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About ‘bloody’ time: New developments in the treatment of heavy periods

The relationship with ‘Aunt Flo’ is one both cherished and (mostly) loathed by many. Occurring approximately once a month, menstruation sees the womb shed its endometrial lining, becoming inflamed and ‘wound-like’ as a result. The endometrium then heals itself without scarring or loss of function, to limit blood loss. In most cases this occurs without error, however for 20-30% of women, heavy menstrual bleeding (HMB) is experienced, which can lead to anaemia and a general lower quality of life.

Heavy bleeding is the most common issue faced by patients visiting gynaecologists. Although there are treatments available in the form of hormone therapies, suc h as the birth control pill, the side effects can counteract any increase in quality of life from reduced HMB. A four year audit found that 43% of patients who experience HMB received surgery within the first year of their first hospital attendance, with surgery commonly being fertility-ending.

Heavy bleeding is the most common issue faced by patients visiting gynaecologists

A recent study by researchers at the University of Edinburgh’s Medical Research Council Centre for Reproductive Health has explored the roles played by hypoxia (low levels of oxygen) and levels of protein HIF-1 (hypoxia inducible factor) in mediating repair of the endometrium, building on their previous research. The group, led by Jackie Maybin, found that patients who experience HMB during menstruation had lower levels of HIF-1 in their endometrium than those that did not.

The HIF-1 protein is the major party in dictating a cell’s response to hypoxia. The protein is inactivated at higher oxygen levels, and so by manipulating the oxygen levels of the womb, the concentration of active HIF-1 in the womb can be changed. The group sought to explore the effects of increased HIF-1 levels in HMB sufferers. Conducting research on genetically modified mice, the researchers subjected the mice to increased oxygen levels (hyperoxia) and normal oxygen levels (normoxia). Their findings revealed that hypoxia of the endometrium during menstruation was prevented at increased levels. In addition, repair of the endometrium reduced in frequency for mice in hyperoxia compared to mice in normoxia, with 56% of mice in normoxia reaching complete repair compared to 22% of those in hyperoxia.

43% of patients who experience HMB received surgery within the first year of their first hospital attendance

With greater establishment of the role of hypoxia in endometrial repair, the group then moved on to administration of echinomycin, which is known to inhibit the action of HIF-1, and DMOG, which inhibits enzymes known to destabilise HIF-1. Mice treated with echinomycin showed reduced repair, whereas those treated with DMOG showed increased repair in comparison, seemingly confirming the role of HIF-1 and hypoxia in efficient endometrial repair.

This development could lead to a new non-hormonal treatment to counter current options for HMB patients, which may have ripple effects socio-economically. A US study estimated HMB patients suffered financial losses of greater than $2000 per year due to work absences and added home-management costs. Availability of a drug with reduced side effects could decrease those losses, increasing their presence in work environments and reducing barriers to advancement. In addition, a reduction in the number of patients who have to receive fertility ending surgery would equate to removal of the risks to life and well-being that accompany all surgeries. An increase in birth rates, notable when many developed countries are at current facing aged/aging populations, could also be seen.

This development could lead to a new non-hormonal treatment to counter current options for HMB patients

The research presents clear advantages for HMB sufferers, and comes at a time where marginalised voices are being centred in social discussions, and the recent #FreePeriods march has brought menstrual issues front and centre. Though current social attitude is unlikely to have played a part in drive for this research (with drugs and treatments for menstruation being a profitable industry), it can be said that the research may not have received as much attention in previous years. Increasingly, science is being used to address both clinical and social needs. These developments represent a relatively small but necessary step forward, welcoming the move to remove barriers and equalize daily experiences.

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