458 - Behavioral Interventions, Heavy Menstrual Bleeding, Knowing When

From the USPSTF

1)  Behavioral Interventions to Promote Health/Prevent Disease 

The USPSTF has made multiple recommendations regarding behavioral counseling interventions to promote health and prevent disease in specified populations.  Here is a review of 3 of them, with the most recent being released in July of 2022 regarding whether behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention in adults without cardiovascular disease (CVD) risk factors is effective. 

It is known that CVD, which includes heart disease, myocardial infarction, and stroke, is the leading cause of death in the US.  A large proportion of CVD cases can be prevented by addressing modifiable risk factors, including smoking, obesity, diabetes, hypertension, dyslipidemia, lack of physical activity, and unhealthy diet.  Adults who adhere to national guidelines for a healthy diet and physical activity have lower rates of cardiovascular morbidity and mortality than those who do not; however, most US adults do not consume healthy diets or engage in physical activity at recommended levels.

In 2020, the USPSTF addressed behavioral counseling interventions to promote a healthy diet and physical activity for CVD prevention in adults with CVD risk factors, including known hypertension or elevated blood pressure, dyslipidemia, or mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater.  Adults with other known modifiable cardiovascular risk factors such as abnormal blood glucose levels, obesity, and smoking were not included in this recommendation.  They concluded with moderate certainty that behavioral counseling interventions have a moderate net benefit on CVD risk in adults at increased risk for CVD and therefore recommended offering or referring adults with CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. (B recommendation)

In July of 2022 the USPSTF released their updated recommendations regarding behavioral counseling interventions for adults 18 years or older without known CVD risk factors, specifically without hypertension or elevated blood pressure, dyslipidemia, impaired fasting glucose or glucose tolerance, or mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater.  While obesity is a risk factor for CVD, a separate recommendation statement addresses individuals with a body mass index (BMI) of 30 or greater (see below). 

The USPSTF concluded with moderate certainty that behavioral counseling interventions have a small net benefit on CVD risk in adults without CVD risk factors.  They recommend that clinicians individualize the decision to offer or refer adults without CVD risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. (C recommendation)

In September of 2018 the Task Force updated their recommendation regarding behavioral weight loss interventions to prevent obesity-related morbidity and mortality in adults.  They concluded with moderate certainty that offering or referring adults with obesity to intensive behavioral interventions or behavior-based weight loss maintenance interventions has a moderate net benefit and recommend that these be offered to all adults with a BMI of 30 or higher.  (B recommendation)

Mark’s Comments:

I worry often that we as a profession too easily dismiss health behavior interventions in lieu of “pills, potions, and procedures.”  Remember, it doesn’t have to be either/or, and as I watch drug prices and the cost of healthcare skyrocket, there are many who are convinced, “there must be a better way.”  Health behavioral counseling and lifestyle interventions certainly offer hope as being part of that way. 

References:

·         Mangione CM et al for the USPSTF.  Behavioral Counseling Interventions to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Disease Risk Factors: USPSTF Recommendation Statement.  JAMA 26 July 2022;328(4):367-374. Link

·         USPSTF.  Behavioral Counseling Interventions to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors.  USPSTF Recommendation Statement.  JAMA. 2020;324(20):2069-2075.  Link

·         USPSTF.  Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults.  USPSTF Recommendation Statement

JAMA. 2018;320(11):1163-1171. Link      

From the Cochrane Database of Systematic Reviews

2)  Best Interventions for Heavy Menstrual Bleeding

Heavy menstrual bleeding is a common problem in primary care – affecting 15-50% of women in their lifetimes. There are different etiologies of this condition and multiple treatments for it.

First, some terminology – the old “menorrhagia,” “menorrhea,” “dysfunctional uterine bleeding,” and other terms are not recommended. Instead, characterize the bleeding as “abnormal uterine bleeding,” and just place the appropriate adjectives in front: heavy/light, frequent/infrequent, prolonged, shortened, or irregular.

Second, the choice of interventions across different menstrual “syndromes” (like “anovulatory bleeding”) is the same, so it is of questionable utility to try to tailor the interventions to the particular syndrome.

Third, a Cochrane Collaboration review team has done us a big favor and combined the evidence from multiple Cochrane reviews into an overview of reviews and network meta-analysis to try to compare all the potential interventions against each other.

The overview of reviews looked for menstrual bleeding and patient satisfaction as the primary outcomes and quality of life, adverse events, and need for additional treatment as secondary outcomes. The review examined a number of medical, procedural, and surgical interventions after assessing the quality of the reviews.

They found nine reviews (which included 85 relevant studies and almost 10,000 patients) and even updated some of them that were over two years old. There were limitations to the evidence, mainly involving allocation concealment, blinding and other biases.

The ranking (by differences in mean blood loss) of most effective (greatest magnitude of benefit) first line treatments for heavy menstrual bleeding is:

1.    levonorgestrel intrauterine device (LNG-IUD) – low certainty evidence

2.    antifibrinolytics (tranexamic acid) – moderate certainty evidence

3.    long-cycle progestogen (depo-medroxyprogesterone) – low certainty evidence

4.    non-steroidal anti-inflammatory agents – low certainty evidence

There was not enough evidence to rank the effect of these interventions on patient satisfaction and improvement as outcomes.

The analysis of second-line therapies (surgical/procedural) revealed that hysterectomy and radiofrequency endometrial ablation (resectoscopic and non-resectoscopic) had significant benefits for mean blood loss. Minimally invasive hysterectomy and non-resectoscopic endometrial ablation increased patient satisfaction.

John’s Comments:

The above information is helpful to simply the management of abnormal uterine bleeding. I have found in my practice that IUDs are still resisted by many patients, so having a range of options for first-line management is most useful. Note that this review doesn’t address severe menstrual bleeding – resulting in significant blood loss and symptoms. That is managed differently (with close monitoring and either intravenous estrogen or surgical management).

Reference:

Bofill Rodriguez M, Dias S, Jordan V, et al. Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis. Cochrane Database Syst Rev. 2022;5:CD013180. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Knowing When to Say When With Work  

“Know When to Say When.”  Anheuser-Busch advertising campaign, celebrating its 40^th year in 2020)

Do you have a professional “Off Button”?  Over the past two decades, as I have had the opportunity to talk with many colleagues around the country in my work to help advance clinician and care team well-being, I’ve noted some recurrent themes that have emerged around the notion of our being indispensable in our work.  Colleagues have shared sentiments such as “My patients need me,” “No one else knows them like I do,”  “Who else is going to do it?  They’re all busy too,” or “There is no one else.”   That posture has often resulted in some doing work 7 days a week and taking minimal, if any, vacation – and, of course, often working during that time as well (the gift of the EHR). 

While certainly dedication and selflessness are worthy qualities, I do know that it is neither admirable nor healthy for a busy clinician to work weeks on end without a significant break.  The fact that such dedication to work is often held up as a standard both within and outside of medicine makes it even harder to break out of the superhuman myth that has been drilled into us in our training, reinforced and even rewarded in our work (“be a team player”), and that the public so badly wants to believe.  I certainly have a heavy dose of that programming running in my “professional operating system”.  

But where in our professional upbringing did we learn how to determine when we had worked “enough” – when we had done “enough?”  Who taught us to “know when to say when” when it comes to our work?!   As I reflect on this, my personal answer is “nowhere and no one.”  

A few years ago, I was introduced to the term “productivity shame.”  Productivity shame is the feeling that you’ve never done enough, and the sense of guilt and shame experienced when you try to relax, because that would be “unproductive.”  That may sound familiar.  It results from having no clear standards as to what “enough” might look like. 

So back to the original question:  Do you have a professional “Off Button”?  Do you have an internal gauge that can help determine when you’ve done “enough?”  If your answer to either or both of these questions is “no,” perhaps you should take some time to gain clarity around what professional “success” AND personal success really look like for you and how you might set reasonable work standards and goals that are in line with that.  Acting on the answers will require you to create and protect explicit boundaries.  And perhaps most importantly, you will need to share your intentions with others in your professional orbit and invite them to help hold you accountable.  For you, one of those persons could be your PeerRxMed partner. 

Over the coming weeks, consider explicitly scheduling some non-working time to determine whether you might be caught in the spell of “productivity shame” and be sure to check in with your PeerRx buddy (and colleagues) and encourage them to do the same.  Then talk about it together.  After all, to quote another famous advertising campaign, “Friends don’t let friends drive …” themselves to exhaustion and distress.  Let’s make sure we heed that wise council ourselves.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org