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Epidemiology of abnormal uterine bleeding
Best Practice & Research Clinical Obstetrics and Gynaecology Vol. 21, No. 6, pp. 887–890, 2007 doi:10.1016/j.bpobgyn.2007.03.012 available online at http://www.sciencedirect.com
1 Epidemiology of abnormal uterine bleeding Manisha Palep-Singh
MD, MRCOG, DNBE
Consultant Gynaecologist and Subspecialist in Reproductive Medicine and Surgery Saint Mary’s University Hospital, CMMC NHS Trust, Manchester, M13 0JH
Andrew Prentice *
BSc, MA, MD, FRCOG
Senior Lecturer and Subspecialist in Reproductive Medicine and Surgery Addenbrookes NHS Trust and University of Cambridge, Rosie Maternity Hospital, Reproductive Medicine and Surgery, Hills Road, Cambridge CB2 2QQ, UK
Menstrual dysfunction is a common cause of referral to the gynaecology clinic, and the problem has a considerable impact on the health status and the quality of life of women. The aetiology is varied and the burden on the healthcare system continues to grow. There is an urgent need for clinicians to develop effective preventive strategies and treatment modalities that can be available to women in the community. Key words: periods; menstrual dysfunction; menorrhagia; dysmenorrhoea; epidemiology.
Abnormalities in menstruation are a common cause of general practice consultations in the primary care setting and specialist referral to the district general hospital or tertiary centre, with considerable health-service resources devoted to their management.1 It appears that some general practitioners fail to recognize a woman’s need for treatment and are slow to comply with requests for referral to a gynaecologist. This means that some women, especially from ethnic minorities, may suffer from period problems for prolonged periods of time without receiving effective health care.2 Women who report one or more menstrual symptoms have significantly lower health status and quality of life compared with women reporting no menstrual symptoms.3 It has been shown that women with heavier periods are 72% as likely to be working as women who have normal flow. Menstrual abnormalities, especially heavy periods, have significant economic implications, and work loss secondary to heavy periods has been estimated to cost $1692 per woman annually.4 * Corresponding author. Tel.: þ44 1223 245151x2227. E-mail address: [email protected] (A. Prentice) 1521-6934/$ - see front matter ª 2007 Published by Elsevier Ltd.
888 M. Palep-Singh and A. Prentice
SPECTRUM OF THE PROBLEM The spectrum of abnormal uterine bleeding comprises of menorrhagia (heavy periods; blood loss >80 mL), metrorrhagia (prolonged, irregular periods), polymenorrhoea (frequent periods), oligomenorrhoea (scanty and infrequent periods), amenorrhoea (absent menstrual periods), intermenstrual bleeding and postcoital bleeding. In a recent publication, the 12-month cumulative incidence of menorrhagia was 25% [95% confidence intervals (CI) 22–29%), metrorrhagia was 29% (95% CI 26–32%), oligomenorrhoea was 15% (95% CI 13–18%), intermenstrual bleeding was 17% (95% CI 14–19%) and postcoital bleeding was 6% (95% CI 5–8%).5 Historically, women had frequent pregnancies followed by prolonged periods of lactation, leading to lactational amenorrhoea and fewer menstrual cycles. In contrast, the modern-day woman has delayed her fertility and tends to have more periods and thereby period-related problems.
QUANTIFYING BLOOD LOSS The ancient Hindu medical texts (Ayurveda, 5000 B.C.) describe the amount of normal blood flow during menses as four ‘Anjalis’. An Anjali is the volume of fluid that can be accumulated in the hollow when one joins the two hands.6 The modern-day definition of menorrhagia is a blood loss of >80 mL. However, the 80-mL criterion of blood loss is of limited clinical usefulness. The diagnosis and treatment of patients appears to be unrelated to the volume of blood loss. Subjective judgement of the volume lost in combination with clinical features can predict a loss of >80 mL.7,8
ADOLESCENCE Menstrual problems are common during adolescence due to a relatively immature hypothalamo-pituitary-ovarian axis and can last for a couple of years after menarche. Most problems can be explained by anovulation; however, other causes must be excluded in a cost-effective and logical manner.9 A study from the USA found that 61% of admissions to hospital for adolescent menorrhagia were in adolescents with significant medical problems. Nearly 63% of adolescents required blood transfusion in view of severe anaemia. Anovulation was the predominant cause of admission (46% of cases), followed by haematological disease (33% of cases). The other causes identified were infection and chemotherapy (11% each).10 In a survey carried out in Nepal (96 school girls with an age range of 11–17 years), menorrhagia was identified in 6.2% of girls. Nearly 10% of girls gave a history of hypomenorrhoea and 6.9% had oligomenorrhoiec cycles.11 A population-based survey of 1019 girls in Sweden with a mean age of 16.7 years found that 73% of girls experienced at least one bleeding symptom and 43% had more than one symptom. Nearly 37% of girls experienced menorrhagia and one-fifth of them were being treated with drugs for this condition. A family history of menorrhagia was documented in 38% of girls and more than 50% of them suffered from heavy periods themselves.12
Epidemiology of abnormal uterine bleeding 889
REPRODUCTIVE AGE GROUP In a cross-sectional survey of 2262 women of reproductive age (18–45 years), moderateto-severe dysmenorrhoea was reported in 33.4% of participants (95% CI 31.4–35.4%). The incidence of dysmenorrhoea was 1.92 times higher in women with menorrhagia (95% CI 1.4–2.6) compared with those with normal periods.13 A postal survey of 4610 women (aged 25–44 years) in Scotland found that 30–35% of women reported menorrhagia, and one-fifth of these women felt that their periods were a problem. Reporting period problems was directly proportional to the incidence of dysmenorrhoea and heaviness of the flow.14 Menstrual irregularities such as oligomenorrhoea and secondary amenorrhoea are more common in female athletes, and have significant associations with low body fat and weight and the stress of sports activity. Ball-game players (35%) and distance runners (51%) most commonly experience oligomenorrhoea or amenorrhoea, whereas swimmers (37%) and sprinters (41%) experience dysmenorrhoea and menorrhagia. It appears that menstrual dysfunction is more common in athletes who begin training prior to menarche (43%).15 INHERITED COAGULATION DEFECTS Women with menorrhagia should be screened for inherited coagulation defects in face of a background history of paternal consanguinity, family history of bleeding diathesis and no obvious pelvic pathology.16 The most common inherited disorder in women with symptoms of menorrhagia is von Willebrand disease. The overall prevalence of the disease is 13% (95% CI 11–15.6%) and it is more prevalent in Caucasians.17 It appears that women from the Indian subcontinent with menorrhagia have a higher prevalence of inherited platelet dysfunction (83.9% of cases). The incidence of von Willebrand disease in this group of women is 11.9%, followed by factor X deficiency in 1.2% of cases and factor VII, XII and XIII deficiency in 0.3% of cases.18 CONCLUSIONS Although benign, menstrual dysfunction continues to be a huge burden on the healthcare system with varying aetiology and considerable social implications. The size of the problem is reflected by the increasing number of referrals seen in the National Health Service. Obtaining a detailed history, physical examination, laboratory investigations and imaging will help clinicians to develop effective preventive strategies and treatment modalities that can be available to women in the community.
Practice points the aetiology of menstrual dysfunction is varied. detailed history, physical examination and appropriate investigations are vital for diagnosis of the underlying pathology. develop effective preventive strategies and effective treatment modalities to manage menstrual dysfunction in the primary care setting.
890 M. Palep-Singh and A. Prentice
REFERENCES 1. Coulter A, McPherson K & Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988; 27: 987–994. 2. Chapple A. Menorrhagia: women’s perceptions of this condition and its treatment. J Adv Nurs 1999; 29: 1500–1506. 3. Barnard K, Frayne SM, Skinner KM et al. Health status among women with menstrual symptoms. J Womens Health (Larchmt) 2003; 12: 911–919. *4. Cote I, Jacobs P & Cumming D. Work loss associated with increased menstrual loss in the United States. Obstet Gynecol 2002; 100: 683–687. *5. Shapley M, Jordan K & Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract 2004; 54: 359–363. 6. Sushruta. Rajovriddhi. Sushruta Samhita, 5000 BC. *7. Warner PE, Critchley HO, Lumsden MA et al. Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. Am J Obstet Gynecol 2004; 190: 1216–1223. *8. Warner PE, Critchley HO, Lumsden MA et al. Menorrhagia II: is the 80-mL blood loss criterion useful in management of complaint of menorrhagia? Am J Obstet Gynecol 2004; 190: 1224–1229. 9. Quint EH & Smith YR. Abnormal uterine bleeding in adolescents. J Midwifery Womens Health 2003; 48: 186–191. *10. Smith YR, Quint EH & Hertzberg RB. Menorrhagia in adolescents requiring hospitalization. J Pediatr Adolesc Gynecol 1998; 11: 13–15. *11. Sharma M & Gupta S. Menstrual pattern and abnormalities in the high school girls of Dharan: a cross sectional study in two boarding schools. Nepal Med Coll J 2003; 5: 34–36. *12. Friberg B, Orno AK, Lindgren A et al. Bleeding disorders among young women: a population-based prevalence study. Acta Obstet Gynecol Scand 2006; 85: 200–206. 13. Patel V, Tanksale V, Sahasrabhojanee M et al. The burden and determinants of dysmenorrhoea: a population-based survey of 2262 women in Goa, India. Br J Obstet Gynaecol 2006; 113: 453–463. *14. Santer M, Warner P & Wyke S. A Scottish postal survey suggested that the prevailing clinical preoccupation with heavy periods does not reflect the epidemiology of reported symptoms and problems. J Clin Epidemiol 2005; 58: 1206–1210. *15. Toriola AL & Mathur DN. Menstrual dysfunction in Nigerian athletes. Br J Obstet Gynaecol 1986; 93: 979–985. 16. Trasi SA, Pathare AV, Shetty SD et al. The spectrum of bleeding disorders in women with menorrhagia: a report from Western India. Ann Hematol 2005; 84: 339–342. 17. Shankar M, Lee CA, Sabin CA et al. von Willebrand disease in women with menorrhagia: a systematic review. Br J Obstet Gynaecol 2004; 111: 734–740. *18. Saxena R, Gupta M, Gupta PK et al. Inherited bleeding disorders in Indian women with menorrhagia. Haemophilia 2003; 9: 193–196.
1 Epidemiology of abnormal uterine bleeding Manisha Palep-Singh
MD, MRCOG, DNBE
Consultant Gynaecologist and Subspecialist in Reproductive Medicine and Surgery Saint Mary’s University Hospital, CMMC NHS Trust, Manchester, M13 0JH
Andrew Prentice *
BSc, MA, MD, FRCOG
Senior Lecturer and Subspecialist in Reproductive Medicine and Surgery Addenbrookes NHS Trust and University of Cambridge, Rosie Maternity Hospital, Reproductive Medicine and Surgery, Hills Road, Cambridge CB2 2QQ, UK
Menstrual dysfunction is a common cause of referral to the gynaecology clinic, and the problem has a considerable impact on the health status and the quality of life of women. The aetiology is varied and the burden on the healthcare system continues to grow. There is an urgent need for clinicians to develop effective preventive strategies and treatment modalities that can be available to women in the community. Key words: periods; menstrual dysfunction; menorrhagia; dysmenorrhoea; epidemiology.
Abnormalities in menstruation are a common cause of general practice consultations in the primary care setting and specialist referral to the district general hospital or tertiary centre, with considerable health-service resources devoted to their management.1 It appears that some general practitioners fail to recognize a woman’s need for treatment and are slow to comply with requests for referral to a gynaecologist. This means that some women, especially from ethnic minorities, may suffer from period problems for prolonged periods of time without receiving effective health care.2 Women who report one or more menstrual symptoms have significantly lower health status and quality of life compared with women reporting no menstrual symptoms.3 It has been shown that women with heavier periods are 72% as likely to be working as women who have normal flow. Menstrual abnormalities, especially heavy periods, have significant economic implications, and work loss secondary to heavy periods has been estimated to cost $1692 per woman annually.4 * Corresponding author. Tel.: þ44 1223 245151x2227. E-mail address: [email protected] (A. Prentice) 1521-6934/$ - see front matter ª 2007 Published by Elsevier Ltd.
888 M. Palep-Singh and A. Prentice
SPECTRUM OF THE PROBLEM The spectrum of abnormal uterine bleeding comprises of menorrhagia (heavy periods; blood loss >80 mL), metrorrhagia (prolonged, irregular periods), polymenorrhoea (frequent periods), oligomenorrhoea (scanty and infrequent periods), amenorrhoea (absent menstrual periods), intermenstrual bleeding and postcoital bleeding. In a recent publication, the 12-month cumulative incidence of menorrhagia was 25% [95% confidence intervals (CI) 22–29%), metrorrhagia was 29% (95% CI 26–32%), oligomenorrhoea was 15% (95% CI 13–18%), intermenstrual bleeding was 17% (95% CI 14–19%) and postcoital bleeding was 6% (95% CI 5–8%).5 Historically, women had frequent pregnancies followed by prolonged periods of lactation, leading to lactational amenorrhoea and fewer menstrual cycles. In contrast, the modern-day woman has delayed her fertility and tends to have more periods and thereby period-related problems.
QUANTIFYING BLOOD LOSS The ancient Hindu medical texts (Ayurveda, 5000 B.C.) describe the amount of normal blood flow during menses as four ‘Anjalis’. An Anjali is the volume of fluid that can be accumulated in the hollow when one joins the two hands.6 The modern-day definition of menorrhagia is a blood loss of >80 mL. However, the 80-mL criterion of blood loss is of limited clinical usefulness. The diagnosis and treatment of patients appears to be unrelated to the volume of blood loss. Subjective judgement of the volume lost in combination with clinical features can predict a loss of >80 mL.7,8
ADOLESCENCE Menstrual problems are common during adolescence due to a relatively immature hypothalamo-pituitary-ovarian axis and can last for a couple of years after menarche. Most problems can be explained by anovulation; however, other causes must be excluded in a cost-effective and logical manner.9 A study from the USA found that 61% of admissions to hospital for adolescent menorrhagia were in adolescents with significant medical problems. Nearly 63% of adolescents required blood transfusion in view of severe anaemia. Anovulation was the predominant cause of admission (46% of cases), followed by haematological disease (33% of cases). The other causes identified were infection and chemotherapy (11% each).10 In a survey carried out in Nepal (96 school girls with an age range of 11–17 years), menorrhagia was identified in 6.2% of girls. Nearly 10% of girls gave a history of hypomenorrhoea and 6.9% had oligomenorrhoiec cycles.11 A population-based survey of 1019 girls in Sweden with a mean age of 16.7 years found that 73% of girls experienced at least one bleeding symptom and 43% had more than one symptom. Nearly 37% of girls experienced menorrhagia and one-fifth of them were being treated with drugs for this condition. A family history of menorrhagia was documented in 38% of girls and more than 50% of them suffered from heavy periods themselves.12
Epidemiology of abnormal uterine bleeding 889
REPRODUCTIVE AGE GROUP In a cross-sectional survey of 2262 women of reproductive age (18–45 years), moderateto-severe dysmenorrhoea was reported in 33.4% of participants (95% CI 31.4–35.4%). The incidence of dysmenorrhoea was 1.92 times higher in women with menorrhagia (95% CI 1.4–2.6) compared with those with normal periods.13 A postal survey of 4610 women (aged 25–44 years) in Scotland found that 30–35% of women reported menorrhagia, and one-fifth of these women felt that their periods were a problem. Reporting period problems was directly proportional to the incidence of dysmenorrhoea and heaviness of the flow.14 Menstrual irregularities such as oligomenorrhoea and secondary amenorrhoea are more common in female athletes, and have significant associations with low body fat and weight and the stress of sports activity. Ball-game players (35%) and distance runners (51%) most commonly experience oligomenorrhoea or amenorrhoea, whereas swimmers (37%) and sprinters (41%) experience dysmenorrhoea and menorrhagia. It appears that menstrual dysfunction is more common in athletes who begin training prior to menarche (43%).15 INHERITED COAGULATION DEFECTS Women with menorrhagia should be screened for inherited coagulation defects in face of a background history of paternal consanguinity, family history of bleeding diathesis and no obvious pelvic pathology.16 The most common inherited disorder in women with symptoms of menorrhagia is von Willebrand disease. The overall prevalence of the disease is 13% (95% CI 11–15.6%) and it is more prevalent in Caucasians.17 It appears that women from the Indian subcontinent with menorrhagia have a higher prevalence of inherited platelet dysfunction (83.9% of cases). The incidence of von Willebrand disease in this group of women is 11.9%, followed by factor X deficiency in 1.2% of cases and factor VII, XII and XIII deficiency in 0.3% of cases.18 CONCLUSIONS Although benign, menstrual dysfunction continues to be a huge burden on the healthcare system with varying aetiology and considerable social implications. The size of the problem is reflected by the increasing number of referrals seen in the National Health Service. Obtaining a detailed history, physical examination, laboratory investigations and imaging will help clinicians to develop effective preventive strategies and treatment modalities that can be available to women in the community.
Practice points the aetiology of menstrual dysfunction is varied. detailed history, physical examination and appropriate investigations are vital for diagnosis of the underlying pathology. develop effective preventive strategies and effective treatment modalities to manage menstrual dysfunction in the primary care setting.
890 M. Palep-Singh and A. Prentice
REFERENCES 1. Coulter A, McPherson K & Vessey M. Do British women undergo too many or too few hysterectomies? Soc Sci Med 1988; 27: 987–994. 2. Chapple A. Menorrhagia: women’s perceptions of this condition and its treatment. J Adv Nurs 1999; 29: 1500–1506. 3. Barnard K, Frayne SM, Skinner KM et al. Health status among women with menstrual symptoms. J Womens Health (Larchmt) 2003; 12: 911–919. *4. Cote I, Jacobs P & Cumming D. Work loss associated with increased menstrual loss in the United States. Obstet Gynecol 2002; 100: 683–687. *5. Shapley M, Jordan K & Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract 2004; 54: 359–363. 6. Sushruta. Rajovriddhi. Sushruta Samhita, 5000 BC. *7. Warner PE, Critchley HO, Lumsden MA et al. Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. Am J Obstet Gynecol 2004; 190: 1216–1223. *8. Warner PE, Critchley HO, Lumsden MA et al. Menorrhagia II: is the 80-mL blood loss criterion useful in management of complaint of menorrhagia? Am J Obstet Gynecol 2004; 190: 1224–1229. 9. Quint EH & Smith YR. Abnormal uterine bleeding in adolescents. J Midwifery Womens Health 2003; 48: 186–191. *10. Smith YR, Quint EH & Hertzberg RB. Menorrhagia in adolescents requiring hospitalization. J Pediatr Adolesc Gynecol 1998; 11: 13–15. *11. Sharma M & Gupta S. Menstrual pattern and abnormalities in the high school girls of Dharan: a cross sectional study in two boarding schools. Nepal Med Coll J 2003; 5: 34–36. *12. Friberg B, Orno AK, Lindgren A et al. Bleeding disorders among young women: a population-based prevalence study. Acta Obstet Gynecol Scand 2006; 85: 200–206. 13. Patel V, Tanksale V, Sahasrabhojanee M et al. The burden and determinants of dysmenorrhoea: a population-based survey of 2262 women in Goa, India. Br J Obstet Gynaecol 2006; 113: 453–463. *14. Santer M, Warner P & Wyke S. A Scottish postal survey suggested that the prevailing clinical preoccupation with heavy periods does not reflect the epidemiology of reported symptoms and problems. J Clin Epidemiol 2005; 58: 1206–1210. *15. Toriola AL & Mathur DN. Menstrual dysfunction in Nigerian athletes. Br J Obstet Gynaecol 1986; 93: 979–985. 16. Trasi SA, Pathare AV, Shetty SD et al. The spectrum of bleeding disorders in women with menorrhagia: a report from Western India. Ann Hematol 2005; 84: 339–342. 17. Shankar M, Lee CA, Sabin CA et al. von Willebrand disease in women with menorrhagia: a systematic review. Br J Obstet Gynaecol 2004; 111: 734–740. *18. Saxena R, Gupta M, Gupta PK et al. Inherited bleeding disorders in Indian women with menorrhagia. Haemophilia 2003; 9: 193–196.