{"paper_id":"a3b113c9-c7b8-43fa-bf0f-33df7bb98a92","body_text":"Gynecol Surg (2006) 3: 253 –258\nDOI 10.1007/s10397-006-0195-z\nORIGINAL ARTICLE\nEmad Louis . P. Gardiner . N. Elkington .\nJ. Frappell . J. Morsman\nA qualitative analysis of patients ’ perception of microwave\nendometrial ablation as a satisfactory treatment for heavy\nmenstrual blood loss\nReceived: 3 June 2005 / Accepted: 26 December 2005 / Published online: 17 October 2006\n# Springer-V erlag Berlin / Heidelberg 2006\nAbstract To explore and analyse patients ’ views and\ncomments on microwave endometrial ablation (MEA), we\ndesigned a simple and concise questionnaire of 10 items\nthat the participants answered by ticking boxes. They were\ninvited to add their own comments and opinions if they\nwished. The questionnaire survey was posted to 470\npatients who were treated with MEA at Derriford Hospital\nbetween 1997 and 2003. We received replies from 343\npatients (73%), of whom 165 included handwritten\ncomments (48%). These were reviewed using content\nthematic analysis. This paper describes the findings of this\nanalysis. Of the 343 respondents, 127 expressed their\nsatisfaction, 32 would recommend MEA to others, and 17\nclaimed that MEA had transformed their lives. They used\nwords such as “delighted,”“ grateful,”“ fantastic,”“ I cannot\ntell you how wonderful it has been, ”“ freedom at last, ”“ I\nfeel so much better within myself, ”“ I cannot begin to\ndescribe the feelings of well-being and relief I have\nexperienced since I had this treatment,” and “it has changed\nmy life from being housebound to never giving my periods\na thought. ” Thirty-eight patients were not satisfied; of\nthese, 14 were experiencing moderate to severe pain, and\nsix claimed to have developed severe pain de novo. Their\ncomments included “I was disappointed MEA did not work\nfor me ” and “I get heavy bleeding and pain each month,\n[whereas] before I had no period pains at all. ” In\nconclusion, MEA has been a “miracle cure ” for many\nwomen who responded, with around 77% being satisfied\nwith this treatment. For a small number, MEA was not\nsuccessful. For some women, pain was a problem that\neither developed de novo or was preexisting in the form of\ndysmenorrhoea. In this paper we also mention success rates\nand figures from quantitative studies, and we recommend\nincluding quotes from satisfied patients in patient informa-\ntion leaflets to further help women and their physicians\nmake informed choices about managing heavy menstrual\nblood loss, particularly when medical treatment is known\nto be less successful and with some women being\nconcerned about its side effects.\nKeywords Microwave Endometrial Ablation .\nPatient satisfaction . Assessment of subjective symptoms\nIntroduction\nIn routine clinical practice, the diagnosis of heavy\nmenstrual blood loss is based on the woman ’s subjective\nassessment. Women often seek treatment when the\nperceived heavy menstrual loss has a negative impact on\nwork attendance, social activities, sex, and holidays,\nalthough the measured loss may well be within the normal\nrange [ 1].\nWomen should be offered a choice of medical treatment,\nwhich include antifibrinolytic drugs, nonsteroidal antiin-\nflammatory drugs, combined oral contraceptive pills [ 2, 3],\nthe levonorgestrel-releasing intrauterine system [ 4, 5], and\nendometrial ablation as an alternative to hysterectomy.\nSecond-generation endometrial ablation technology\nsuch as microwave endometrial ablation (MEA) was\ndeveloped to provide a simple and rapid procedure that is\neasy to learn and safe to perform [ 6, 7].\nShortly after this paper was submitted, Emad Louis tragically died\nfrom complications following surgery, whilst waiting to take up\nhis post as a Consultant at St. Mary ’s Hospital, Isle of Wight. We\nremember him with great affection as a wonderful colleague, who\nis held in the highest regard by his patients and all who worked\nwith him. He is greatly missed.\nHe leaves a wife and son who are enormously proud that his\nresearch has been published.\nP . Gardiner\nHealth Sciences Research, RDSU, Room N17, ITTC Building,\nPeninsula Medical School,\nTamar Science Park, Research Way,\nPlymouth, PL6 8BX, UK\nE. Louis . N. Elkington .\nJ. Frappell ( *) . J. Morsman\nDepartment of Obstetrics and Gynaecology,\nLevel 7 Medical Administration, Derriford Hospital,\nPlymouth, PL6 8DH, UK\ne-mail: jonathanfrappell@phnt.swest.nhs.uk\n\nThe only guarantee of amenorrhoea is hysterectomy,\nwhich, despite being a far more invasive procedure, has a\nhigh rate of patient satisfaction. However, about half of all\nwomen treated with hysterectomy for heavy menstrual loss\nhave a normal uterus removed [ 8]; they would have been\nsuitable candidates for MEA.\nWomen’s perceptions of satisfactory resolution of\nheavy menstrual blood loss should be explored further\nbecause the aim of endometrial ablation is not to achieve\ntotal cessation of menstruation but to restore menstrual\nbleeding to an acceptable level.\nFor this reason, qualitative research and follow-up of\nlong-term patient satisfaction —i.e. improvement of the\nsymptoms together with the absence of complications —\nis important.\nMicrowave Endometrial Ablation (MEA) Follow-up Survey\n(Please tick boxes) \nAge at time of MEA \nUnder 30 30-34  35-39  40-44 \n45-49  50-54  55-59 \nOverall are you satisfied with the result of your MEA treatment? \nVery  Satisfied Neither satisfied Dissatisfied Very  \nsatisfied   nor dissatisfied   dissatisfied\nBefore MEA treatment my periods were: \nVery heavy Heavy  Normal Light  Very light\nAfter MEA treatment my periods were: \nVery Heavy Heavy  Normal  Light  Very light\nHow many months after MEA treatment did your periods stop? \n…………….. months \nIf your periods have not stopped are they:   Better     Worse \nBefore MEA treatment did you have painful periods? \nVery painful  Painful  Average Painless\nAfter MEA treatment my periods were: \nVery painful  Painful  Average Painless\nPLEASE TURN OVER\nFig. 1 Questionnaire\n254\n\nMethod\nWe designed a questionnaire survey, which was posted to\nall the patients who were treated at Derriford Hospital,\nPlymouth, between 1997 and 2003. The South West Devon\nResearch Ethics Committee approved the study. The\nquestionnaire consisted of 10 items (Fig. 1), which the\nparticipants answered by ticking boxes. The design was\nsimple and concise to encourage a high response. At the\nend of the questionnaire, participants were invited to add\ntheir own comments and opinions if they wished.\nWe sent out 470 questionnaires, of which 343 were\nreturned (73% response rate). Among those who re-\nsponded, 165 included handwritten comments (48%).\nThese were reviewed using content thematic analysis.\nThis paper describes the findings from these comments.\nResults\nOf the 343 respondents, 127 (77%) expressed their\nsatisfaction with MEA. Among them, 31 stated they\nwould recommend this treatment to other women experi-\nencing similar problems, and 17 claimed that MEA had\ntransformed their lives.\nThirty-eight (23%) respondents commented that they\nwere dissatisfied with the results of MEA. Among them, 14\nwere experiencing moderate to severe pain, and 12 were\nsuffering from other effects.\nTwenty-eight respondents described how their lives had\nbeen before MEA, and 17 commented on aspects related to\nthe treatment itself, the day of the operation, and the\nimmediate postoperative period. Thirteen other comments\ncould not be categorised but are worth relating.\nAll comments are described in more detail below.\nSince your MEA treatment, have you had: \nNo further  Tablets  HRT  Repeat  Hysterectomy\ntreatment      MEA \nIf you have had a hysterectomy following MEA treatment was it due to \npersistence of heavy periods / pain? \nYes No\nWhat type of contraception are you using?\nNone \nNot sexually active \nCondoms \nCombined oral contraceptive pill \n Mini pill \n Depot injection \n Coil \n Diaphragm \n Female sterilization \n Male sterilization \n Other ………………………………… \nComments: \nWe are very interested in your opinions and views. Please use the reverse of this \nform for any further comments that you wish to make. \nPlease return the questionnaire in the stamped addressed envelope. \nMany Thanks. \nFig. 1 (continued)\n255\n\nBefore MEA\nTwenty-eight respondents described their heavy, pro-\nlonged, and/or painful periods and the effects these had\non their lives: “I had years of heavy periods, clotting, and\nflooding,”“ I had heavy blood loss and anaemia, ”“ I was in\nagony for at least 10 days per month with uncontrollable\nheavy periods. ”\nSome respondents described periods lasting up to\n3 weeks or with only a few days between each one. They\nwere unable to work or even to go out: “Before this\ntreatment I lost over a week each month. ”\nOther effects of heavy blood loss commonly included\ncomments describing anaemia, feelings of being “tired” or\n“totally drained, ” and the need to take “tablets almost\nconstantly.”\nOne respondent described how she used to sit on carrier\nbags to prevent leaks from spoiling the furniture.\nFor a number of respondents, heavy periods had “ruled\ntheir lives”; other such comments included “I went through\nhell” and “heavy periods made everyday living a problem.”\nMEA procedure\nSeventeen women commented on the procedure itself,\nseven positively and 10 negatively. The operation was\ndescribed by some as “a very simple procedure ” and\n“relatively painless, ” with one respondent stating “I could\nhardly believe such a quick minor operation could sort out\na major problem. ”\nFour described the procedure as “very painful, ” two\n“needed at least 2 weeks to recover, ” and another two felt\nthey had been sent home too early ( “with hindsight, I\nwould have stayed in hospital that night ”).\nTwo were pleased with their postoperative care: “All the\nhealthcare professionals were really helpful and reassuring\n—made a difficult day much more bearable ”; however, one\nfelt that “the postoperative care in a busy ward was\ninappropriate and unhelpful. ”\nA small number complained about the inadequate level\nof follow-up.\nEffectiveness of MEA\nFifty-two respondents specifically commented on how\neffective MEA had been in resolving their problem.\nAmong them, 31 now had lighter or absent periods, 12\nstill had heavy periods, and a small number found that the\ntreatment had been a success initially, but then their periods\nstarted to get heavier again. Three respondents mentioned\nthat although their periods were lighter, they had become\nmore painful.\nSatisfaction with treatment\nA total of 127 expressed their general satisfaction with the\nresults of MEA, using words such as “delighted,”“\ngrate-\nful,”“ fantastic,”“ I cannot tell you how wonderful it has\nbeen,” and “freedom at last! ”\nFive described MEA favourably compared with needing\nhysterectomy, indicating that they were glad to have been\nable to avoid the latter.\nThese comments have been grouped into subcategories:\n– General health:\nEight respondents felt that their general health was\nbetter since having MEA. This may have been due to\nimprovement of anaemia but was probably also due to\npsychological factors. Several commented on their\nprevious worry about blood loss and the subsequent\nfeeling of freedom: “I feel so much better within\nmyself,”“ I can’t begin to describe the feelings of well-\nbeing and relief I have experienced since I had this\ntreatment.”\n– Life-changing treatment:\nTwenty-nine respondents claimed that having MEA\nhad transformed their lives or had restored their lives\nto normal. “It’s made such a difference to my life ” was\na typical comment; other respondents were more\nspecific: “It changed my life from being housebound\nto never giving my periods a thought. ”\n– Recommendation to others:\nThirty-two respondents mentioned that they would\nrecommend MEA to others experiencing heavy and\npainful periods. Several had already advocated the\noperation to friends. Three wished that MEA had been\navailable years ago. Another expressed her hope that\nMEA will be offered to more patients in the future.\nDissatisfaction with treatment\nAlthough the majority of respondents were very satisfied,\n38 (23%) expressed some degree of dissatisfaction in their\ncomments.\nFor 14, moderate to severe pain after MEA was a serious\nproblem. Among them, eight had experienced painful\nperiods before treatment and were hoping that this would\nbe resolved. More important is the fact that six respondents\nclaimed to have developed severe pain, which they had not\nexperienced before the operation: “I get heavy bleeding\nand pain each month, [whereas] before I had no period\npains at all. ”\nEight respondents expressed general dissatisfaction: “I\nwas disappointed MEA did not work for me.” Four had had\nrepeat MEA and were still dissatisfied, and three went on to\nhave hysterectomy. Eleven had noticed the gradual recur-\nrence of their original symptoms: “After 2 years, I get pains\nand bleeding if I do any lifting or strenuous exercise. ”\n256\n\nUnrelated events attributed to treatment\nSix respondents claimed that the operation had resulted in\ntheir putting on between half a stone and one-and-a-half\nstone in weight. Four mentioned that they became very\nbloated. One, on the other hand, had lost a significant\namount of weight. Two had constant vaginal discharge, and\nanother two described “having contracted long-term\ninfection following surgery. ” A further two had suffered\nfrom hot flushes since the treatment: “I get bad sweats and\nflushes all the time, [but] I am only 35 [so] it can ’t be the\nmenopause.” One respondent mentioned that she had\ndeveloped high blood pressure since the operation, while\nanother stated that following treatment her raised blood\npressure was restored to normal levels. One respondent\nclaimed that MEA had cost her her sex drive.\nDiscussion\nPatient satisfaction is a subjective concept related to patient\ncharacteristics such as age, education, social class, and\nhealth [ 9]. Moreover, the symptom of heavy menstrual\nblood loss is notoriously subjective, and the loss is\nperceived to be heavier when it is associated with pain\n[10]. We know from research that objectively confirmed\ndiagnosis is more likely to be associated with a higher\ntreatment success rate than when the treatment is offered on\nthe basis of a subjective diagnosis [ 11]. Also, around one-\nthird of women have a strong preference towards a\nparticular treatment option [ 12].\nWe felt that by reporting the patients ’ own comments, a\ndifferent insight into the perception of the problem and its\nmagnitude can be presented, as well as truly reflecting the\nimpact of treatment as seen through the eyes of the service\nusers. This is important because it depicts themes and\nhighlights consistencies in opinion, which are not given\nmuch emphasis in the commonly used outcome scales such\nas the menorrhagia outcome questionnaires [ 13], the multi-\nattribute questionnaire [ 14], the generic measure of quality\nof life [ 15], or the short form with 36 items (SF-36).\nFor many women in our study, MEA may be a “miracle\ncure.” Around 77% are still satisfied with the success\nachieved by this treatment. The satisfaction noted in this\nstudy related not only to improved physical health but also\nto psychological benefits and feelings of release or even\ntransformation.\nThis survey also revealed a number of comments\nrelating to dissatisfaction. It is recognised that open-\nended questions often produce a disproportionate level of\nnegative responses, respondents sometimes perceiving this\nas a legitimate channel for their complaints [ 16].\nFor a small number, MEA was not successful. Although\ninitial follow-up after MEA revealed a hysterectomy rate of\n10% after 2 years, this rose to 25% after 5 years [ 17].\nLonger follow-up might reveal an even higher failure rate.\nStudies reporting short-term follow-up, particularly among\nyounger cohorts of women, may overestimate the benefits\nof ablation.\nPain was a problem for some women. It either developed\nde novo after MEA or was due to preexisting dysmenor-\nrhoea that did not resolve after treatment, even though\nMEA was successful in curing or reducing heavy menstrual\nblood loss. Possible explanations are the presence of\nundetected adenomyosis and the regeneration or incom-\nplete destruction of the endometrium, particularly in the\ncornual regions of the uterus. This might be responsible for\nthe development of pockets of trapped blood in the cornual\nregion or the fallopian tube [ 18]. The treatment is usually\nhysterectomy.\nThese findings confirm that in suitable patients, MEA\nshould be offered as first-line treatment for menorrhagia,\nalong with medical management. Withholding endometrial\nablation until after the failure of medical treatment should\nbe discouraged; this may result in less satisfaction than\nwould otherwise have been achieved had the endometrial\nablation been offered to women who were not keen to be\ntreated medically [ 19, 20].\nConclusion\nFor the majority of women experiencing heavy and painful\nmenstrual blood loss and who are anxious to avoid\nhysterectomy whenever appropriate, a 77% success rate\nand a quick recovery with very few complications make\nMEA a valuable treatment option.\nMost respondents in this survey expressed their long-\nterm satisfaction with MEA. For some, it has had a major\nimpact on their health and quality of life. However, for a\nsmall number, MEA has had no effect on their symptoms,\nand in a very few it resulted in new side effects.\nWe recommend providing more information, both verbal\nand written, before the operation. Including patient quotes\nin the information leaflets as “statements of satisfied\npatients” might be more beneficial than simply relying on\nfigures and success rates quoted from quantitative research\nstudies. Patients who make their own informed choices\nabout their treatment are likely to be more satisfied.\nPhysicians should be able, whenever appropriate, to offer\nMEA as first-line treatment for heavy menstrual blood loss,\nparticularly since medical treatment is known to be less\neffective and some women may be concerned about its side\neffects.\nFollow-up appointments may provide an opportunity to\ndiscuss any side effects and to evaluate any residual\nproblems. However, their cost-effectiveness and impact on\npatient satisfaction is doubtful. To allow more efficient use\nof time and resources, it might be more appropriate to\narrange follow-up appointments only for the small\npercentage of patients who did not benefit from MEA or\nwho experience pain after the operation.\n257\n\nReferences\n1. Chimbira TH, Anderson ABM, Turnbull AC (1980) Relation\nbetween measured blood loss and patient ’s subjective assess-\nment of loss, duration of bleeding, number of sanitary towels\nused, uterine weight and endometrial surface area. Br J Obstet\nGynaecol 87:603 –609\n2. Royal College of Obstetricians and Gynaecologists (1998)\nNational evidence-based clinical guidelines: the initial manage-\nment of menorrhagia. Guideline no. 1. RCOG Press, London\n3. Royal College of Obstetricians and Gynaecologists (1999)\nNational evidence-based clinical guidelines: the management of\nmenorrhagia in secondary care. Guideline no. 5. RCOG Press,\nLondon\n4. Chi IC, Farr G (1994) The non-contraceptive effect of\nlevonorgestrel-releasing intrauterine device. Adv Contracept\n10:271–285\n5. Henshaw R, Coyle C, Low S, Barry C (2002) A retrospective\ncohort study comparing microwave endometrial ablation with\nlevonorgestrel-releasing intrauterine device in the management\nof heavy menstrual bleeding. Aust N Z J Obstet Gynaecol 42\n(2):205–209\n6. Sharp NC, Cronin N, Feldberg I, Evans M, Hodgson DA, Ellis\nS (1995) Microwaves for menorrhagia: a new fast technique for\nendometrial ablation. Lancet 346(8981):1003 –1004\n7. Hodgson DA et al (1999) Microwave endometrial ablation:\ndevelopment, clinical trials and outcomes at three years. Br\nJ Obstet Gynaecol 106:684 –694\n8. National Institute for Clinical Excellence (2004) Fluid-filled\nthermal balloon ablation techniques for heavy menstrual\nbleeding. Technology appraisal no. 78. NICE, London\n9. Crow R, Gage H, Hampson S et al (2002) The measurement of\nsatisfaction with healthcare: implications for practice from a\nsystematic review of the literature. Health Technol Assess 6\n(32):1–244\n10. Gannon MJ, Day P , Hammadieh N, Johnson N (1996) A new\nmethod for measuring menstrual blood loss and its use in\nscreening women before endometrial ablation. Br J Obstet\nGynaecol 103:1029 –1033\n11. Hurskainen R, Teperi J, Turpeinen U et al (1998) Combined\nlaboratory and diary method for objective assessment of\nmenstrual blood loss. Acta Obstet Gynecol Scand 77:201 –204\n12. Coulter A, Peto V , Doll H (1994) Patients ’ preferences and\ngeneral practitioners ’ decisions in the treatment of menstrual\ndisorders. Fam Pract 11:67 –74\n13. Lampling DL, Rowe P , Clarke A, Lethaby A (1998) Develop-\nment and validation of the menorrhagia outcomes question-\nnaire. Br J Obstet Gynaecol 105:776 –779\n14. Shaw RW, Birckly M, Evans L, Edwards M (1998) Perceptions\nof women on the impact of menorrhagia on their health using\nmulti-attribute utility assessment. Br J Obstet Gynaecol\n105:1155–1159\n15. Clark TJ, Khan KS, Foon R, Pattison H, Bryan S, Gupta JK\n(2002) Quality of life instruments in studies of menorrhagia: a\nsystematic review. Eur J Obst Gynecol Reprod Biol 104:\n96–104\n16. Youngman MB (1987) Designing and analysing questionnaires.\nUniversity of Nottingham School of Education, Nottingham\n17. Myer WR et al (1998) Thermal balloon and roller ball ablation\nto treat menorrhagia: a multicentre comparison. Obstet Gynecol\n92:98–103\n18. Bae IH, Pagedas AC, Perkins HE, Bae DS (1996) Postablation-\ntubal sterilisation syndrome. J Am Assoc Gynecol Laparosc\n3:435–438\n19. Cooper KG, Parkin DE, Garret AM, Grant AM (1999) Two\nyear follow-up of women randomised to medical management\nor TCRE for heavy menstrual loss: clinical and quality of life\noutcomes. Br J Obstet Gynaecol 106:258 –265\n20. Cooper KG, Jack SA, Parkin DE, Grant AM (2001) Five year\nfollow-up of women randomised to medical management or\nTCRE for heavy menstrual loss: clinical and quality of life\noutcomes. Br J Obstet Gynaecol 108:1222 –1228\n258","source_license":"CC0","license_restricted":false}