Menorrhagia is a condition which affects a considerable number of women. The traditional treatment is hysterectomy, which has significant morbidity associated with it. Over recent years more minimally invasive techniques have been developed to treat menorrhagia without resorting to hysterectomy. Photodynamic therapy (PDT) is a non-thermal technique which can be used to cause tissue damage. It requires the activation of a photosensitiser with light, which in the presence of oxygen produces cytotoxic oxygen species. 5-aminolaevulinic acid (ALA) is a photosensitising agent which has been used as a pre-cursor for the photoactive protoporphyrin IX (PPIX) in the past to successfully destroy the endometrium in the rat and rabbit model. When the technique has been used in humans, the effect has been unsatisfactory and has not been reproducible. This thesis demonstrates that by the addition of an iron chelator CP94 there is a significantly increased level of PPIX in the endometrium, as measured with fluorescence microscopy after both chemicals are instilled into the uterine cavity of the rabbit. We show that pH has little effect on these data. The optimum time for PDT was shown to be seven hours after instillation. We show a dramatically increased PDT effect when using a combination of ALA and CP94 in the rabbit endometrium. In addition this PDT effect remains at 28 days. These studies showed that it may be possible to improve on the previously reported disappointing clinical results using ALA-PDT by the addition of the iron chelating agent, CP94. We performed preclinical trials of light distribution within the human uterine cavity using different light delivery systems. This showed that an effective light dose could be applied to the irregular shaped endometrial cavity, in order to maximise the PDT effect in humans. The technique is now ready to take into pilot clinical studies.

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Introduction: Heavy menstrual bleeding is known to impact on health, wellbeing and social functioning. There is limited research examining women’s experiences of treatment for this complex condition. This longitudinal qualitative study explored women’s experiences of medical treatment for heavy menstrual bleeding with particular reference to women’s treatment preferences, quality of life and cultural variation. Methods: Data were generated by a series of two semi-structured interviews conducted with women who had either consented to participate in a randomised controlled trial (investigating effectiveness of levonorgestrel intra-uterine system [LNG-IUS] compared with standard medical treatments) or had declined due to an expressed treatment preference. The sample was purposefully selected to include a wide range of demographic characteristics and medical treatment options. Interviews were audiotaped and transcribed verbatim before being coded. A grounded approach to analysis was used with concepts emerging from coded data. Data generation and analysis were iterative and continued until theoretical saturation was reached. Findings: Twenty-seven women were selected and consented to the interview study, ten of whom expressed a treatment preference. A broad range of demographic characteristics and treatment options was achieved. In addition to physical aspects of heavy menstrual bleeding, most women described maintaining the societal norm of concealment of menstruation distressing. Expectations of positive treatment outcomes were high, but the experience of most treatment did not, in the initial stages, meet women’s expectations. After one year, women using LNG-IUS felt less restricted in their daily activities and described feeling less distress about their heavy menstrual bleeding. Many women who were using other treatments had discontinued them, several opting to manage their heavy menstrual bleeding by adapting coping behaviours rather than seeking alternative treatment. Treatment preferences appear to be influenced by knowledge gained from peers with LNG-IUS being the most preferred treatment. For many women in this sample the impact on quality of life was determined by their perceived ability to continue with their roles and responsibilities both at home and in the workplace. A conceptual model was developed when descriptive themes emerging from coded data were overlaid with recorded treatment outcomes. The model illustrates the complexity of heavy menstrual bleeding and highlights common feelings and experiences could be aligned to particular treatment trajectories. Conclusion: This study adds understanding to women’s experiences of medical treatment for heavy menstrual bleeding, preferences for treatment and how quality of life changes over time. The conceptual model developed highlights the complexity of this condition and might be used to improve communication between women and health professionals.