Menstrual Wellbeing Toolkit

Menstrual Wellbeing toolkit header

Menstrual related problems affect a significant proportion of the 25 percent UK female population of reproductive age, from menarche to menopause, affecting their physical, psychological and social well-being. 


Opportunities to manage ‘period problems’ are often delayed because of stigma and myths, which leave women unsupported and in some cases at risk of long-term effects of untreated disease. 

The Menstrual Wellbeing Toolkit, developed in partnership with Endometriosis UK, is an ‘easy to use’, logical, evidence-based resource for GPs and other primary care clinicians to help diagnose, support and manage problems caused by menstrual dysfunction.

 

Key facts about menstrual dysfunction

  1. Dysfunction of the menstrual cycle causes physical, social and psychological impact, compromising education, work, social and family life.

  2. There are many myths and stigma about periods meaning many women and girls are too embarrassed to discuss their problems.Empowering women of all ages to raise their concerns openly, including any problems related to sex, improves the short and long-term outcomes.

  3. Not all menstrual dysfunction causes bleeding problems.Taking a careful history or using a symptom diary can be helpful in determining a cyclical pattern of associated bowel or urinary or mood problems.

  4. One in five women of reproductive age suffer with heavy menstrual bleeding (HMB), causing one in 20 women aged 30-49 to contact their GP each year.

  5. One in 10 women of reproductive age suffer with endometriosis; affecting 1.5 million women - the same number diagnosed with diabetes – costing the health and social care economy an estimated £8.2 billion/year.

  6. Early management of endometriosis is important to reduce the long-term consequences of untreated disease: subfertility, ectopic pregnancy and chronic pelvic pain.

  7. Premature ovarian insufficiency (POI), defined as menopause aged less than 40, affects 1 in 100 women.Management with replacement hormone therapy reduces the long-term consequences of POI: cardiovascular disease, osteoporosis and cognitive impairment.

  8. The psychological impact of menstrual disorders is underestimated.A recent survey of women with heavy menstrual bleeding found that of 1000 surveyed, 74 percent had experienced anxiety, 67 percent suffered with depression.

  9. Endometrial cancer is the commonest gynecological malignancy in the UK with increasing incidence exacerbated by obesity, with nearly 9000 new cases diagnosed in 2015.

  10. Recently published NICE guidance provide evidence based recommendations on the management of menstrual dysfunction, much of which can be managed in primary care with specialist referral for diagnosis and treatment when indicated or chosen.
  11.  

Top tips for managing heavy menstrual bleeding in primary care

  1. Heavy menstrual bleeding is common; one in five women experience heavy periods with one in 20 women aged 30-49 presenting to primary care each year.
  2. HMB affects a woman’s physical, psychological and social health and wellbeing.
  3. The history of the problem and any co-morbidities determine if examination and investigations are required.
  4. HMB occurring in women with obesity or any condition causing unopposed oestrogen excess requires investigation to exclude endometrial hyperplasia and cancer, rates of which are rising in the UK.
  5. Treat without further need to examine or investigate if there are no additional symptoms and low risk for endometrial pathology.
  6. Basic laboratory investigations include:

No indication for testing thyroid function, hormone levels or ferritin without the presence of additional symptoms.

  • FBC for all
  • Testing for coagulation disorders only if HMB since menarche or personal/FH of coagulation disorder
  • Consider sexual health screen
  • Cytology if due
  1. Recommended investigations for women with HMB:
    Pelvic ultrasound scan (trans-vaginal preferably) for possible larger fibroids or adenomyosis:
  • Enlarged uterus/ pelvic mass/ pelvic pressure symptoms
  • Dysmenorrhea

  • Hysteroscopy for possible endometrial pathology (hyperplasia/polyps/submucosal fibroids).Persistent irregular and/or intermenstrual bleeding:
  • Infrequent heavy bleeding plus obesity or PCOS
  • Late menopause (over 55)
  • Use of tamoxifen
  • FH Breast/bowel/ovary cancer
  • Abnormal ultrasound scan findings
  • If previous treatment unsuccessful
  1. Treat with tranexamic acid +/- analgesia at first visit, including while waiting for further investigations or referral.
  2. Future treatments depend on investigation findings, imminent fertility requirements, risk assessment and informed patient choice:

    Hormonal: 
    i. Levonorgestrel intra-uterine system
    ii. Combined hormonal contraception
    iii. Long-cycle or continuous progestogens 

    Non-hormonal:
    i. Tranexamic acid (1.5g three or four times daily)
    ii. Plus/or NSAID of choice

    Surgery referral:
    i. Fibroid resection or embolization
    ii. Endometrial ablation
    iii. Hysterectomy

  3. Following endometrial ablation women require reliable contraception and combined HRT preparations for menopausal symptoms even if amenorrhoeic.

Top tips for managing endometriosis in primary care

Adapted from Top Tips developed by Primary Care Women's Health Forum.

  1. Endometriosis is common affecting approximately 10% of women of reproductive age. There are as many women with endometriosis as there are with either diabetes, asthma or back pain. The average time to diagnosis is 7.5 years.

  2. Endometriosis usually causes cyclical problems. Using a 3 month menstrual diary found on line or as an app is a good diagnostic tool. This can also be used to determine the pattern of urinary and bowel symptoms.

  3. Endometriosis affects a woman’s physical, psychological and social health and wellbeing.

  4. NICE recommend an abdominal +/- pelvic and speculum examination is performed. Sexual health screening should also be considered.

  5. An UltraSound Scan, preferably transvaginally if acceptable, is recommended to exclude endometriomas or adenomyosis. BUT a normal result does not exclude endometriosis or adenomyosis.

  6. Simple analgesia or combined hormonal contraception or desogestrel should be commenced at the first visit. An understanding of imminent fertility requirements assists treatment choices.

  7. On review the use of continuous hormonal treatment (any hormonal contraception) should be commenced to control symptoms if the diagnosis of endometriosis is likely. Signposting to patient information for support i.e. Endometriosis UK is recommended.

  8. Referral to secondary care should be considered if symptoms change, continue, recur or if there are symptoms of bowel or urinary tract involvement or for patient choice.

  9. Early prevention of ovulatory bleeding will reduce the longer-term complications of endometriosis such as reduced fertility and chronic pelvic pain. These issues require management as appropriate with early referral to fertility services for women with endometriosis if conception is delayed.

  10. For women with endometriosis who have required surgical treatment with pelvic clearance (hysterectomy and BSO) consider use of continuous HRT or tibolone for 12 months before changing to oestrogen only HRT.

Top tips for managing menopause in primary care

Adapted from Primary Care Women’s Health Forum top tips, with permission

  1. The diagnosis of menopause in women aged over 45 is clinical and based on symptoms. It does not usually require confirmation with an Follicle-stimulating hormone (FSH) level.

  2. Remember that contraception is needed until infertility can be assumed.  The use of intra-uterine progestogen offers endometrial protection and contraception. Refer to FSRH CEU Guideline Contraception for women over 40 for further information.

  3. Consider menopause as a possible cause of amenorrhoea in women under 45 who are not using hormonal contraception once pregnancy is excluded.

  4. Recommend Hormone Replacement Therapy (HRT) routinely to women who are menopausal aged under 45, even if they are asymptomatic, to reduce the consequences of long-term hypo-oestrogenism such as osteoporosis and cardiovascular disease.

  5. Provide and signpost women to reliable patient information, for example, menopause matters and manage my menopause, to allow informed and shared decision making between the woman and her healthcare professional.

  6. Prescribing is not difficult and decision-making guides are available. Refer PCWHF guidance on management and prescribing HRT in primary care.

  7. HRT is much safer than you think. NICE Clinical Guidance (2015); Diagnosis and Management provides the evidence and reassurance for use.

  8. Support the woman to initiate HRT and continue with a review after three months. Once stable review annually to reassess the risk/benefits of ongoing HRT use for her. There is no arbitrary limit to length of use.

  9. The benefits of HRT outweigh the risks for most women who start treatment aged under 60.  Women with any cardiovascular or thrombotic risk factors who are eligible for HRT would benefit from a transdermal preparation.

  10. Low dose vaginal oestrogens are safe to use for as long as required in most women.  Some women will require the use of vaginal oestrogen in addition to their systemic HRT to control their genito-urinary problems.

     

Clinical resources for training and appraisal

The RCGP women’s health library has been developed in conjunction with RCOG and FSRH to provide educational resources and guidelines on women’s health that are relevant to GPs and other primary healthcare professionals. These resources will be helpful for those who wish to develop a more specialised interest in women's health.

NICE Guidelines

UK Guidances 

European Guidances 

Quality Standards

Additional resources

RCGP resources:

Clinical Knowledge Summaries:

Guidelines in Practice:

Others

Information and support for patients and carers

Period problems are very common and may affect physical, social and psychological health and well-being. Many women experience one or a number of concerns including; heavy periods, painful periods, infrequent periods, no periods or irregular bleeding.  

Sometimes women experience bowel, urinary, sexual, mood and fatigue symptoms which may not obviously be related to a period problem and keeping a diary of concerns can often help. 

Many women do not feel confident talking about the period problems they have because they do not realise their experience is not normal or they may feel too embarrassed to raise the issue. 

NHS Choices has an excellent overview of periods and the conditions that can cause the problems women experience.

Further information and resources

Endometriosis

Heavy Menstrual Bleeding

Fibroids

Womb (endometrial) cancer

Polycystic Ovarian Syndrome (PCOS)

Premature Ovarian Insufficiency (POI)

Support organisations

RCOG: Patient information resources; menopause and women’s health in later life, including:

  • Menopause
  • HRT
  • Gynaecological cancers

Endometriosis UK  
Support organization with a vision to improve the lives of people affected by endometriosis and work towards a future where it has the least possible impact on those living with the condition

Fibroid Network
A UK based, Patient Led volunteer, support group, serving as a focal point for women’s fibroid and health issues with the aim to improve women with fibroids, healthcare and health education in the United Kingdom and internationally

Verity – PCOS 
A self-help group with a goal to improve the lives of women with polycystic ovary syndrome (PCOS)

The Daisy Network
Network dedicated to providing support to women with Premature Ovarian Insufficiency (POI), also known as Premature Menopause

 

Background information for commissioners

Menstrual related problems affect a significant proportion of the 25 percent of the UK population who are female of reproductive age between puberty and menopause, affecting their physical, psychological and social well-being.  If unmanaged some of these conditions can cause lifelong problems including metabolic disease or chronic pelvic pain.

In the UK an estimated:

  • One in five women of reproductive age suffer with heavy menstrual bleeding (HMB)
  • One in 20 women aged 30 to 49 contact their GP with HMB each year
  • One in 10 women of reproductive age suffer with endometriosis affecting 1.5 million women - the same number diagnosed with diabetesEndometriosis costs the health and social care economy an estimated £8.2 billion/year

The psychological impact is also underestimated and a recent survey of women with heavy menstrual bleeding found that of 1000 surveyed:

  • 74% experienced anxiety
  • 67% suffered with depression.

There are opportunities to reduce the health and social impact resulting from menstrual-related problems, whilst improving patient choice and experience, in primary care and out-of hospital settings by applying recommendations from recently updated NICE guidance and improved access to diagnostics and minimal intervention technologies.

Resources

RCOG. Advice for Heavy Menstrual Bleeding (HMB) services and commissioners

Making it work. PHE: A guide to whole system commissioning for sexual health, reproductive health and HIV 

NICE recommendations – putting this guideline into practice

This toolkit has been developed in partnership between the Clinical Innovation and Research Centre (CIRC) at RCGP and Endometriosis UK. 

Please send any feedback or suggestions to circ@rcgp.org.uk

 

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