• Close collaboration with haematologists is required in the management of women with menorrhagia, when a bleeding disorder is suspected or diagnosed.
• Women with bleeding disorders suffer significant gynaecological morbidity, including menorrhagia, dysmenorrhea and mid-cycle pain that can affect their health and quality-of-life.
• Increased awareness among clinicians of these problems and treatment options available is essential to improve quality-of-life. Tranexamic acid is a safe, effective and inexpensive treatment for menorrhagia in these women and should be used as first-line management.
• DDAVP nasal spray increases von Willebrand’s Factor and Factor VIII levels and can be used as a home treatment for some women with bleeding disorders. A test dose is required to assess
response.
• The Levonorgestrel intra-uterine system should be considered prior to surgery.
• A multidisciplinary team approach is required when contemplating gynaecological surgery in these women to minimise bleeding complications.
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Until the introduction of the first generation, hysteroscopic methods of endo- metrial laser ablation (ELA) and transcervical resection of the endometrium (TCRE) in the late 1980s, a hysterectomy was the only definitive surgical treatment for dysfunctional uterine bleeding (DUB). Despite hysterectomy being very common, there was little hard evidence regarding its role. The new endo- metrial ablative methods (including resection) gave the promise of replacing hysterectomy with a minor, quick, and safe technique.
The early 1990s was a time when the concept of evidence-based medicine was becoming established. This meant that the newly introduced endometrial ablative methods were rigorously assessed with randomised controlled trials comparing them to hysterectomy, medical treatment and the differing methods of ablation. As a result, evidence regarding all the surgical methods including hysterectomy began to accrue. At the same time, national audits of endometrial ablation, and recently hysterectomy gave robust data regarding safety.
Despite the increasing acceptance of the role of randomised trials, it is unfortunate that the majority of publications in this area are uncontrolled observational studies. Furthermore, only the minority of studies have used power calculations to determine the size of the population studied.
Outcome measures are a problem with studies on surgery for DUB. Patient satisfaction is the most useful and important measure, followed by hyster- ectomy rates following ablative surgery. Amenorrhoea rates are useful when comparing one ablative method with another, but less so when comparing ablation to hysterectomy. Surrogate measures of menstrual loss are even less useful as even the PBLAC score has been shown to be unreliable in women with DUB.1
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David E. Parkin MD FRCOG, Consultant Gynaecologist, Department of Gynaecology, Aberdeen
Royal Infirmary, Forresterhill, Aberdeen AB25 2ZN, UK (for correspondence)
Stuart JackMRCOG, Specialist Registrar, Department of Gynaecology, Aberdeen Royal Infirmary,
Forresterhill, Aberdeen AB25 2ZN, UK
David E. Parkin Stuart Jack