Clinical perspectives on the menstrual pictogram for the assessment of heavy menstrual bleeding

Abstract

Heavy menstrual bleeding (HMB) has an estimated prevalence of 18-32% but is known to be under-reported due to poor recognition and estimation of menstrual blood loss (MBL). HMB can negatively impact quality of life, affecting social interactions, work productivity and sexual life. Abnormal menstrual bleeding may have an underlying structural or systemic cause, such as endometrial and myometrial disorders; however, for some, there is no identified pathological cause. Several methods are available for assessing MBL, including the alkaline hematin (AH) method and the menstrual pictogram (MP). The AH method is considered to be the most accurate way to monitor MBL; however, it is associated with inconvenience and expense, therefore limiting its value outside of research. The MP requires the user to select an icon from a chart that reflects the appearance of a used sanitary product; the icon is associated with a blood volume that can be used to determine MBL. Validation studies have demonstrated that the results of the MP and AH method are well correlated, showing that the MP can measure MBL with sufficient accuracy. Additionally, the MP is more convenient for users, less expensive than the AH method, may be used in regions where the AH method is unavailable and may also be used as part of a digital application. Overall, the MP offers a convenient approach to monitor MBL both in research and clinical practice settings.

Keywords: abnormal uterine bleeding; alkaline hematin method; heavy menstrual bleeding; menstrual blood loss; menstrual pictogram; uterine fibroids.

Figure 1.

The revalidated menstrual pictogram. The menstrual pictogram requires women to assess their sanitary product upon changing, by selecting the image that looks the most like the underside of their sanitary product. In Magnay et al. (2014), blood loss (ml) was assigned to each pictogram: 0.5, 1.5, 4, 6.5 and 12.5 for icons 1–5 of the ‘normal’ sanitary products, 0.5, 1.5, 3.5, 6.5 and 12.5 for icons 1–5 for the ‘long’ sanitary products, and 0.5, 2, 4.5, 8 and 14 for icons 1–5 of the ‘night’ sanitary products. Reprinted with permissions from Magnay et al. (2014).

Figure 2.

Bland–Altman analysis of menstrual blood loss based on participant estimates with the menstrual pictogram versus alkaline hematin method. Bland–Altman analysis of participant revalidated menstrual pictogram (MP) estimate of menstrual blood loss (MBL) versus alkaline hematin estimate of menstrual blood loss (A) before and (B) after revision of icon blood volume, in Magnay et al. (2014). Symbol interpretation: light blue diamond = true negative; red circle = true positive; green triangle = false negative; black square = false positive. Dotted lines indicate 95% limits of agreement. Reprinted with permissions from Magnay et al. (2014).