Why you need to ask your patients about heavy menstrual bleeding

Dr Jacqueline Maybin from the University of Edinburgh's Centre for Reproductive Health said one in three women experience heavy menstrual bleeding but often it is normalised or overlooked.

She defines heavy menstrual bleeding as blood loss of more than 80mls per cycle, which if experienced regularly would cause iron deficiency. On top of that, it can significantly impact quality of life.

In Australia, in accordance with the Australian Commission on Safety and Quality in Health Care Clinical Standards, heavy menstrual bleeding is not defined by a specific amount it is based on a person-centred approach to what excessive menstrual blood loss looks like to an individual patient.

“Less than 10% of healthcare professionals will ever ask about menstruation,” Dr Maybin told Medical Forum.

“It should be treated like pulse, blood pressure, temperature and menstrual parameters,” she said.

"Quite often women normalise or feel dismissed if they have heavy menstrual bleeding but when people are directly asked, one in three women will report it. If you compare that to other conditions, that’s 10 times the rate of asthma or diabetes in the same population," she said.

“It can lead to iron deficiency - up to 50% of reproductive aged women are iron deficient - even in higher resourced settings, with much of that due to heavy menstrual bleeding."

She said it was often undiagnosed, under treated and can cause significant health problems. It can also cause people to miss school, work and compromise their mental health.

Dr Maybin is in Perth to give a keynote speech at the Women and Infant Research Foundation’s Scientific Dialogue event on August 28.

She is also a program director for The Missed Vital Sign program, which is working to develop tools to robustly identify women at risk of iron deficiency due to menstruation.

Those involved in The Missed Vital Sign program are aiming to bring the average time it takes for women to get effective treatment for heavy menstrual bleeding down from the current five years to five months.

Dr Maybin said just 50% of women who experience it seek help and only about 8% of ever get proper testing or treatment.

As well as there still being a taboo in society around talking about menstrual bleeding, she said there can be a stoicism from some women.

Dr Maybin also referred to UK research which found that 84% of women felt dismissed when they raised the topic with a primary health care professional.

“I believe that dismissal comes from the fact it is very difficult for both women and healthcare professionals to quantify the volume of bleeding that a woman is experiencing," she said.

“There is a real lack of tools to identify heavy menstrual bleeding that are robust and quantitative and there is problems with diagnostics and new treatments that are specific for women.

"Alongside improved education, there is a need to develop the tools required to do this properly. When you compare it to something like diabetes, GPs don't dismiss blood glucose results. I think if we have those kind of tools for gynaecological problems that dismissal will be fixed."

She said work was ongoing to develop those tools but until then GPs could encourage the use of apps to summarise menstrual parameters and have conversations with women about their bleeding.

"Asking about how often they have to change pads, whether they are passing large blood clots and how many days they are bleeding for can be very informative to a diagnosis, as well as listening to the impact on someone's day to day life," she said.

"If someone is telling a GP their blood loss is too heavy for their life, considering treatment is a good idea."

Dr Maybin encouraged GPs to consider checking ferritin levels and a top up of iron if they are low.

"Quite often women will compensate for having an increased blood loss and their haemoglobin levels will be maintained, but its their ferritin and iron stores that are depleting," she said.

While iron tablets can be of use, in many cases treatment should be considered.

The contraceptive pill and hormone intrauterine devices can be used as treatments as well as tranexamic acid and hormonal preparations, Dr Maybin said.

Researchers are currently working on non-hormonal treatments that women can use at the time of menstruation.

Dr Maybin's recent research, which compiled a list of the Top 10 Research Priorities for Problematic Menstrual Bleeding in the UK with input from both experts in the field and those with lived experience, was published in the The Lancet Obstetrics, Gynaecology & Women’s Health earlier in August.