The National Institute for Health and Care Excellence defines heavy menstrual bleeding (HMB) as excessive menstrual blood loss that interferes with the woman’s physical, emotional, social and material quality of life and can occur in combination with other symptoms. The menstrual blood loss that occurs is >80ml.1

There are various methods of collecting and measuring blood loss which include extracting blood from sanitary pads, and tampons which is often difficult, or assessing the amount of blood on sanitary pads and tampons using a pictorial blood loss assessment chart (PBAC). Another way to determine the amount of loss is by measuring the fluid loss by weighting the sanitary products before and after use.1

One of the most important signs and symptoms of HMB include changing the tampon or the pad more frequently than hourly. It also leads to clot sizes of >1 inch in diameter.2 HMB has a significant impact on a woman’s quality of life, for instance, it may lead to inability to work. HMB has a substantial impact on a woman’s physical, social, psychological, professional, and family aspects. It may lead to the inability to leave home because of the amount of blood lost, reduced productivity at work because of the need to change pads and tampons frequently, and limited social engagements out of concern about staining outer clothing with blood.1

Development of a screening instrument was carried out that could be used by women’s healthcare practitioners to determine the presence of a bleeding issue. There are four characteristics that were suggestive of a bleeding problem along with HMB.2

• Duration of menses of ≥7 days and flooding (a change of pad or tampon more frequently than in an hour) or impairment of daily activities with most periods
• Family history of a diagnosed bleeding disorder
• History of treatment of anemia
• History of excessive bleeding with tooth extraction, delivery or miscarriage, or surgery

While the above-mentioned screening tool had a sensitivity of 82%, adding a pictorial blood assessment chart score of >100, increased its sensitivity to 95%.2 A pictorial blood assessment chart uses pictograms of pads and tampons that have been soiled to various degrees as a way to quantify blood loss. The user keeps track of how many products have been used in relation to each pictogram.3 

Physical examination of women having HMB may reveal a cervical polyp (a small growth on cervix), intrauterine fibroid (growth made up of muscle and fibrous tissue in uterus) or malignancy (a cancerous tumour that can spread).4 This may be supported by the presence of abnormalities such as polyps and fibroids detected via imagining tests done on the uterine muscle. Transvaginal ultrasound tests can also be used as support to detect the presence of fibroids, polyps etc.4

Overall, HMB, which can be also known as menorrhagia affects up to 46% of the women with bleeding disorders.5 Several tests need to be carried out to determine what the cause behind HMB. Each patient should have a treatment plan that is specifically designed for them after an in-depth assessment of the clinical findings and their relevance to the involved bleeding pattern.1,2

References:

1. Sriprasert I, Pakrashi T, Kimble T, et al. Heavy menstrual bleeding diagnosis and medical management. Contracept Reprod Med. 2017;2:20.
2. James AH. Heavy menstrual bleeding: work-up and management. Hematology Am Soc Hematol Educ Program. 2016;2016(1):236-42.
3. Spence M, de Repentigny K, Bowman M, et al. Validation of the pictorial blood loss assessment chart using modern sanitary products. Haemophilia. 2021;27(5):e632-5.
4. Herman MC, Mol BW, Bongers MY. Diagnosis of heavy menstrual bleeding. Womens Health (Lond). 2016;12(1):15-20.
5. Laksham KB, Selvaraj R, Kar SS. Menstrual disorders and quality of life of women in an urban area of Puducherry: a community-based cross-sectional study. J Family Med Prim Care. 2019;8(1):137-40.