Family Practice Advance Access originally published online on November 20, 2007
Family Practice 2007 24(6):532-537; doi:10.1093/fampra/cmm068
Abnormal bleeding patterns associated with menorrhagia in women in the community and in women presenting to primary care
Primary Care Sciences Research Centre, Keele University, Staffordshire ST5 5BG, UK
Correspondence to Mark Shapley, Primary Care Sciences Research Centre, Keele University, Staffordshire ST5 5BG, UK; Email: m.shapley{at}cphc.keele.ac.uk
Received 5 July 2006; Revised 27 June 2007; Accepted 15 October 2007.
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Abstract |
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Background. There is an assumption that in women with menorrhagia ‘excessive menstrual loss in regular cycles is the most common clinical presentation’ yet epidemiological studies show irregular cycles and bleeding are common.
Objectives. To test the hypothesis that, in women who present to primary care with menorrhagia, excessive menstrual loss in regular cycles is the most common clinical presentation, and to determine the frequency with which symptoms known to be associated with gynaecological malignancy occur.
Methods. A postal survey of all women aged 18–54 years was used to identify symptoms of vaginal bleeding in an urban general practice with 10 000 registered patients. Follow-up surveys were carried out at 6 and 12 months. Consultation data from general practice held records were gathered from baseline to 18 months. Women who consulted with increased vaginal bleeding during the 18-month study period were separately analysed according to their self-reported symptoms in the questionnaire completed in the 6 months prior to the consultation.
Results. At baseline, of the 736 women in the community identified with menorrhagia, 46% had at least one symptom of irregular vaginal bleeding. In the subgroup of 138 women with menorrhagia who consulted primary care with increased vaginal bleeding, the proportion with at least one symptom of irregular vaginal bleeding was 73%.
Conclusion. In women with heavy menstrual bleeding, excessive menstrual loss in regular cycles is not the most common clinical presentation in primary care. Guidelines on menorrhagia should acknowledge the variety of symptoms that women with heavy menstrual bleeding present to primary care.
Keywords. Epidemiology, menorrhagia, menstruation disorders, primary care, vaginal bleeding.
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Introduction |
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There is an assumption that in women with menorrhagia ‘excessive menstrual loss in regular cycles is the most common clinical presentation’.1 Studies concerning the epidemiology of menstrual loss in the community show that irregular cycles and bleeding are common.2–5 There are no studies concerning the symptom complexes that women with heavy menstrual bleeding have when they present to primary care. In view of the frequency of irregular vaginal bleeding in the community, the assumption that menorrhagia without irregular bleeding is the most common presentation may be incorrect.
The importance of irregular bleeding is that guidelines and textbooks have linked such symptoms to serious but unusual events such as cancer of the endometrium or cervix1,6–10 and the implication is that these clinical presentations should be investigated. As a consequence, guidelines for primary care management of heavy menstrual bleeding exclude women with irregular, intermenstrual or postcoital bleeding.8
It is known that general practitioners find gynaecological definitions and texts unhelpful11 although the full reasons for this are not known. It may be that the guidelines do not represent the symptom complexes that women present to primary care and/or they have poor predictive value for serious pathology.
Predictive values for presenting symptoms as an indication of serious physical pathology are dependent on the prevalence of symptom and disease in the population from which they are derived and to which they are applied. The evidence base for guidelines concerning malignancy lies with secondary care12 and therefore the guidelines may not be applicable to primary care where symptoms are common and cancer is rare.13,14
We have previously undertaken a longitudinal population-based survey.5,15 This has now been linked to general practice consultation data with the primary objective of testing the hypothesis that in women who present to primary care with menorrhagia, ‘excessive menstrual loss in regular cycles is the most common clinical presentation’.1 The secondary objective was to determine the frequency with which symptoms that are associated with gynaecological malignancy occur in such women.
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Methods |
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The study took place in a four-partner urban general practice with a total registered population of 10 000 patients. Survey data have been used from a previous prospective population-based cohort study of women identified through a baseline postal survey and followed 6 and 12 months later.5,15 All women in the age group 18–54 years registered with the practice were sent the baseline questionnaire. Non-respondents were sent a second questionnaire after 2 weeks. Respondents to the baseline questionnaire were asked for consent to the sending of 6- and 12-month follow-up questionnaires. Respondents who only partially completed the questionnaire were contacted by telephone (three attempts) or if they did not have a telephone a photocopy of the missing items was sent to them.
The instrument used in the questionnaire to determine the woman's perception of the heaviness of her menstruation had been validated and used in a previous study.16 Questions relating to other symptoms of vaginal bleeding, including short cycle,4,17–19 intermenstrual bleeding,4 postcoital bleeding20,21 and prolonged period,22 were derived from other studies. In addition to these, the baseline questionnaire enquired about social status, race and parity and all questionnaires enquired about female hormone and contraceptive coil use and contained a 20-question General Health Questionnaire.23,24 The questionnaires were piloted for comprehension and completion prior to the study.
At each time point, women were also asked to report the presence or absence of vaginal bleeding symptoms as detailed in Table 1. Those who reported a period in the previous 6 months were categorised on the basis of their perception of the heaviness of their menstruation into ‘heavy’ or ‘non-heavy’. ‘Heavy’ were women who replied to the question ‘over the past 6 months how do you regard your periods?’ with the terms ‘fairly heavy’, ‘very heavy’ or ‘variable’. This definition of heavy menstruation based on the survey responses is referred to in the text, for the purposes of this study, as ‘menorrhagia’. ‘Non-heavy’ were women who replied ‘very light’, ‘fairly light’ or ‘neither heavy nor light’.
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Computerised searches of the clinical database in the study practice for 18 Read codes or their ‘daughter’ codes concerning increased vaginal bleeding were carried out to identify all women in the target population who consulted during the time from posting the baseline questionnaire to 6 months after posting the 12-month questionnaire. These codes are shown in Table 2. These codes did not include any related to pregnancy or post-menopausal bleeding. We refer throughout the text to all consultations identified in this way as consultations for ‘increased vaginal bleeding’. The first date of consultation with an increased vaginal bleeding Read code during the time frame was linked to the first questionnaire completed in the 6 months prior to this date for each woman and used in the analysis. Women with possible pregnancy-related bleeding were excluded from the analysis of women with survey-defined menorrhagia.
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The practice records all consultations on a computerised database (ViSion) and submits data to the Royal College of General Practitioners Weekly Returns Service and The North Staffordshire General Practice Research Network. All data entries have an associated Read code (a hierarchical coding system of morbidity and practice activity used in the UK comparable to the International Classification of Diseases25). The practice undergoes regular audit to ensure the quality of data recording.26
Analyses were performed using Microsoft Access 2000 and SPSS 11.0. Responders and non-responders to the survey were compared using chi-square tests for nominal data and t-tests for continuous data.
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Results |
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A total of 2435 questionnaires were sent out at baseline and 1861 women replied giving a response rate of 76%. A total of 1763 women were sent a 6-month questionnaire with a response rate of 92% (1617 women). A total of 1734 women were sent a 12-month questionnaire with a response rate of 92% (1593 women). A total of 1513 women replied to all three questionnaires (62% of those sent the baseline questionnaire) (Fig. 1).
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Non-respondents at baseline were slightly younger than respondents (mean difference 3.6 years, 95% CI 2.6, 4.6). Non-respondents at 6 months and at 12 months were younger than respondents (P < 0.001) and less likely to be married or cohabiting (P < 0.01).
In total, 736 (40%) women who responded to the baseline survey reported menorrhagia (Fig. 1). The number of these women who also reported abnormal bleeding patterns in the baseline survey is given in Table 3. Nearly a half reported at least one significant bleeding symptom in addition to their menorrhagia in the previous 6 months.
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During the 18-month follow-up time frame, 280 women in the target population sent the baseline questionnaire consulted a primary care clinician with one or more of the Read codes used to define increased vaginal bleeding (7.7 patients consulting per 100 women aged 18–54 per year). Of these, 73 had failed to respond or only partially completed a questionnaire (baseline or follow-up) in the 6 months prior to their first consultation with increased vaginal bleeding. This left 207 women who had responded in the 6 months prior to their consultation with complete answers to the questionnaire (Fig. 1).
Of these 207 consulting women, 138 (67%) had reported menorrhagia in the previous 6 months on their questionnaire (Fig. 1). The number of the consulting women who had reported menorrhagia and also reported abnormal bleeding patterns on the questionnaire completed in the previous 6 months is given in Table 3. Nearly three-quarters had reported at least one additional significant bleeding symptom in the 6 months prior to consultation.
Among the 207 women who consulted with increased vaginal bleeding and responded fully to the questionnaire in the 6 months prior to their first consultation, there was variability in the correlation between the Read codes used by the clinicians and the degree of menstrual loss reported by the women. In the 138 consulters who reported menorrhagia in the questionnaire completed in the 6 months prior to consultation, 57 had a Read code indicating definite heavy menstrual bleeding as assessed by the clinician (Read terms menorrhagia, heavy period, pre-menopausal menorrhagia). In the remaining 69 consulters, 43 women reported non-heavy periods in the questionnaire of whom 10 had a Read code at consultation indicating definite heavy menstrual bleeding (Read terms menorrhagia and pre-menopausal menorrhagia), 18 of the remaining 69 women reported amenorrhoea in the questionnaire completed in the 6 months prior to consultation of whom three had a Read code at consultation indicating definite heavy menstrual bleeding (Read terms menorrhagia, heavy period, pre-menopausal menorrhagia) and eight of the remaining 69 women in their questionnaire indicated possible pregnancy-related bleeding.
The proportion of women who reported an associated abnormal bleeding pattern in the survey ranged from 1.5 to 3.5 times higher in women consulting compared to those in the community depending on the combination of symptoms (Table 3). As an example, for the associated symptoms of short cycle, intermenstrual or postcoital bleeding, the proportion of women in the community with menorrhagia who report at least one of these symptoms in the previous 6 months is 41% while in those who consult it is 67%.
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Discussion |
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We have found in women who consult primary care and have heavy menstrual bleeding that the assumption ‘excessive menstrual loss in regular cycles is the most common clinical presentation’1 is incorrect. The majority of women have some form of associated irregular bleeding. Even in the community among women who self-report heavy menstrual bleeding, almost half have some associated form of irregular bleeding. The higher proportion of women with symptoms within the primary care setting compared to the community is consistent with the notion that women with more severe symptomatology consult.
Many studies have reported symptoms of menstrual loss in the community using objective and subjective methods. There have been no previous studies reporting the proportion of women who have combinations of symptoms of menstrual loss either in the community or in the primary care setting.
This study used the whole adult female population aged 18–54 years registered with an urban group general practice within the UK. The practice population resides in electoral wards of average deprivation. The response was high although there was some evidence that responders differed from non-responders in being older and more likely to be married or cohabiting. The effect of this potential source of bias is unknown. Although it is possible that receiving the questionnaire precipitated consultation when a woman would not normally have consulted, consultation rates in this study are comparable with those from national data.27
In the consulting women, the questionnaires were not completed at the time of consultation but during the 6 months prior to consultation. The reported presence or absence of symptoms on the questionnaire may therefore not have been the same at the time of consultation. It is unlikely that the women would have consulted with fewer symptoms and this is confirmed by the higher proportion of survey reported associated symptoms in women who consulted compared to those in the community. We estimate that the effect of the time delay between completing the questionnaire and consulting would be to under-report the proportion of women in the primary care setting with associated symptoms. It is also likely that in those who consulted for the first time during the first 6 months of the study, there was a higher proportion of prevalent cases and lower proportion of incident cases than those first consulting in the subsequent 6 or 12 months. It is possible that some prevalent women were receiving treatment for a menstrual disturbance and this may have improved their symptoms and reduced the reporting of symptoms in the previous 6 months. Again we estimate that this effect would be to under-report the proportion with associated symptoms in the primary care setting. The clinicians may have had a heightened awareness of menstrual problems and this may have promoted the self-reporting of prevalent but not incident menstrual symptoms. This effect if present would be to over-report the proportion of women with associated symptoms. The similarity of the practice consultation rate with the national rate27 argues partly against this effect as if the clinicians had a heightened awareness there would be a higher recording of increased vaginal bleeding Read codes.
The Read codes used to identify consulting women were designed to obtain all consultations concerning increased vaginal bleeding. The clinician ‘collapses’ or ‘re-frames’ all the information contained in a consultation into a single Read code representing their diagnosis or summarising their category of clinical management. All symptoms determined by the clinician are not recorded in the medical records (and this includes the free text). It may not have been the clinician's opinion that the woman had menorrhagia but both the clinician and the patient are equally entitled to define the symptoms as ‘menorrhagia’. While all the women identified from Read codes as having increased vaginal bleeding did not have the summary Read code of definite heavy menstrual bleeding (Read terms menorrhagia, heavy period or pre-menopausal menorrhagia), all the women reported their periods as heavy on a questionnaire completed within the 6 months prior to consultation. Difficulties in assessing a woman's menstrual complaint and using the medical model given by Read codes are suggested by the women who were non-heavy or amenorrhoeic according to their survey report but had their consultation summarised as definite heavy menstrual bleeding. The time delay between completing the questionnaire and consulting would increase the discrepancy but the size of the overestimate caused by this effect is unknown.
Carcinoma of the cervix and endometrium in women under the age of 55 years is rare in primary care;28 yet the symptoms of short cycles, intermenstrual bleeding and postcoital bleeding in association with heavy periods are common. The predictive value of these symptom complexes in primary care for gynaecological malignancy is therefore poor.
Primary care clinicians do not find current gynaecological terms and guidance helpful.11 This study suggests that many women who present to primary care with heavy menstrual bleeding do not have symptomatology that fits with guidelines concerning menorrhagia. Future guidelines should acknowledge the variety of symptoms women present to primary care.
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Declaration |
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Funding: NHS(E) West Midlands R&D office and the North Staffordshire Primary Care R&D Consortium.
Ethical approval: North Staffordshire Local Research Ethics Committee.
Conflicts of interest: None.
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Acknowledgments |
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We wish to thank the doctors, nurses and staff at Wolstanton Medical Centre. We acknowledge the work of administrative staff at the Primary Care Sciences Research Centre, Keele University.
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Notes |
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Shapley M, Jordan K and Croft PR. Abnormal bleeding patterns associated with menorrhagia in women in the community and in women presenting to primary care. Family Practice 2007; 24: 532–537.
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References |
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