We need to talk about periods

I’m sure most of us find it extraordinary that in 2023 periods and their impact can still be regarded as a taboo subject by many. However, there have been positive steps to help redress this in the last year. The England’s Women’s football team, the Lionesses, have helped shine a light on the impact periods can have on sport performance and participation, and the government announced the Women’s Health Strategy for England in 2022, with one of the key areas identified for improving women’s lives being menstrual health. This is a long overdue recognition that menstrual health needs more recognition, discussion and support. Over 50% of our population will have periods during their lifetime, with about 1/3 of them suffering heavy menstrual bleeding (HMB), yet the Government survey suggested only 17% of women felt they had enough information on menstrual wellbeing.

HMB has also featured in recent research. The ECLIPSE study published it’s 10 year follow-up data last year (BJGP 2022; 72 (725)). This was a primary care based RCT comparing levonorgestrel IUS to usual medical care (oral treatments) and how many required surgery for HMB over time. IUS was superior to oral treatments with a cumulative surgery free rate of 74%, however 2/3 of those in the oral treatment group also needed no surgery. As always quantitate data like this is useful, and as one would predict suggests levonorgestrel IUS is superior to oral treatments. But the subsequent qualitative data, based on semi-structured interviews with women participating in the ECLIPSE trial, published last month (BJGP 2023; 73 (729)) really helps lift the bonnet on wider themes and problems women face when dealing with HMB.

Top of the discussion points was the impact HMB has on women and its taboo aspect. ‘Women had experienced a profound and debilitating impact from HMB, affecting multiple aspects of their lives. They described flooding and unpleasant release of clots, and precautions they would take to manage or conceal their blood loss. They highlighted the burden of needing large amounts of sanitary products, soiling of bed linen and clothing, and avoiding social events and activities when menstruating. Intimate relationships suffered, including lack of libido and prolonged bleeding preventing sexual activity’. The personal accounts of the effects of HMB were insightful - being unable to go to work due to flooding, fearful of telling managers the reason for missing work due to worries about losing jobs and the impact on mental health and wellbeing. Women highlighted the ongoing concerns about stigma and taboo - as menstruation and HMB were still not being openly talked about or publicly portrayed they felt pressure to conceal their menstruation and cite a lack of awareness that this is a problem that can be helped, leading to them normalising severe symptoms for years before seeking help. 

But what can we do as primary care clinicians? The ECLIPSE qualitative study gave a number of learning points and take home messages for me: 

1. Be aware that by the time a woman comes to see you with HMB she is likely to be experiencing a significant impact on her quality of life, and may have been suffering with this for many years - we need to explore and acknowledge the impact this is having on work, relationships and mental health, as well as hobbies, sports and activities. 
2. Patient centred communication, shared decision making and flexibility are crucial - women’s experiences of HMB may change over time depending on the level of symptoms, and her changing needs and circumstances e.g. age, proximity to the menopause, contraception and fertility. 
3. Be positive but realistic about treatments, and keep all options open - we need to be cognisant that responses to treatments can vary considerably e.g. the levonorgestrel IUS can be life changing for some women, but for others, it may cause annoying irregular bleeding and mood changes; keep your door open to review the woman’s response and your mind open to alternative options, which may include referral for further investigation and secondary care treatment including surgery. As the authors highlight ‘A positive experience occurred, even if multiple treatments were tried, when women felt fully informed about all their options and realistic expectations were set about the likelihood of success for each.’
4. Finally, come and join Steph and the Women’s Health Team for their next webinar on Friday 16th June! Steph and the team discuss HMB and menstrual health amongst a range of other key primary care topics on Women’s Health.