Management of heavy menstrual bleeding: Towards a patient-centred approach

Heavy menstrual bleeding (HMB) is a common problem in women of reproductive age and has a major impact on psychosocial well-being. The subject remains a taboo to discuss with friends, family or a medical professional. This thesis focuses on the management of HMB in general practice and at the gynaecology department. We found that a majority of women with HMB in primary care opt for a wait-and-see policy or drug treatment. For women in whom this is ineffective or undesired, the levonorgestrel intrauterine system (LNG-IUS) and endometrial ablation are possible treatment options. The IUS suppresses endometrial growth through the local release of hormones in the uterine cavity. The endometrial ablation technique removes endometrial tissue by bipolar radiofrequency energy. We conducted a study in which 270 women were randomly assigned to either treatment and were followed for two years. We showed that both strategies lead to a significant reduction in menstrual blood loss and comparable satisfaction and quality of life. When starting with the LNG-IUS, there is a higher chance of needing additional interventions and it takes longer to achieve the desired effect. However, the LNG-IUS strategy was cheaper and is easy to initiate in primary care. Other characteristics, such as a hormonal, contraceptive effect, a less invasive and reversible treatment compared to endometrial ablation, should be discussed with each woman so that she can make a well-informed choice. Future research on treatment preferences and factors related to treatment success may contribute to this process of shared decision-making.