Prevalence of heavy menstrual bleeding and associations with physical health and wellbeing in low-income and middle-income countries: a multinational cross-sectional study

The Association Between Menstrual Disorders and Workforce Participation: A Prospective Longitudinal Study

OBJECTIVE

To assess the association between menstrual disorders and workforce participation among Australian women.

DESIGN

Population-based cohort study.

SETTING

Secondary analysis of eight surveys collected between 2000 and 2021.

POPULATION

A total of 11 152 Australian women, born between 1973 and 1978.

METHODS

Between 2000 and 2021, self-reported longitudinal survey data were collected. At each survey, menstrual disorders and workforce participation were measured. Data were analysed using generalised estimating equations for multinomial responses, with stratification by age.

MAIN OUTCOME MEASURES

Workforce participation.

RESULTS

Women who often experienced premenstrual tension reported lower odds of working part-time compared to full-time work (Adjusted Odds Ratio (AOR) = 0.74; 95% CI: 0.61, 0.90), with this finding strongest among women aged 31 to 40 (AOR = 0.68, 95% CI: 0.59, 0.78). While overall, women who often experienced irregular periods had higher odds of working part-time compared to full-time (AOR = 1.32, 95% CI: 1.08, 1.61), women aged 22 to 30 had lower odds of working part-time (AOR = 0.61, 95% CI: 0.39, 0.97). Women who experienced severe period pain had higher odds of being unemployed compared to working full-time (AOR = 1.18; 95% CI: 1.01, 1.36), with this association strongest in women aged 41 and older (AOR = 1.19, 95% CI: 1.01, 1.40).

CONCLUSIONS

There is substantial variation in the association between menstrual disorders and workforce participation, and the role of women's ages in these associations. Increased awareness of and further elucidation of these factors may improve women's engagement in the workforce.

Thyroid and reproductive hormonal factors associated with menorrhagia among women in Kenya

Background

Menorrhagia, characterised by menstrual blood loss exceeding 80 mL per cycle, is a common issue in Western Kenya. However, there are insufficient data on how hormonal disorders contribute to its occurrence.

Objective

This study aimed to examine the differences and associations between thyroid and reproductive hormone levels in women with menorrhagia versus those without, in Bungoma County, Kenya.

Methods

A comparative cross-sectional study was conducted among 428 women (214 with menorrhagia and 214 controls) aged 18-45 years, between 01 December 2022 and 31 September 2023 at Bungoma County Referral Hospital. The analysis included thyroid stimulating hormone, total and free triiodothyronine, thyroxine, follicle stimulating hormone (FSH), luteinising hormone, prolactin, oestrogen, progesterone, and testosterone.

Results

Women experiencing menorrhagia had statistically significant increases in levels of FSH (p < 0.0001), oestrogen (p < 0.001), and total testosterone (p < 0.001), while prolactin levels had a statistically significant decrease (p < 0.001) compared to those without menorrhagia. There were no statistically significant differences in total triiodothyronine (p = 0.384), free triiodothyronine (p = 0.610), total thyroxine (p = 0.127), free thyroxine (p = 0.360), or thyroid stimulating (p = 0.118). No associations were found between menorrhagia and either thyroid or reproductive hormones.

Conclusion

Elevated levels of FSH, oestrogen, and testosterone, along with reduced prolactin, may serve as potential biomarkers for diagnosing menorrhagia in premenopausal or reproductively aged women. A screening tool that integrates these hormonal markers could improve the accuracy of diagnosis and optimise treatment strategies in primary healthcare settings.

What this study adds

The study suggests that levels of FSH, oestrogen, total testosterone, and prolactin differ significantly between women with and without menorrhagia, indicating their potential use in predicting the condition.

Epidemiology of menstrual-related absenteeism in 44 low-income and middle-income countries: a cross-sectional analysis of Multiple Indicator Cluster Surveys

BACKGROUND

Menstrual-related absenteeism from work, school, or social activities is an important functional indicator of poor menstrual health that disrupts women's and girls' daily lives and exacerbates gender inequality. We sought to estimate the prevalence of and factors contributing to menstrual-related absenteeism across low-income and middle-income countries.

METHODS

We analysed cross-sectional data from 47 nationally or subnationally representative Multiple Indicator Cluster Surveys from 2017 to 2023, which comprised 3 193 042 individuals from 555 869 households across 44 countries; those with available information on the outcome of interest were included in our analysis. The outcome of interest was menstrual-related absenteeism from work, school, or social activities during the respondent's last menstrual period. Independent factors included age, household wealth index, use (vs no use) of menstrual materials (eg, pads, tampons, or cloth), availability of a private place to wash at home during menstruation, and contraceptive use (hormonal and other). Univariable and multivariable associations between each factor and menstrual-related absenteeism were analysed using log-binomial models. Prevalence ratios, estimated from the log-binomial models, represent the relative prevalence of menstrual-related absenteeism across different levels of the independent variables. Prevalences and associations were pooled by geographical region and overall across all surveys using a random-effects meta-analysis. Heterogeneity was assessed using the I2 statistic, and prediction intervals generated to reflect the variation in associations.

FINDINGS

We included 673 380 women and girls aged 15-49 years in this analysis. The overall pooled prevalence of menstrual-related absenteeism was 15·0% (95% CI 12·7-17·3), with prevalence being highest in south Asia (19·7% [11·6-27·8]) and west and central Africa (18·5% [13·5-23·5]). After pooling data across surveys, girls aged 15-19 years were found to have a higher prevalence of menstrual-related absenteeism than those in older age groups, with overall pooled prevalence ratios ranging from 0·75 (0·68-0·82) in those aged 35-39 years to 0·92 (0·87-0·97) in those aged 20-24 years relative to the 15-19 years age group, with adjustment for area type (urban or rural). There was no association between menstrual-related absenteeism and household wealth or the use of menstrual materials. By contrast, having a private place to wash at home was associated with an increased prevalence of menstrual-related absenteeism (overall pooled prevalence ratio 1·25 [1·05-1·48], adjusted for wealth and area type). Menstrual-related absenteeism was less prevalent in women and girls using any contraceptives compared with those not using contraceptives (0·92 [0·87-0·96]), and for those using hormonal contraceptives compared with those using non-hormonal or no contraceptives (0·91 [0·84-0·99]), after adjusting for age, wealth, education level, parity, and area type.

INTERPRETATION

Menstrual-related absenteeism is prevalent, especially in Asia and Africa and among adolescent girls. The age-independent protective effect of hormonal contraceptive use suggests that symptoms such as heavy menstrual bleeding or pain contribute to absenteeism. Future studies are urgently needed to better characterise these findings to inform relevant public health interventions.

FUNDING

National Health and Medical Research Council, Australia.

Linguistic Validation of a British-English Version of the SAMANTA Questionnaire and HMB-VAS Tool: A Step Toward Improved Diagnosis of Heavy Menstrual Bleeding

Background

Heavy menstrual bleeding (HMB) is a common disorder interfering with physical, emotional and social domains, and overall quality of life (QoL). The Heavy Menstrual Bleeding-Visual Analog Scale (HMB-VAS) tool, including the VAS for menstrual bleeding intensity (VAS-Int) and the VAS for its interference with daily activities (VAS-Imp), is useful for HMB screening. The SAMANTA questionnaire (SAMANTA-Q) was developed and psychometrically validated in Spanish to easily identify women with HMB. However, these instruments have not been validated in other languages. This study seeks to linguistically validate the SAMANTA-Q and the HMB-VAS tool in British English.

Methods

Linguistic validation was conducted following the principles laid out by the International Society for Health Economics and Outcomes Research (ISPOR). This process included two forward translations by two independent native English-speakers; reconciled version; two backward translations by two independent native Spanish-speakers; review and reconciliation; 60-minute cognitive debriefing interviews with women with HMB balanced by educational levels; analysis and integration of changes in the reconciled version; proofreading, and creation of the final version.

Results

No major issues were found in the linguistic validation process. Overall, cognitive debriefing participants with HMB considered that the SAMANTA-Q and the HMB-VAS tool were easy to read, comprehensive, quick to answer, and covered most of the issues related to HMB.

Conclusions

Linguistically validated British-English versions of the SAMANTA-Q and HMB-VAS tool are now available for clinical practice and research. These validated tools will be useful to easily diagnose excessive menstrual blood loss impacting on QoL.

Knowledge and attitudes on anemia and menstrual health among Malaysian female university students

Anemia is a significant public health concern, particularly among young female adults due to its potential impact on reproductive health. This study investigated the association between anemia-related knowledge, attitudes, menstrual health, and anemia status among Malaysian university students. This was a cross-sectional study named "SCARF" - Study to Combat Anemia - Research for Female Students, involving 674 university students in Malaysia. Anemia status was determined based on haemoglobin level, while knowledge, attitude and menstrual health were measured using validated questionnaires. The mean menarche age of students in this study was 12.1 ± 1.21 years. Students who were anemic had significantly longer menstrual cycle duration (P = 0.034) and more days with heavy flow (P = 0.038). Most students had poor knowledge (44.5%) and attitudes (84.1%) towards anemia. Students with good knowledge were 1.1 times more likely to have better anemia status compared to those with poor knowledge (95% CI: 1.0-1.2, P = 0.049). This study highlighted a lack of practical application of the knowledge to dietary habits. Collaborative efforts between educators and healthcare providers are crucial in developing a comprehensive strategy, such as interventions to prioritise educational initiatives and practical support to enhance overall menstrual health among female students.

Recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia

Iron is an essential nutrient and a constituent of ferroproteins and enzymes crucial for human life. Generally, nonmenstruating individuals preserve iron very efficiently, losing less than 0.1% of their body iron content each day, an amount that is replaced through dietary iron absorption. Most of the iron is in the hemoglobin (Hb) of red blood cells (RBCs); thus, blood loss is the most common cause of acute iron depletion and anemia worldwide, and reduced hemoglobin synthesis and anemia are the most common consequences of low plasma iron concentrations. The term iron deficiency (ID) refers to the reduction of total body iron stores due to impaired nutrition, reduced absorption secondary to gastrointestinal conditions, increased blood loss, and increased needs as in pregnancy. Iron deficiency anemia (IDA) is defined as low Hb or hematocrit associated with microcytic and hypochromic erythrocytes and low RBC count due to iron deficiency. IDA most commonly affects women of reproductive age, the developing fetus, children, patients with chronic and inflammatory diseases, and the elderly. IDA is the most frequent hematological disorder in children, with an incidence in industrialized countries of 20.1% between 0 and 4 years of age and 5.9% between 5 and 14 years (39% and 48.1% in developing countries). The diagnosis, management, and treatment of patients with ID and IDA change depending on age and gender and during pregnancy. We herein summarize what is known about the diagnosis, treatment, and prevention of ID and IDA and formulate a specific set of recommendations on this topic.

Adequate menstrual suppression in adolescents with inherited bleeding disorders often requires multiple treatment changes: Retrospective cohort study of a multidisciplinary clinic

Heavy menstrual bleeding (HMB) is often the presenting symptom for females with inherited bleeding disorders (IBD). Multidisciplinary clinics leverage the expertise of hematologists and women's health specialists. This study characterizes the complexity of HMB management for adolescents with IBDs from a large multidisciplinary clinic. Adolescents often required multiple different menstrual suppression treatments, with only about 20% achieving acceptable suppression with their first treatment. Adolescents switched therapy most often for uncontrolled bleeding, followed by adverse effects, and patient preference. Given the difficulty in achieving adequate menstrual suppression, multidisciplinary clinics offer necessary expertise in accomplishing bleeding control with minimal adverse effects.