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Gupta JK, Daniels JP, Middleton LJ, et al.; on behalf of the ECLIPSE Collaborative Group. A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial. Southampton (UK): NIHR Journals Library; 2015 Oct. (Health Technology Assessment, No. 19.88.)

Cover of A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial

A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial.

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Chapter 5Women’s experiences of medical treatments for heavy menstrual bleeding: a longitudinal qualitative study

Introduction

Heavy menstrual bleeding and other changes in menstrual experience may affect many aspects of women’s health, well-being and social functioning.83 Although there is existing evidence comparing the effectiveness of various treatments in reducing menstrual blood loss, we know less about women’s experiences or expectations of medical treatments. The ECLIPSE trial, therefore, provided an opportunity to generate qualitative insights in this context by exploring the perspectives of trial participants or women with HMB who declined to be randomised, but who nevertheless commenced medical treatment in primary care. A longitudinal qualitative study was undertaken to enable the ECLIPSE trial outcomes to be further contextualised in ways that may enhance the utility of the quantitative results and their application in clinical practice.

Women have discussed the management of menstruation including its concealment in order to conform to societal norms,84 their reluctance to request treatment85,86 and their experience of a change in menstruation requiring further explanation. Women with psychological distress appear more likely to report heavy periods13,87 and the effect of menstrual bleeding on mood may influence a woman’s ability to continue life as normal.88 Similarly, other menstrual symptoms such as pain, mood changes and irregular bleeding may influence perceptions of the severity of HMB.2,89

Women who seek treatment for HMB can have predetermined expectations and preferences for a treatment influenced by diverse factors, such as employment status as well as severity of symptoms.90,91 They may also reflect contraceptive preferences, attitudes to hormonal treatments, ‘the pill’ or ‘coil’ and the presence of other symptoms such as painful periods.

Clinical guidelines for HMB from NICE, issued towards the end of the current ECLIPSE trial recruitment,1 introduced the option of the LNG-IUS on the basis of limited evidence to date, with other usual, and mainly oral, medical treatments as further choices. Women’s expectations about treatments have obvious implications in discussing these options and concordance with treatment. There was also a need to better understand the impact of medical treatments on HMB-related QoL from a qualitative perspective,1,92 alongside the trial’s quantitative measures of the QoL. This study sought to explore women’s experiences and expectations of medical treatments used in the ECLIPSE trial for HMB.

Methods

Sampling

A purposeful sample was selected from women approached for inclusion in the ECLIPSE trial of the effectiveness of medical treatments for HMB in primary care.93 They had consulted their GP about HMB (lasting three or more consecutive cycles). Women participating in the trial had either agreed to be randomised to the LNG-IUS or to other standard treatment (including oral tranexamic acid, mefenamic acid, norethisterone, contraceptive pill or medroxyprogesterone acetate injection) or had declined to enter the trial because they had a strong preference for a particular medical treatment, which they had then commenced. We selected women from eight general practices across five counties of the UK of varying demographics (age, social and educational background, ethnicity) and parity, who experienced different medical treatments for HMB of differing treatment duration.

Recruitment and consent

Practitioners identified potential participants at the time that interest in participation in the ECLIPSE trial was discussed, and trial participation accepted or declined. Permission was sought to pass contact details to the research team, who sent study information and a request for written consent, translated where appropriate, to participants.

Data generation and analysis

Semistructured face-to-face interviews were conducted by a female researcher (G Prileszky), with a midwifery background, at respondents’ convenience and in their own homes. The support of an interpreter was offered where appropriate (four cases), but all interviewees opted to be interviewed in English. Initial interviews were conducted within 1–3 months of commencing medical treatments. A second interview was conducted, if participants were willing, between 12 and 14 months following commencement of treatment to explore any changes in experience or treatment, or in views occurring over time.

Interviews were digitally audio-taped and transcribed verbatim, and contemporaneous field notes kept of the interview context. Verbatim quotations are annotated with participant number and suffixed with ‘A’ for the initial interview and ‘B’ for the follow-up interview. They followed broad topic areas including menstrual history and experience, social factors influencing experience, relationships and family life, and emotional well-being as well as treatment preference and experience of treatments. The topic prompts were modified and refined following early interviews, with participants encouraged to discuss their perceptions and experiences freely. A sample of participants was also asked to participate in further respondent validation.

Data were analysed using constant comparison94 by the field researcher, with two researchers of different disciplinary backgrounds (academic midwifery and clinical primary care) contributing to development of the analysis. Coding was aided by application of NVivo software (QSR International, Warrington, UK) in identifying emerging themes from the data. Data generation and analysis were iterative, each informing the other, with further theoretical sampling and data collection to extend and challenge earlier data and interpretation, both within and between first and second interview data sets. This tested the integrity and credibility of the analysis until no new themes emerged, which suggested saturation.

Validation

Interim findings were also fed back and reviewed with a sample of six interviewees who were willing to be involved a third time. This was by audio-taped telephone interview following prior distribution of written summaries. Respondents were asked to consider and comment on the findings, enabling the research team to confirm and further refine data interpretation and analysis where appropriate.

Findings

Consent to contact forms were received from 52 women over an 18-month period of recruitment, of whom 27 were purposefully selected and interviewed within 3 months of commencing treatment for HMB. Of these women, 24 were interviewed again more than 12 months after commencing treatment. The 51 interviews lasted between 30 and 85 minutes. Characteristics of women are summarised in Table 9.

TABLE 9

TABLE 9

Characteristics of women interviewed in the qualitative study

Concealment of menstruation

Framing women’s experiences of treatments, women felt a strong societal pressure to remain silent about menstruation, which remained taboo and was amplified by experiencing HMB.

I think in society it’s quite a taboo subject. I work in an all-female environment with one man who is obviously married, who has got children but if we were actually talking about periods we would stop if he came into the room.

11B

It makes me feel not so much like a normal woman really when I have a heavy period because you feel like you’re the only one that’s having a heavy period. Obviously there are hundreds of women out there that are having them but it’s not common knowledge that a lot of women are having heavy periods like I did, I kept it quiet.

15A

The taboo existed within families and among friends. It was strongest in the workplace and could persist within consultation with a health professional.

A lot of women don’t like to go [to the GP] because it’s this taboo subject, so it has to start somewhere other than a GP. It’s got to start somewhere that you know that it is acceptable to have a problem, there isn’t a right and a wrong.

27B

Women could maintain the societal norm by denying their problems, lying to employers and withholding information from their doctors in order to stay silent about HMB. Not speaking about HMB (and menstruation in general) had a negative impact on most women’s QoL.

I had gone to the doctors a few times and somebody had asked me and I wished somebody had asked me earlier and perhaps if you talk about it then somebody perhaps at work might actually well I am doing this, this and this and then you are more confident then to seek help.

26B

Women also expressed a strong sense that women should ‘put up’ with HMB and not complain about it by maintaining a stoic silence. The decision to seek treatment and therefore break the silence was seen as a weakness or failure and was often associated with reduced self-esteem.

And you just feel a bit, not worthless because worthless is the wrong word – but you think some people must think you are one of these women. That you have just got a heavy period – get on and sort of deal with it – but you can’t physically get on unless you have actually been through a phase of having heavy periods – you can’t. And I am the same because I didn’t understand when people said they had really heavy periods because I never had them before.

26B

Expectations of treatments

Many women interviewed had high expectations of a prompt positive outcome from their treatments, both those prescribed standard treatments and those prescribed the LNG-IUS. Women recounted only positive information tended to be shared by friends about treatment for HMB, using upbeat language. The reported benefits of a particular treatment in the lay press or online underline this, in particular, expectations for the effectiveness for the LNG-IUS. Some women expected a very significant impact, not only on a range of menstrual issues, but also on other areas of life, such as life at home, relationship issues and career. This highlighted how HMB could dominate their lives.

I would never have to worry again, it might be the miracle cure that I am after.

18A

Most women had other concerns in relation to HMB. These included pain (cramping period pain), fatigue, anaemia, irritability, low mood, joint pain, lack of energy and headaches. These were highly individual and often combined. Many women did not think of their menstrual bleeding in terms of blood volume, but were far more concerned about rate of blood flow, the presence of blood clots and controlling this flow in order to maintain concealment of their menstrual state. In addition, related pain, cramps and backache were the most significant issues they wanted to address. Many of these women felt this pain to be severe and debilitating and were completely unable to continue with their normal daily activities during menstruation, resulting in taking time off work.

It’s a strange sensation because it’s coming away from you and you have no control over it . . . I have blood clots sometimes the size of a fist and it’s awful.

15A

But it wasn’t the actual bleeding part, it was more the pain … doubled over with the pain.

5A

Then the last year they have got worse with pain and having to have time off work for a couple of days … It always felt like my insides were dropping out the pain on the first 2–3 days.

5A

Women described complex behaviours and coping mechanisms to enable them to both manage their menstrual bleeding and to conceal their condition not only from work colleagues and friends, but also from family members. Preparatory coping behaviours included carrying extra sanitary protection at all times, frequent changes and checking of blood loss, and having a spare change of clothes (sometimes two).

It was every handbag had some sanitary wear in it just in case . . . I always knew it was best to stock up at that time ready for next time.

29B

Avoidance behaviours included rescheduling activities at home and at work, cancelling meetings both social and professional, taking time off sick from work and remaining at home during menstruation. Other mechanisms included having someone else take care of children, or take their place or shift at work. These coping mechanisms for HMB allowed the woman to rest and ensured that their menstrual difficulties remained concealed. If these failed, women reported feeling embarrassment, guilt and shame, particularly if other people needed to help them. They often became distressed and upset, affecting self-esteem and mood.

It was on our staff party [date] it was and it was mid-afternoon and . . . I just thought I need to go to the ladies but . . . when I got to the ladies toilets . . . I had wet my, soiled my trousers, my underwear was saturated through and the pain and the contractions were really bad and it was just pouring out of me . . . I was too embarrassed to come out . . .

39B

Heavy menstrual bleeding could have a negative and wide-ranging impact on women’s QoL, which was most often related to their ability to function effectively in their daily roles, to be able to cope well with their responsibilities at home, at work and within their relationship with their partner during menstruation. The negative impact of HMB on their roles and responsibilities was influential in women’s decisions to seek treatment.

I would say it’s not trivial. You know to them it may be something that you know if they are a gynaecologist and they are dealing with it may be the least of someone’s problems but to that woman it is the butt of her problems you know and it has an impact on her whole being her whole holistic being revolves around that one thing.

27B

Beyond peers and family, few women had sought information about treatment from other sources such as the Internet and all had a treatment preference prior to their medical consultation. The most requested treatment was the LNG-IUS. Women who expressed a preference for other standard treatments did not want the LNG-IUS because of its effect on fertility and also the invasive nature of the coil. Women who rejected the LNG-IUS because of its contraceptive effect were all in their forties and most strongly wanted to conceive a child.

Initial experiences of the levonorgestrel-releasing intrauterine system

Many women who were treated with the LNG-IUS found the coil fitting to be more distressing than anticipated and some felt unprepared psychologically for the procedure. While many doctors did not recommend the LNG-IUS for nulliparous women, multiparous women still had problems. They recounted feeling pain and discomfort in excess of other medical procedures within their previous experience and used emotive language.

I suppose I was a bit naïve, I suppose a picture might have helped. I was thinking of like a smear test but they actually have to open you up a bit more and obviously that’s not very pleasant.

29B

I had it done [LNG-IUS fitting] and it really hurt. I think you would really have to make that clear to somebody. Even if they have not even had a baby or something. It hurts for a short time I suppose. But you wouldn’t like, if you were doing that to somebody’s neck it would be classed as torture or something you know it really is nasty. You know a bit sort of medieval.

29B

Some women had been told to take oral analgesia before the procedure, but many did not. Most women did not specifically mention or recall local anaesthesia in discussing their experience of the LNG-IUS insertion but those that did were dissatisfied with it.

I don’t think she put any [expletive] numbing lotion there to be fair, there is no way on earth that she put anything to numb me because there was no numbness.

Women felt that health professionals taking consent for the procedure had downplayed the possible intensity of the pain and also the complexity of the procedure itself. Women had a strong sense that while this was a simple procedure for the health professional, it was not simple for them experiencing it.

She said it’s going to be feeling like this, this, and this, you are going to feel a little bit of pain and it should be over and done within like 2 minutes, OK, right, not a problem. Oh how very wrong she was. The little [nationality] nurse I was holding her hand and I had to let go of her hand because I would have broke her fingers because in the end it was literally gripping on to the sides of the bed, tears coming down my eyes, excruciating pain . . . I felt sick, I felt giddy I just wanted to be sick and then she done it and the pain was just excruciating, she said you are going to have to wait like half an hour in here. I couldn’t walk when I got off.

23A

Women then found the LNG-IUS troublesome within the first 3 months of treatment because irregular bleeding interfered with women’s long-established behavioural coping mechanisms.

I was quite anxious because I kept thinking that at some point they could come back or they could start or I could spot and that did actually happen. Initially I was having spotting or a mild period pain and things like that but they just got less and less.

Some considered removal of the LNG-IUS during this time but did not seek to do this partly because they were advised or anticipated it would improve over time, or they thought removal would be difficult, or they might lack an alternative treatment. Some women did not ask for the LNG-IUS to be removed because they did not want to go through the process of revisiting their GP and having a vaginal examination within such a short time.

The other day it [intermittent bleeding following treatment with LNG-IUS] drove me so mad somebody actually offered me pliers and I nearly took them [pause] you know.

27B

Tell you the truth I did actually think about going back to the doctor because I thought . . . perhaps there was something wrong, perhaps the coil perhaps wasn’t working properly or perhaps something had happened and it was sort of making it go a bit weird but then I never sort of got round to making an appointment and then the next month would come and it would be a bit better and then by the third or fourth month it seemed to have settled down anyway.

Most women attending for their routine check, around 6 weeks after IUS fitting, were asked by health professionals about whether or not their menstrual blood loss had reduced. However, women found that explaining blood loss in terms of volume was challenging and, moreover, felt that questioning changes in menstrual blood flow did not reflect a more desired holistic change for them.

I think sometimes [doctors] are dealing with the problem as opposed to the woman and that is the mistake; that is the mistake.

27B

Women expected a period of transition following the initial fitting of the LNG-IUS, perhaps reflecting information given by most health professionals about the initial side effects at the time the LNG-IUS was fitted. However, women were surprised at the amount of disruption to their cycle or amount of irregular bleeding as this was greater than either their peers or health professionals had indicated, and indeed some had thought their menstrual bleeding would cease completely within 1 or 2 months

It took a while, it didn’t do much at the beginning, it took a while for it to do anything. I didn’t think it was going to do anything at first but yeah, it took a while and I noticed it slowing down. That was the big thing for me. It didn’t matter if it didn’t stop or anything, just slowing it down. It has done it in the same year, it has done it bit by bit, it slowed down and slowed down and now for the last 2 or 3 months I have not had anything, not a thing.

15B

Women who had a positive experience of treatment were more inclined to talk about it, while women who had had a negative experience of treatment were more likely to remain silent. Women did not anticipate major changes in their menstrual cycle, such as irregular bleeding and spotting, or that this might last much longer than expected before they saw an improvement in their condition.

Experiences of the levonorgestrel-releasing intrauterine system after 12 months of treatment

Most women persevered with the LNG-IUS and at 12 months were satisfied with this treatment, experiencing a positive and often major impact on their QoL. The treatment took effect gradually over the first 3–6 months.

It started off really, really excellent then we tended to have a bit of a dip where it was a bit hit and miss some months but now it seems to have settled back down again so I don’t know whether that was just a fluke or perhaps whether I was a bit more stressed at work at the time and you know busy in my life that made an impact on that but now on the whole is the best decision I could have made.

26B

Most women had, as expected, experienced amenorrhoea (cessation of periods) with this treatment after 12 months, but even those still having menstrual periods felt significantly better.

I was concerned because obviously they advised that if this [LNG-IUS] didn’t control it, it would be a hysterectomy, which was obviously not what I would like. I was only 40, 39 or 40, at the time and so I had that fitted now for a while and everything is now wonderful so I have had no more problems any more.

42B

It is such a relief, it really is, after the pain that I used to have before and the tiredness and the flooding and the whole, it was almost like your whole life revolved around periods and being comfortable or uncomfortable and you know it was, it was awful and I was feeling constantly tired and thinking this is just, you know, that just awful and now that has all gone and it is just such a relief, it really is.

16B

It just sort of gave us I suppose my bit of life back, my bit of independence back that I could do, you know carry on without thinking you know have I leaked.

26B

Most women with a LNG-IUS were happy to continue with this treatment long term. Several women who had considered hysterectomy prior to commencing their treatment with the LNG-IUS now no longer considered surgery as necessary or appropriate use of health-service resource.

What I have now is not worth going through an operation for . . . If it hadn’t worked and I was still having heavy periods then I would think about it but no, not with the coil, no it’s not worth having that done, taking up space in the hospital just to have that.

5B

Experiences of standard treatments

Women who were prescribed standard treatments (most commonly oral tranexamic acid, but also norethisterone, medroxyprogesterone acetate injection and the oral contraceptive pill) had widely varying perceptions and experiences. They were regularly less satisfied with their treatment, with most having ceased prescribed medication at 12 months.

Women were generally dissatisfied with tranexamic acid, but did acknowledge some reduction in menstrual blood flow. Some were concerned about the physical size of tablets and the number that they had to take each day (two tablets, three times per day is commonly recommended). Most did not perceive significant improvements in the short term and so stopped taking their medication after 2 months.

If I take them it does keep the bleed, you know, under control. If I leave it a little bit too long before I take the next lot I am just like flooding again so it’s, I am not really one to take tablets though, it’s very hard.

32B

It’s like remembering to take X, Y, Z and the amount of tablets all the time, that can be a problem . . . remembering to take tablets and making sure there’s the right spaces in the day between these tablet taking that can be a problem in itself ‘cos you might not be where your tablets are or you might be, you know, hung on at work doing extra hours and that and it’s all that and it’s all that added stress that you don’t really need.

7B

I was taking, I had got good at remembering to take them, take them just before and take the maximum dose and I thought they are not making much difference at all, I still can’t get out of bed without hopping to the bathroom cross-legged.

29B

The experience of the few women prescribed oral and injectable contraception for HMB was also generally not satisfactory.

I hardly have any periods, I think I have 2 days of bleeding, don’t get any pain but 2 weeks before my period is due I get terrible depression where I am always crying. I just feel dead depressed and I just let small things become big things and it’s just when I am coming up to my period.

43B (oral contraceptive)

So I had the injection in [month] I haven’t stopped bleeding since, now it’s not working and I am getting chronic migraines all the time. And I have ballooned in weight in the last 3 months so suddenly it is not working, not suiting me. I am changing my treatment as of next week.

18B (Depo-Provera)

Oral contraception was continued for other reasons such as familiarity, reversible contraceptive effect and lack of interference with other medical treatments.

I have been taking the iron tablets, which help with the dizzy spells and things like that. I did try the other medication [tranexamic acid] but I tried it and I felt, no, I didn’t feel anything changes much and therefore I thought is there any point taking another medicine if it doesn’t make any difference? I still have the pain and I still felt the same and the blood flow seems to be no better so I haven’t taken it again.

28B

Women perceived standard treatments to be a short-term measure. Many who discontinued treatment elected not to try any other treatment, preferring to manage their condition themselves by changing coping behaviours and strategies. This was particularly true of the women who had a long history of HMB and those who anticipated the onset of menopause within the next few years.

Some women were concerned about the physical amount of tablets that they would have to take over the course of their remaining years of menstruation. Most disliked the thought of taking medication, with concerns about the long-term effects of the medications prescribed. For some, this was related to potential unknown side effects.

They [tranexamic acid] did work but I didn’t like the quantity of tablets that I was taking.

18A

I will probably go back to the doctor and get some more tablets . . . unless there was something else that they could try instead rather than stay on them long term. But in the short term, yes . . . I know they research them but they never know until years later the effects. It might not have an effect now but in years to come and I’d rather not take the risk of causing anything long term. If I had a choice I would rather not take the tablets.

30B

Women who were initially treated with standard treatments commonly changed their treatment over time, with six women in this sample eventually opting not to use any treatment at all and manage without: two resuming standard treatment after intervals of using no treatment and four women switching to the LNG-IUS. One woman had a hysterectomy.

Discussion

This study has found women’s expectations, and experiences of use and effectiveness, of medical treatments for HMB to vary considerably and change over time. These findings highlight a range of implications for clinical practice, which are discussed in Implications for Practice below, and may be used to enhance more informed shared decision-making and improve care for HMB when women seek help.

Strengths and limitations

The work provides qualitative insights in to how women experience current medical treatments for HMB, with the advantage of a longitudinal design, over a timeframe of around 1 year. Methods were used to enhance rigour, including purposeful sampling, involving researchers from differing disciplines in analysis and respondent validation. The sample is described in some detail, which may aid assessment of relevance of findings beyond the study and trial context. However, it is recognised that this was inevitably a selected sample of women willing to articulate their experiences. Although participants were engaged in the context of clinical trial recruitment, we actively included those unwilling to be randomised and those with preferences for a particular treatment for HMB.

Comparison with existing work

Previous work has found that health professionals may be preoccupied with volume of blood loss, within a biomedical model, rather than addressing the impact on women’s health.95,96 Although highlighted in more recent research,89 assessing reduction in blood volume for treatment efficacy,97 or what reduction in menstrual blood loss is meaningful to women,98 remains a focus of research. Higher volume of daily menstrual blood loss has been correlated with limitations in functioning and social activities.99 Women in this study were as concerned with menstrual pain and psychological distress affecting their health and QoL as with HMB itself. This finding is consistent with other work.95,96 Going beyond reduction in volume of blood loss alone, measures of QoL are now becoming more widely used to determine treatment efficacy.69,93

More than 1 year following initial treatment with the LNG-IUS most women were satisfied with their treatment and had experienced an improvement in their perceived QoL. This finding concurs with the quantitative results of the ECLIPSE trial in Chapters 3 and 4.93 Narrative accounts were overwhelmingly positive and a number of women used emotive language to describe the improvement in their health and well-being. Most women had experienced amenorrhoea, but even women who still experienced regular menstrual bleeding felt better. The change in perceptions of health and well-being was always associated with being able to fulfil roles and responsibilities. Some women described an improvement in physical well-being, but the emphasis for all was on the psychological benefits of being able to maintain the societal norms of concealment of menstruation. The later acceptability of the LNG-IUS reported here concurs with Lete et al.,100 who found that 87.9% of pre-menopausal women in their study would use a second LNG-IUS device.

Women who were prescribed tranexamic acid initially took the medication as prescribed and experienced some benefit, but most did not feel better quickly enough to continue with their treatment. However, others have found long-term use of tranexamic acid to be well tolerated over a 15-month timeframe, although emergent adverse effects such as headaches, menstrual and back pain were commonly reported.86

Implications for practice

These qualitative findings suggest that discussion with women about medical treatments for HMB should not be confined to orthodox clinical considerations, such as volume of heavy bleeding or a woman’s wish to avoid having an IUS or contraception. Rather, health professionals could also helpfully consider the wider impacts of HMB on women’s lives and respond to these appropriately in sharing decision-making with women about choosing and using treatments. Women’s high expectations of a prompt effect from treatments may be understood in terms of their prolonged toleration of the impacts of HMB and its concealment, which had typically preceded seeking medical help. Potentially high expectations of treatment (and the potential influence of peers) should be appreciated and explored appropriately when discussing treatment.

In assessing treatments with women, practitioners should consider that issues such as effect on rate of blood flow, pain and well-being, as well as wider functioning socially or at work, may be as or more important to individuals than amount of menstrual blood loss. Women’s accounts also underline other points for helping women make more informed decisions. These include avoiding ‘underplaying’ initial problems that may be unanticipated by those considering the LNG-IUS, by ensuring that women are appropriately prepared (physically and psychologically) for fitting the LNG-IUS in practice, and in particular for troublesome changes in pattern of bleeding that may commonly occur and can be prolonged.

Unpredictable irregular bleeding with the LNG-IUS was more problematic than the volume of blood loss for women in this study owing to its impact on their established behavioural coping mechanisms for HMB. Irregular bleeding is recognised as a common reason for discontinuing the LNG-IUS.48,81 Nevertheless, the current qualitative findings, in line with the strong pragmatic clinical trial evidence reported in Chapters 3 and 4, underline that women can be advised that, if they persevere with leaving their IUS in place, they are likely to experience significant improvement in menstrual symptoms and related QoL.

Women’s perceptions of other treatment options, as a more short-term measure they could control themselves (stopping and starting as they wished), may provide helpful information to offer women considering what may suit their individual circumstances. Information provided may highlight that improvements in the impact of HMB may be expected, but may be variable and may not be as substantial as for the LNG-IUS, in line with the trial evidence. Women may also be given advice regarding practical considerations, such as the inconvenience of taking several large tablets in the case of the most commonly prescribed oral medication, tranexamic acid.

The findings also highlight an important wider context for discussing HMB treatments in relation to effect on fertility and desire to conceive among women in their forties presenting to services with change in menstrual experience, often at a time of other life transitions.

Copyright © Queen’s Printer and Controller of HMSO 2015. This work was produced by Gupta et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK321928

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