a place\nfor guidelines developed in partnership with pri-\nmary care, thereby engendering a feeling of ‘own-\nership’ of the guidelines, perhaps alongside improved\ntraining, both in terms of clinical management of\nmenorrhagia, and communication of diagnoses that\nfit in with patient expectations, values and prefer-\nences (Kennedy et al., 2002). Other reasons for this\n222 Joanne Protheroe and Carolyn Chew-Graham\nPrimary Health Care Research and Development 2005; 6: 217–223\nPC-251oa-5.qxd  03-06-2005  14:01  Page 222\nhttps://doi.org/10.1191/1463423605pc251oa Published online by Cambridge University Press\n\nThe role of primary care in the management of menorrhagia 223\nPrimary Health Care Research and Development 2005; 6: 217–223\nperceived failure may be due to the constraints in\nprimary care such as short consultations and diffi-\nculty negotiating appointment systems.\nPractice implications\nThese findings suggest that more effort may need\nto be made by the GP to understand the women’s\nconcerns and expectations regarding her menstrual\nsymptoms, and to explain the nature of bodily func-\ntions and likely causes of these symptoms. Women\nmust be able to feel first that they have been lis-\ntened to and then diagnosed in order that treat-\nment options can then be properly discussed, and a\nshared management decision reached.\nMenorrhagia may be seen to represent an\nexemplar of other problems that also cannot be\nobjectively diagnosed, such as irritable bowel syn-\ndrome and chronic lower back pain, that are pre-\nsented in primary care and which GPs may \nbe insufficiently skilled in managing. The place \nof a decision aid to assist both the GP and the\nwoman with menorrhagia needs careful but urgent\nevaluation.\nAcknowledgements\nThis study represents research submitted as part\nof a dissertation for the degree of MRes by the\nfirst author and was funded by a Training\nFellowship from the MRC.\nThanks are extended to the consultants and\npatients of the gynaecology outpatient depart-\nment at St Mary’s Hospital, Manchester, involved\nin this study.\nReferences\nChapple, A. 1999: Menorrhagia: women’s perceptions of this\ncondition and its treatment. 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The\nLancet 353, 2175–76.\nTudor Hart, J. 1997: What evidence do we need for evidence\nbased medicine?. Journal of Epidemiology and Community\nHealth 51, 623–29.\nVuorma, S., Rissanen, P ., Aalto, A.M., Hurskainen, R.,\nKujansuu, E. and Teperi, J. 2003: Impact of patient infor-\nmation booklet on treatment decision – a randomized trial\namong women with heavy menstruation.Health Expectation\n6, 290–97.\nPC-251oa-5.qxd  03-06-2005  14:01  Page 223\nhttps://doi.org/10.1191/1463423605pc251oa Published online by Cambridge University Press","source_license":"CC0","license_restricted":false}