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Practice Nurse

Menstruation

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General practice nurses (GPNs) may frequently be asked for advice on menstrual problems, which may include issues around how regularly – or irregularly – bleeds occur, how heavy the flow is and how painful periods may be. Menstrual problems can start at menarche, or even before, right through to the menopause. As GPNs are often involved in seeing women for contraception, pregnancy planning and cervical screening, the subject of menstruation will often be broached. It is important, then, that all GPNs are able to discuss these issues knowledgeably.

This resource, consisting of five assessment questions at advanced level, tests your knowledge of these issues. The level of these questions reflects the fact that they are aimed at people working in an extended role who may also be prescribing. Complete the resource, including the further reading and some or all of the suggested activities, to obtain a certificate for one hour of continuing professional development to include in your annual portfolio.

On completion of this resource, you should have an understanding of:

The significance of oligomenorrhoea in adolescents

Evidence based interventions for menorrhagia

Evidence based interventions for dysmenorrhoea

http://www.nhs.uk/Conditions/Periods/Pages/Introduction.aspx

Georgia is 14 years old and her periods started a year ago. She attends the surgery and asks her mother to come in with her. She expresses concern that her bleeds are irregular. She can have 3 weeks between bleeds then wait another 8 weeks before her next period. She is not sexually active and is not keen to take the pill. However, both Georgia and her mum are worried that something is wrong as neither mum nor Georgia’s sister had period problems. What would you advise?

It is entirely normal for periods to be irregular at the menarche. Many women who seek advice about their periods are mainly looking for reassurance that there is nothing untoward going on. Irregular periods (oligomenorrhea) are common in the first 1-2 years after menarche so, in the absence of any other symptoms, Georgia (and her mother) can be reassured. Although the combined oral contraceptive pill can regulate the cycle and treat the symptoms of PCOS, it is not neccessary in Georgia's case, particularly as she has said she doesn't want to go on the pill.

Hillard PJA. Menstruation in adolescents: what’s normal? Medscape J Med 2008;10(12):295 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2644006/

http://www.nhs.uk/conditions/Polycystic-ovarian-syndrome/Pages/Introduction.aspx

PCOS may be the cause of irregular or absent periods in some women but there are other signs, other than menstrual disorders, that may be seen. What are the cardinal symptoms of PCOS that might make you suspect the diagnosis? Have a look at the two websites above and reflect on what you knew about PCOS and whether you have found any information which is new to you. Note down your findings in your reflective diary.

Question 1

Carrie is 20 years old and her menarche occurred when she was 12. She is complaining that she has irregular, heavy, painful periods and that these are having an impact on her quality of life. She is in a same sex relationship and does not use contraception. She is keen to ‘normalise’ her periods as much as possible. However, she is not keen to go on the pill as she suffers from migraines. What might you advise?

If Carrie wants to improve all aspects of her menstrual problems then a treatment such as tranexamic acid will not be enough. Endometrial ablation may well improve her symptoms but the cost may be her fertility. Although she is currently in a same sex relationship, Carrie may want children in the future. The low dose COC is not suitable with her history of migraines, and furthermore, she has expressed reluctance to try this option. Therefore, the IUD offers her the best solution to her heavy, painful periods, with the chance of lighter, pain-free periods and the possibility of no bleeds at all. However, Carrie should be warned that her periods may still be irregular for the first few months.

Faculty of Sexual & Reproductive Healthcare. New product review Jaydess 

http://www.fsrh.org/pdfs/CEUProductReviewJaydess.pdf

Mirena and Jaydess are two versions of the IUS. Have a look at the information for each product and see how they differ. There are pros and cons to each device and these will differ from woman to woman. For example, have a look at the rates of amenorrhoea cited in the Faculty of Sexual & Reproductive Healthcare review above, and consider whether this might influence some women’s preference.

Question 2

Ingrid is 36 years old and has come in to see you about her heavy periods. She had been on the combined pill for the past 5 years, since having her last baby, but she has now stopped as she has decided that she would like to have another child. She says she needs something to lighten her flow which won’t interfere with her fertility. After taking a full history and carrying out an assessment, there are no signs or symptoms to suggest anything sinister. What is the best response here?

The progestogen-only pill (POP) is still a contraceptive, and if taken as directed, will prevent pregnancy so is not appropriate for a patient who is intending to become pregnant. At age 36, it may take Ingrid longer to conceive than it would if she was younger, so asking her to put up with her symptoms is unacceptable. Menopause is unlikely at the age of 36; what is more likely is that after being on the COC, Ingrid has become used to having lighter bleeds and what she describes as 'heavy' bleeds may in fact be normal. The recommended options for the treatment of menorrhagia are tranexamic acid or the non-steroidal anti-inflammatory drug (NSAID) mefanimic acid, which have been shown to reduce blood loss by 29-58% and 20-49%, respectively, and to improve quality of life.

Electronic Medicines Compendium (2014) Tranexamic acid 500mg 

http://www.medicines.org.uk/EMC/medicine/24325/SPC/Tranexamic+Acid+500mg+Tablets/

NICE (2015) Heavy menstrual bleeding overview 

http://pathways.nice.org.uk/pathways/heavy-menstrual-bleeding#content=view-index

Look up the Summary of Product Characteristics for tranexamic acid on the Electronic Medicines Compendium. What dose is recommended for menorrhagia? What are the contraindications to using it?

Question 3

Katy, age 37, has come to see you for advice about dysmenorrhoea. She never had any problems until about 6 months after the birth of her second child when she noticed that her periods had become slightly heavier but much more painful. She tried the pill but it didn’t really help. She’s not keen on other forms of contraception as her youngest child has just started school and she is thinking of having another baby ‘before it’s too late’. Her dysmenorrhoea has forced her to take time off from her job as a teacher on three separate occasions in the past 6 months and she feels at her wits end. How should you take this consultation forward?

Dysmenorrhea can be primary or secondary and secondary causes should be ruled out before diagnosing primary dysmenorrhea. The chances of a secondary cause increase if a woman develops dysmenorrhea after years of painless periods, as is this case with Katy. Careful history taking will identify possible red flags, and nurses who are competent to do so may decide to carry out a pelvic examination to assess for the presence of a mass, which may indicate fibroid or other disease. Referral (to the GP or gynaecology, depending on the nurse's role and competence) for further investigations should be initiated. For primary dysmenhorrea, pain relief e.g. an NSAID or more comprehensive approach including adjunctive therapies e.g. TENS (transcutaneous electronic nerve stimulation) and/or local application of heat may be appropriate.

http://cks.nice.org.uk/dysmenorrhoea#!scenario

Do you carry out pelvic examinations in practice? If so, who trained you and assessed your competence? Recognition of competence is part of the revalidation process that the NMC is bringing in from 2016. Consider how you might work with your GPs to ensure that your practice in this extended role is accurate and up to date. If you do not carry out pelvic examinations at present how could you learn more about them, both in theory and in practice? Again, could you work with your GPs or a local GPwSI to develop your skills? Is there a programme in place locally to support the development of skilled practitioners?

Question 4

Geraldine is 50 years old and is finding that her periods are very unpredictable at the moment. Approximately 2 years ago they started to get less frequent and she thought it was ‘the change’. However, in the past 6 months they have gone the opposite way and have become heavier and more frequent. She wonders whether she should go on the pill to sort them out as she never had problems when she was on the pill before. What would you say to Geraldine?

Women's bleeding patterns may vary considerably around the time of the menopause, although the most common pattern is for periods to become lighter and less frequent, rather than heavier and more frequent as Geraldine's have. Before assuming that this change is due to the menopause, it is important to consider other possible causes for her menorrhagia. Geraldine is the right age for menopausal symptoms, which may include vasomotor symptoms (hot flushes and night sweats) and genito-urinary symptoms, but it is important not to assume that this is the diagnosis until other possibilities have been considered.

Ask the next 10 women aged 45-50 who are attending for cervical screening if they are experiencing any period problems. How many say yes? Of those, how many have sought advice? Do they know where to get help? For example, do you have a nurse or GP who specialises in menopause management? Is this evident from your practice materials – leaflet/website?

Menstruation

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