It is welcome news that Gail Prileszky and colleagues are addressing the evidence gap for this common condition and are looking at patient preferences in their trial. The NICE guideline's ranking of levonorgestrel-releasing intrauterine system (LNG-IUS or Mirena®) above other treatments is indeed problematic in practice, where an emphasis on choice for the fully-informed patient seems more appropriate.
The NICE guideline is likely to benefit women in other ways, for instance in shifting the emphasis away from assessing volume of loss and towards assessing impact on quality of life. Unfortunately, the guideline only set out to address heavy menstrual bleeding and we know that other menstrual symptoms, mainly menstrual pain, increase the impact of heavy menstrual bleeding.1,2 This is relevant to the difficulties with the ranking system. For instance, many women reporting heavy menstrual bleeding actually find menstrual pain more problematic, and for these women non-steroidal anti-inflammatory drugs (NSAIDs) might be a first-line rather than second-line treatment.
Prileszky and colleagues refer to the influence of social factors on women's perceptions of heavy menstrual bleeding. Social factors may influence their views of treatment as well. We found that women view heavy menstrual bleeding as ‘not real illness’, leading them to attempt to self care, including seeking information widely informally, and to consult only where self care has failed.3 Women may therefore already hold strong views about different treatment options by the time they see a health professional.
Heavy menstrual bleeding is a condition which has long been in need of a stronger evidence base. Together, the randomised controlled trial and qualitative findings from the ECLIPSE trial should enhance our ability to help women make the best choices about their health.
REFERENCES
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