Testing of the model using case studies

5.4 Testing of the model using case studies

In order to explore and test out the model more clearly the following three case studies were explored and used to illustrate the model further.

Case Study One

This woman identified herself as being in the outer ring of the conceptual model, with mild disruption to her lifestyle, who ultimately opted for no treatment at twelve months.

Anne (pseudonym), an ECLIPSE Trial participant was originally randomised to LNG-IUS but quickly decided not proceed with this treatment option for reasons relating to wanting to remain drug free and take a natural approach to her heavy menstrual bleeding. She had a long history of heavy menstrual bleeding and had developed complex coping behaviours that she was comfortable with and that proved to be effective for her. A well educated woman, Anne had researched her prescribed treatment and determined that the potential side effects would counteract her coping behaviours which she knew to be effective. She had a great deal of control over her working and family life, being a successful self employed business woman with excellent childcare systems and family support. Her husband was supportive of her both in terms of her decision to remain drug free and self manage her condition and in terms of his role in making sure that her coping behaviours worked. This influenced her ability to manage her heavy menstrual bleeding without treatment considerably. Anne had a clear sense of responsibility for her own health and being in her forties saw the menopause as not very far away. She felt confident that she would able to continue to self manage her heavy menstrual bleeding until menopause.

She had been treated in the primary care setting, and had a long standing

relationship with her female GP. She was open to the possibility of seeking treatment in the future but was confident that her coping behaviours would mean she didnÕt have to.

Case Study Two

Belinda (pseudonym) was a younger nulliparous woman at the start of a physically demanding, male dominated professional career. She lived with her parents and reported having heavy menstrual bleeding since puberty.

Her heavy menstrual bleeding, whilst being physically very similar to Case Study One, had a much more significant effect on her working life. She had already experienced a significant lack of empathy from her predominantly male managers and colleagues and a detrimental impact on her ability to physically cope with her job. It also impacted greatly on her personal relationships and her perceived potential for family life in the future. In the first interview she stated that she would rather have a hysterectomy and have no children than continue having heavy periods. She had a strong preference for LNG-IUS after hearing accounts of its effectiveness from friends but found this difficult to communicate to her health professional due several factors relating to her previous health care experiences.

Belinda found the fitting of the LNG-IUS particularly traumatic due to what she described as a lack of psychological preparation and physical pain.

The first three months of her treatment were difficult due to breakthrough bleeding but she did persist and at twelve months was very satisfied with the treatment outcomes she experienced. Her persistence with LNG-IUS was attributed to the fact that she had chosen the treatment herself and had faith in her friendsÕ accounts of their own experience of breakthrough bleeding. Having initially placed herself in the middle ring of the conceptual

model, by the second interview she considered herself to have no place on the model at all due to her amenorrhea. She used the model as an assessment tool and was able to articulate her experience of treatment for heavy menstrual bleeding much more clearly using ELMA to pinpoint improvements in quality of life since having the LNG-IUS fitted.

Interestingly a number of other aspects of her life had changed following successful treatment. She was more positive about her career, being able to cope well with the physical and emotional demands of her job better.

She had moved out of the parental home and was confidently living independently. She was now in a stable relationship and was considering having children in the future. Both her physical appearance and her attitude and demeanour had improved markedly since successful treatment.

Case Study Three

This is an example of a woman who fitted into the centre ring of the conceptual model. CatherineÕs (pseudonym) heavy menstrual bleeding had a severe impact on her life and had been a factor in marriage breakdown and job loss in the past. She was an ECLPISE Trial participant who was initially randomised to tranexamic acid.

Whilst she was in equipoise for her randomisation she did have previous experience of most of the medical treatments before including tranexamic acid. Although she took her prescribed medication as directed she found no effect and returned to her health professional requesting a change of treatment. At this time she was prescribed LNG-IUS and was examined and found to have a slight uterine prolapse and small fibroids. The health professional still recommended LNG-IUS and fitting was attempted. During

the procedure it was determined that the uterine prolapse had worsened and that hysterectomy would be the best option.

A hysterectomy was performed twelve months following randomisation.

When considering treatment options for Catherine, communication would have been improved using ELMA. The impact on quality of life was extreme and also Catherine had tried numerous medical treatments in the past without success. Added to that there were underlying gynaecological complications, namely fibroids and a uterine prolapse. The use of ELMA may have indicated that discussion about surgical treatment for heavy menstrual bleeding was indicated much earlier in this womanÕs journey.

Interviewed post hysterectomy Catherine was satisfied with the surgical procedure. She questioned why she had needed to try so many other treatment options before her surgery, given that she had lost a husband and jobs because of heavy menstrual bleeding over the years and had additional gynaecological issues. She was accepting that health professionals had used correct clinical judgement at the time but felt that using ELMA to aid communication would have enhanced her ability to communicate the severity of her condition to her health professional.

This chapter has offered and discussed a conceptual model ELMA developed from womenÕs experiences. The following chapter is focused on discussion of the findings of this study, including the descriptive themes and the conceptual model.

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