Spotlight on… heavy menstrual bleeding and uterine fibroids

Heavy menstrual bleeding (HMB) is a common condition affecting 20–30% of women of reproductive age.1 In England and Wales, nearly 80 000 women a year are referred to secondary care, with one-third of those subsequently undergoing surgical interventions.1 It is not uncommon for HMB to be associated with fibroid uterus, endometriosis and adenomyosis, and in a minority of cases, it may be an early sign of endometrial hyperplasia or cancer. The national HMB audit also highlighted that almost one-third of women affected by HMB had not received treatment in primary care before referral to secondary care.1 This figure could be quite different during the current COVID-19 pandemic. The audit also pointed out that women from ethnic minority groups and those from more socio-economically deprived areas made more visits to their GP regarding their HMB and saw less improvement in their condition.1 Women from more deprived areas also reported more severe HMB symptoms and poorer quality of life.2 It is therefore important to recognise any intervention should aim to improve quality of life rather than focusing on blood loss.3 Heavy menstrual bleeding is also the most common cause of iron deficiency and iron-deficiency anaemia in premenopausal women, which is frequently overlooked in routine practice (TOG 2017;19:155–61). In the last 10 years, The Obstetrician & Gynaecologist (TOG) has featured a number of articles covering HMB-related topics. A well-established National Institute for Health and Care Excellence (NICE) guideline on assessment and management of HMB was updated in 2018 and 2020.3 Since the first edition published in 2007, there have been very few changes in the medical management of HMB. Carey and Allen (TOG 2012;14:223–8) described the noncontraceptive uses and benefits of combined oral contraception, while Murdoch and Roberts (TOG 2014;16:46–50) explored the mode of action and the potential use of selective progesterone receptor modulators in treating fibroid uterus, although its use on uterine fibroids has been largely halted in the last couple years due to serious health complications.3 Nearly one-third of women with HMB referred to secondary care will subsequently require surgical interventions.1 Saraswat and Cooper conducted an in-depth review of endometrial ablation (TOG 2017;19:37–45), which covers its development, patient satisfaction rates, safety, the long-term sequelae and the cost-effectiveness of first- and second-generation techniques of endometrial ablation. Overall patient satisfaction rates and amenorrhoea rates were up to 80% and 50%, respectively. Nevertheless, around one in six women would still require further surgical intervention within 5 years. Ultimately, only hysterectomy can ensure long term amenorrhoea. The same authors (TOG 2017;19:101–8) also examined different surgical approaches to hysterectomy (laparoscopic, abdominal and vaginal) as well as myomectomy. A recently published multi-centre randomised controlled trial (the HEALTH study)4 concluded that laparoscopic supracervical hysterectomy is superior to second generation endometrial ablation in terms of clinical effectiveness, although the differences were relatively moderate. A laparoscopic approach may and should become the standard approach in performing hysterectomy. Elnasharty and Moustafa provide useful tips and techniques on dealing with the challenges in laparoscopic hysterectomy (TOG 2020; 22:313–7). HMB is often found to be associated with fibroid uterus, although not all women with fibroid uterus complain of HMB. This poses a significant management dilemma, especially among women with a history of subfertility. Younas et al. summarised the recent evidence on managing uterine fibroids including uterine artery embolisation, magnetic resonance imaging-guided focused ultrasonography as well as a different surgical approach on myomectomy (TOG 2016;18:33–42). A similar review was also published in 2018, when Bryant-Smith and Holland predominately explored the techniques and controversies in laparoscopic myomectomy, although they also examined the potential risk of unintentional dissemination of malignant cells during intracorporeal morcellation of undiagnosed leiomyosarcoma (TOG 2018;20:261–8). In the same issue of TOG, Sampat and Alleemudder reviewed the management and outcomes of fibroids in pregnancy (TOG 2018;20:187–95). As mentioned earlier, HMB can be a sign of endometrial hyperplasia or cancer, particularly in women with history of polycystic ovary syndrome and/or being overweight. Jones et al. discussed the diagnostic tools for detecting endometrial cancer (TOG 2021;23:103–12). All of the above contributing authors emphasised the importance of involving patients in the decision-making process, however, Jeffery, Kayani and Garden reminded us of the difficulties in managing menstrual problems in adolescents with learning disabilities (TOG 2013;15:106–12). This article also evaluated the need for different management options. An online collection of TOG articles on heavy menstrual bleeding and uterine fibroids is available at http://onlinetog.org.