Episode 1: Heavy Periods

TRANSCRIPT

Speakers: Dr. Bassel Wattar, Olivia Moir

00:00:04 Olivia 

Hello everyone and welcome back to It All Starts Here, a podcast focusing on the communication and education of topics in reproductive science and Women's Health.  

I am your host, Olivia Moir, and we are back here today to talk about the menstrual cycle, also known as periods, that time of the month, whatever it is that you call it, we are going to be diving into this topic, but specifically on heavy periods -  and to do this I have with me Dr Bassel Wattar, who has been a guest on the podcast previously where we talked about PCOS and if you missed that episode, definitely go and check it out for anyone who hasn't listened to the episode. 

I will let Dr Wattar take it away and introduce himself and what he does. 

00:00:51 Bassel 

Thank you, Olivia, for having me again. So lovely to be on the podcast. So my name is Bassel Wattar. I'm a consultant gynecologist and specialist in reproductive medicine. 

I'm an associate professor of reproductive medicine at Anglia Ruskin University in UCL and at UCLH I lead a specific research group called EVIE where we focus on Women's Health studies, specifically synthesizing evidence to inform clinical practitioners on the best treatments and sort of diagnostics and assets and to help women enjoy healthier lives, in a very brief summary . 

00:01:27 Olivia  

Yes, which is so important and we've focused a lot on that on this podcast before and the importance of evidence based research. So it's such a pleasure to have you back here today. And as I said on this episode you're going to be guiding us through heavy menstrual bleeding. So what it is, how common it is, how do we diagnose it and how do we treat it? 

00:01:52 Olivia 

We're also going to be talking about research in this area and specifically the importance of including the community perspectives and research practice and how Dr Bassel Wattar’sa team has been going about this. So, as I said, I'm so excited to have you back here, and why don't we jump in and talk about what heavy menstrual bleeding is? 

00:02:15 Bassel 

Well, such an interesting yet very basic question because what is a heavy period? I think we all know that every woman, someone who menstruates have this time of the month where the lining of the uterus is shedding out. And that is when there is a pregnancy did not take place. And that is a sign of good health. So a woman who's having regular periods is in very good health, and someone who has absent periods - there's something not right in their hormones or in their reproductive organs. 

00:02:46 Bassel 

However, the complexity comes to: when we discuss what is a heavy period - because what's heavy for one person could be very different, could be very normal to someone else. And so when someone comes goes to the doctor and say I have heavy periods, unfortunately we as doctors were guilty in oversimplifying it in somewhat dichotomizing it: Is it heavy or is it not heavy? But we don't really go about quantifying it. The while naturally everyone who's listening to us will be thinking “oh about the volume of blood loss” when someone is having heavy periods - but it goes a little bit more in depth and the having heavy periods have varied impact into someone's life. And when someone is having  heavy periods, invariably they are in pain, they might feel isolated, fatigued, tired, unable to engage in their routine life activities. They might not be able to go to work, to school, they might not be able to be intimate with their partners, so it is quite multidimensional and it's not just about the volume of blood loss. 

00:03:52 Bassel 

Back in the days, we used to say that it is an equivalent of 75 or 80 mL’s lost per month, but if you if you sort of critically appraise this idea, you'll quickly realize that it doesn't mean anything because it could be just the 80 and it could be significantly affecting someone. So now the current sort of guidance, and all practitioners in the UK in many places in the world are bound by the guidelines from NICE that basically details the assessment and treatment for heavy periods in the in the UK, in the NHS and it quantifies it by a heavy periods that significantly affecting someone's life. And that's what is a heavy period. But as we discussed, this definition is really varied and it should be, you know, framed within the context of a, you know, each person individualized assessment of it. 

00:04:43 Olivia 

Mm-hmm. Absolutely. And I mean, I had the pleasure of attending your event back in March, which, let me say, was the best podcast episode briefing I've ever attended - It was a great way to learn more about heavy menstrual bleeding because, as you said, what is that and how do you quantify that and you know it can't really be generalized, but at the same time when you're trying to diagnose it, I mean, I guess that's my question is, what are these barriers to diagnosing it? And I remember you you touched on the fact that it took 30 years to get information just to be able to diagnose it present day and that might not even be the best way to do it. 

00:05:27 Bassel 

So unfourtunately and traditionally, doctors and researchers looking into the topic of heavy periods would use something called pictorial blood charts, where basically you have sort of like a graph with several pads or sanitary towels or tampons. And they are like color-coded quarter full, half full or completely full to have a sort of a indirect assessment of how heavy a period is. 

00:05:55 Bassel 

Now, while this might be helpful at the time, let's say in the 60s or the 70s, that probably was the best tool that someone can come up with, I guess we all can agree that nowadays when we have that many digital technology and digital health tools, this is quite archaic and we should be moving to something a bit more modern.  

So if someone is coming in the clinic and I give them that chart and tell them well, please fill it up for me and you know well, it will vary by the type of tampon, and as you heard from someone from our patient  representatives at the event you attended, when the woman is having heavy periods, a lot of the blood is actually lost on the on the toilet.  

And I'm sorry I'm being graphic in the in the podcast, but I think it's important that we voiced these women concerns. A lot blood is lost and it's not quantified on a pad and sometimes someone will change a pad when it's half full, where someone will wait until it's absolutely full, and then they would change it and quantify it.  

So it's such an inaccurate way to assess a volume of flow loss and the other thing is, as we mentioned is that is not just about the volume of the blood loss, but it should be about a holistic assessment of how a heavy period is affecting someone's quality of life and how the treatment that we are proposing is improving their overall quality of life, not just limiting the amount of blood they're losing every time. 

00:07:17 Olivia 

Yeah, absolutely. And I think on that, the social effects of heavy periods and the struggles, different things that we talked about during that event that I think is important for people to think about is the different workplace legislations around, you know, heavy periods. And I mean that can be applied of course to any sort of health condition that someone has - it's a different thing for different people, but highlighting those struggles, maybe you can talk about that that people experience. 

00:07:52 Bassel 

Certainly. And this is specifically because periods as a topic has been taboo for many, many, many years. And in many societies, even till today in some, for example, religious societies, women who are menstruating are being are asked to, to isolate or being left alone until they are so-called “cleansed” and then they can resume their social activities, which is, you know, nonsensical. Because as we started by  in our discussion, this is a completely healthy thing is, to go through a period, and it's part of someone's normal Physiology. So why we would annotate it by being dirty or unclean or unsacred, or whatever other terms. So I think as health professionals we have the duty sort of to normalise discussion and discourse around around periods.  

And also to normalize the sort of assistance that someone would seek in the workplace or in the study place and when they are on their heavy periods. So if someone is is having very like, you know, passing clots for example, they might not be able to go on public transport and go all the way to work to engage in, let's say, laborious or even sit at your desk. Having said or in a meeting. So they might opt to work for a home, for example. I'll take a day off and you know, maybe thanks to COVID, we're all having more flexibility in working from home nowadays. And this is probably here to stay. But the indications for it should be completely normalized. If someone is having a, you know, Women's Health condition, it's completely fine and should be enabled by the employer to work from home in their comfort zone where they are most productive, I would argue, and they're not actually missing a completely they, you know, complete day off work because of, you know, their period. So that's one example.  

But other other examples could be having a female friendly, for example, lavatories and and bathrooms where there is sanitary tiles provided for free and we're seeing more legislation about around that in schools and other public places and you think that this is the sort of basic decency that you can offer to someone who's ever periods, but it takes it takes lobbying, it takes advocacy, and it takes, you know, us working together to change such laws and making work and study places more, more female friendly. 

00:10:13 Olivia 

Yeah, absolutely. And you know, as going back to what you said, how it's sort of a topic not sort of, it is a topic that is taboo. As we move forward, it’s becoming increasingly less so I think. How can healthcare professionals, let's say, kind of help to reduce that taboo around that topic. Where does that come from? Is that, you know, I think what you said during your event, how you have 10 minutes with your patients and it's very hard in those 10 minutes to be able to properly assess and be able to talk about for example, in this context a conversation that, although you're a healthcare professional, it can be really hard to bring these things up. 

00:11:00 Bassel 

Indeed. I mean it's a quite a private thing to speak about someone's periods and you might be meeting a male doctor for the first time and it's hard to immediately break through and just talk about something that personal. So GP's have in the NHS just 10 minutes to do a consultation, which is frankly impossible and I don't know why we keep, you know, sticking with this system, but let's leave this topic for another day. We're not going to fix it today!  

But I do think that we need to use other resources to make patients more informed. We need to have help them, for example, with digital health apps with online available, patient friendly information and other resources with peer supports. And there's different versions where a patient can seek reliable information like, for example, we're just right now doing an exercise where we're evaluating how many women in the NHS are admitted overnight to have blood transfusion because of heavy periods. 

Imagine in my hospital it's a weekly thing. So in a country that is has the sixth biggest economy in the world, we still having women with heavy periods being that neglected to the point that they're bleeding, and they need the blood transfusion instead of just being able to access reliable treatment in the community you know, to stop their heavy periods,  before they reach that point, which is quite mind boggling if you think about it and maybe the the answer would be that we should just do more work in the Community where women can immediately access reliable, easy and and effective treatments in the community to stop them needing these blood transfusions and being admitted because it's such a health burden on society and on the women themselves. 

00:12:54 Olivia 

Absolutely, yeah. No, it it is. And it's so important to highlight that.  

In terms of research in this field, so as a step sort of forward and current research going on, you mentioned the NICE guidelines at the beginning of the episode, How is that do you think right now, currently and how is your research going to help with the diagnosing and eliminating some of the barriers around heavy periods, would you say? 

00:13:24 Bassel 

So as you are mentioning, so we do have a grant currently from the NIHR looking into all treatments for heavy periods and indeed the origin of this is a very simple idea. It’s for me as a gynecologist when sitting caring for someone with heavy periods, I have currently in the NHS, we have 19 different treatments for heavy periods. 

00:13:44 Bassel 

It's almost impossible to summarize all these 19 treatments in a very quick and succinct way in 10 or 15 minutes - the patients will simply not have enough time to digest all the information. 

So we wrote to NIH and said look we want to do an exercise where we synthesize evidence and rank these treatments for their order of safety and important and effectiveness. But most importantly what has been missing in the literature to date is what's the patient preference. And so and so that was part of the reason we did this event because we want to, to promote women's voices, we want to factor in patient preference into what is the best treatment.  

For example patient group, because if someone is a teenager and they're they're 18,19, they're starting their, you know, work or education, they're probably going to opt for let’s say the contraceptive pill, and they would not want a Myreena (IUD) or hysterectomy. 

Versus someone who might be in their late 40s and they've completed their family. They might say, well, just give me a key whole hysterectomy. Like, let it be done with. It's just so much nicer for me. 

00:14:57 Bassel 

And unfortunately, the current NICE treatment and the NICE guideline does not factor in that patient preference visibly and clearly. I think there is more work to be done on that. So that's part of the exercise that we're doing. But the, vision is that we want to produce a very easy decision, aid tool that can help both the doctor and the women consider all these treatmentoptions and help them come to a treatment plan very quickly and save all the sort of side effects that can come from chronic heavy peers that no one is doing anything about. 

00:15:33 Olivia 

That was something that I loved a lot about your event, was the fact that you had patient voices there, and you were amplifying them because, as you said, it is so important to have that input. And I think it's funny how we can overlook not funny, but interesting how we can overlook the opinions and the voices of people who are directly affected and are interacting with healthcare.  

Of course, the healthcare practitioner is important and you know, as you said, the 10 minutes is not exactly enough, but the patient as well - it should be considered. 

00:16:16 Bassel 

100%. And you know for me as a as a researcher and a gynecologist, I learn a lot every time I interact with with my patients and with you know, we host these patient events, because something very important that came to light from from that event is that, let's say someone come with heavy periods and we traditionally give them something called GNRH analog, which is an injection that switch off their periods and put them in artificial menopause.  

For healthcare professional, we cured the problem - there is no more periods, but the patients were saying well not really, you gave me menopausal side effects and so my quality of life, did not really improve. So that was very valuable feedback. Because if we don't factor this side effect then that treatment might be ranked as very effective.  

But in reality it's not that effective because it causes additional side effects to the women. So it's this kind of discourse that we need to sort of promote and research and in healthcare provision so that you know you optimize the outcome for the patients ideally. 

00:17:16 Olivia 

Yes. Yeah. And I think that that is such a good way. I mean in terms of including these people in your event of including the Community, but what are some other ideas or examples that you might know of where a patient can maybe look to get involved, or the community can look to get involved and put their voices like whether it's research or just specifically like feedback that they're giving, where are some areas that people can go to? 

00:17:48 Bassel 

I think look, it all starts with your trusted Doctor, the other thing is you for example, you and your podcast is a great example where patients can know learn about what research is happening and how they can actively take part in it. And I think in the UK, we're fortunate in that nowadays we have a charity or a health advocacy group for many conditions. And so I think we're having, for example, in our event, we were lucky to have 4 charities that are representing Women's Health and heavy periods and for example: 

•  Well-being of women  

• Menstrual health projects 

These are great places, and they're non-governmental organization, they're charities that are advocating on behalf of patients. So I strongly emphasize and support and ask every patient to really take part in such organization because that's the great example of how they can make their voice heard and a great example, for example, following our last episode on PCOS we, you know, we worked very hard to ask the government for more research on PCOS treatment and very recently the NIHR announced a call for lifestyle intervention treatments on PCOS.  

So that's a great example of how you know charities for PCOS have been advocating for more research and the government would listen and they would Commission more research. So that's great sort of successful example and we need to continue to work collaboratively to improve healthcare in in the UK, hopefully and worldwide. 

00:19:18 Olivia 

Yes, it's all about working as a team, I agree, and I will link those charities in the show notes so that people can interact with them. 

Going forwards, kind of stepping into a different field that I don't necessarily love so much, but, was highlighted during your event, which is that of economics: Why is the treatment so expensive for women? I mean, how can we improve this, something that was highlighted so much in that event was how it seemed like there was a disproportionate kind of expense around Women's Health and women's healthcare. Let's say specifically relating to heavy menstrual bleeding, what are some things that you can say about that in terms of the treatment being so expensive and how we can improve it? 

00:20:15 Bassel 

I think a large part of it is the nature of how we provide care, which is very fragmented, as in like the patient journey until they reach the exact specialist that they can help them and the NHS is often a bit too long winded more than that is needed, a flip example is that if you place a community gynecologist who can do a scan and input for example a Myreena coil immediately, is one intervention that will significantly reduce the cost, the weight and promote efficiency into the treatment. 

00:20:47 Bassel 

And we all know difficulties in healthcare provision in the UK and the difficulty in finding staff and we always have a lot of you know vacancies. So that is a continuous struggle, but also about the current model of how do women access the care that they want. There was an idea about community health hubs for women, you know, I don't think this is becoming reality, unfortunately, due to lack of funding in many places, but this is a great example that could have significantly improved specifically on the topic of heavy peers. I think the first point of call should be the GP, and the GP should be empowered and enabled to provide very quick at least rapid treatment. At least stop the period until they go and see a special 

This often doesn't happen unfortunately, due to lack of expertise. I mean, you're lucky if you see the same GP nowadays twice. It's very difficult, they try there best, it’s just that the system is suboptimally run. The additional thing is an idea that we're trying to feature in our analysis, which is what is the chance of treatment failure? 

Meaning, if you're gonna give a treatment, that might work like for today and tomorrow. But then day after, it will fail. And then you're then waiting for another treatment. That's an opportunity wasted and featuring in this treatment failure, and what is the treatment progression is very important specifically when you have 19 different treatments to choose from and combine and contrast. And so we need more research to sort of tell us what which treatment is the most cost effective per patient group per their specific characteristics so that we can maximize the chance that they will see most benefit from the very first treatment and they don't need anymore further treatments after that. 

00:22:50 Olivia 

Thinking about it going forwards, I mean you've you've said the importance of the GP being able to not only sort of diagnose the heavy menstrual bleeding, but then also be able to treat it in that same appointment would reduce costs and wait times in this kind of thing, but something that you, I feel like, are alluding to and talked about slightly in the presentation or the event that you hosted, just about tools in this area that you feel would be helpful going forwards in the field. 

00:23:23 Bassel 

Yeah, as I said, like we're we're hoping to be reproduce a decision aid tool whereby you know, you would put in the patient characteristics and then it will suggest potential treatments and then obviously no AI will, I don't think and I will replace a doctor ,because there is a doctor patient relationship where a doctor is understanding the patient and treating them as an individual rather than just another case that the AI would treat.  

And so we want to help the GP or the gynecologist, and to say these are the available options. These are the side effects. These are the chances of success. 

And then in a discussion jointly with the patient, they will be able to allocate the best available treatment tool for them and that hopefully they will eliminate some barriers because like for example, there's very new treatments that are coming in the field of heavy periods, for example, a tablet called reecho dot is looking very promising in our analysis. But most GP's would not have heard of it and they will not be familiar with it. So having this this sort of decision-aid tool might break the barrier to quickly adopting novel treatments that might be very effective and help women to reduce the need to try one treatment and failing and then treatment 2 when they're failing it and then ending up with a hysterectomy four or five years down the line after trying so many, you know, failed treatments, which is what we're. 

00:24:52 Olivia 

Yeah. Something that really resonated with me in that event, is I can't remember who said it. I think it might have been you, but I think that you said that the goal with this is to remove noise around management of heavy menstrual bleeding, and I thought that would be a good point to end on with the podcast. But maybe you could touch on that and what you meant. 

00:25:16 Bassel 

Look, ultimately the objective should be to empower each patient with the right knowledge and information to help them make the most informed decision about managing their health. Every patient needs support and we just want to give them the right source of information that's reliable. That is evidence based on the best quality available evidence and help them with their healthcare professional to make the best decision. 

And so I'm a strong believer that the only way to do that is via good quality research, and that's what we're hoping we're hoping to do. And when you do that, you reduce a lot of this additional noise, which is you go on Mr. Google and you're ask it to tell you this treatment or that treatment, then you ask your, I don't know, your cousin or your neighbor, they tell you, oh, I tried to coil, it didn't work for me. 

And I mean, I hear that a lot “the coil didn't work for me” like no the coil is actually very effective in the far majority of women, but those who don't like it are those the ones who speak on the Internet. Unfortunately those who like it, they just don't don't say anything about it. 

And so that's what I mean is that there's a lot of noise and and misinformation and we need reliable tools to inform the patients and the healthcare professionals to offer the right treatment. 

00:26:31 Olivia 

I love that, you worded it so perfectly, and I think everyone listening and would agree with that strongly.