Heavy menstrual bleeding and quality of life

For a long time there has been uncertainty in how to classify and categorize abnormal bleeding from the uterus. The old terms of menorrhagia, metrorrhagia, menometrorrhagia have lingered on and there will be those who do not know how these Latin words are made up and what they mean. We asked a team lead by Hilary Critchley and colleagues from the FIGO working group on menstrual disorders to write about the new nomenclature for AOGS and the result can be seen in the commentary on pp. 619–625. Heavy menstrual bleeding (HMB) is the simple and understandable descriptive term now to be used instead of menorrhagia. It is high time to go over to this, as we will also strive to do in this journal by asking authors to adopt the new FIGO (or PALM-COEIN) classification where possible. “Dysfunctional” bleeding is also to be abandoned as a term in favor of HMB and AUB (abnormal uterine bleeding) and descriptive sub-classifications. We advise all readers to take the time to first read this commentary and then follow that up with looking at the original article from FIGO 1. The couple of hours spent on this will take the reader to new thinking on the problem of abnormal uterine bleeding and keep you as gynecologists abreast with the future. There is a related article by Pirkko Peuranpää and her colleagues in Finland (with an Australian addition; pp. 647–653) which should be noted in this respect as well, since there the aim was to assess the impact of anemia and iron deficiency on health-related quality of life in women treated for HMB. Is a vital issue for women. One-third of fertile women complain about HMB at some point of their life. It is clear that HMB has a significant impact on the quality of life for affected women, with a decrease comparable to those who are chronically ill. Furthermore HMB requires resources and money. This was the topic of several ground-breaking studies by Göran Rybo and collaborators in Gothenburg in the seventies. In several clinical and experimental studies, many of which were published in AOGS, these researchers aimed at defining normal blood loss and factors influencing HMB 2-5. They also performed many studies on the treatment of HMB and anemia 6, 7. Now Pirkko Peuranpää and colleagues present a secondary analysis of a randomized trial where hysterectomy and the levonorgestrel intrauterine system (LNG-IUS) were compared for the treatment of HMB. They provide evidence for improved health-related quality of life following treatment of HMB and in particular correction of the often accompanying anemia. The study conveys an important message, to women and doctors alike, namely that (a) anemia in women with HMB in the pre-menopausal years must be taken more seriously, that (b) anemia should be screened for and (c) early iron therapy is to be considered as an important component in the treatment of HMB. It is noteworthy that it took 5 years to achieve normal serum ferritin levels, but when the anemia was corrected, the women′s scores for energy, physical and social functioning improved, while there was also less anxiety and depression. Is active management of the third stage of labor and controlled cord traction of use? There have been voices of doubt about this raised in the aftermath of the 2003 FIGO/ICM statement 8. Yongming Du and colleagues from Wenzhou, China, have reviewed this situation on pp. 626–633 and they come to the conclusion that controlled cord traction reduces the chances of postpartum hemorrhage, and the need for manual removal of the placenta, while the occurrence of severe postpartum hemorrhage is by itself not diminished. Figure 2 gives a good overview of the situation and it seems that still further and well designed randomized trials in this field might be indicated, now at multi-center level to remove any vestiges of doubt. Meanwhile there is no reason for not using active management of the third stage as recommended both by FIGO and ICM (the international midwives′ association) a decade ago. At the same time this well constructed article from China is a reminder of the increasing globalization of research and of the appraisal of evidence. In terms of population and academic institutions the status of China is enormous and growing. Higher quality academic work in that country is of course reflected in more accepted contributions from Chinese academic institutions. This review is just one of many submitted to AOGS and a number of these contributions have the quality required for acceptance. The article on pp. 634–639 by Gunilla Sydsjö and co-workers in Linköping, Stockholm and Uppsala, Sweden, on acceptable numbers of donations of spare gametes, is of importance and rather unique as well, not least in the light of recent debates on many “offspring” from sperm donation. “I fathered 34 children through sperm donation” says a man in the UK to the Guardian newspaper on 31st January last (http://www.theguardian.com/lifeandstyle/2014/jan/31/fathered-34-children-sperm-donation). That article and the one in AOGS raise many points which should simulate the quest for more practical information on the handling of gamete and even embryo donation, both as regards donors, recipients and not least the offspring. Mette Løkeland and co-workers in Bergen. Norway, supply on pp. 647–653 data on the home administration of misoprostol and show that this can in conjunction with mifepristone be both acceptable and safe as a method for termination of pregnancy up to 8 and even 9 weeks gestation. This has been described before and even the use by telemedicine has been explored and found to be safe 9, 10. The important matter here is to note the time gap until potential complications appear and that distance from the hospital was not the problem which many might have feared. This is a well conducted study and should form a good additional basis for implementing medical home abortion services to a wider extent at least up to 9 weeks gestation, given adequate knowledge of gestational age and good back-up health services. Miriam Lukasse leads a consortium from six countries, i.e. Norway, Denmark, Sweden, Iceland, Finland and Estonia (pp. 669–677) writing on the prevalence of violence against women who attend antenatal clinics. Even though there are variations between countries, the rates are high. It is clearly common that women suffer emotional, physical and sexual abuse from their partners. For about one in ten of them this is severe and recurrent. There is no reason why this should not be the same and even worse around the world. There are ways to combat and limit this, but it must be addressed at society levels, from early school to adult education and by constant propaganda to keep the issue awake and make such conduct unacceptable in society. There are good points to note in this article. Referring to our cover photograph the height of summer is special. For those who live at northern latitudes, July is a month dedicated to being outdoors with the family and in the company of friends. On the other side of the globe people might be enjoying the best of what winter can offer. Near the equator it may be unbearably hot and for those who live there a longing for milder temperatures and cool evenings occupies the mind. In democratically stable societies with freedom of speech, freedom to travel, freedom to worship, freedom from prejudice and violence, even freedom from excessive and uncontrolled fertility, we look forward with a degree of confidence in the summer days. Sonoelastography of the cervix adds a new tissue stiffness dimension to assessment by Bishop score and cervical length measurement (pp. 684–690). Classifying uterine anomalies by the number of uterine cavities and external uterine orifices is useful for predicting pregnancy outcome (pp. 691–697).