A scoping review on heavy menstrual bleeding and anemia: A less explored phenomenon.

Anemia is a significant public health problem globally. It affects 1.9 billion individuals across the world and disproportionately affects adolescent girls and women of reproductive age group.[ 1 ] In the recent document “Accelerating Anemia Reduction: A Complex Framework for Action,”[ 2 ] the World Health Organization (WHO) has, for the first time, recognized “Gynecological and Obstetric Conditions” as one of the direct causes of anemia. The lack of access to family planning and maternal and child care is highlighted as an immediate risk factor, and managing heavy menstrual bleeding is stated to be prioritized as part of key preventive and therapeutic interventions.[ 2 ] Heavy menstrual bleeding (HMB) also known as menorrhagia is a neglected public health problem. HMB accounts for 18-30% of the gynecologic visit in the United States[ 3 ] and other developed countries. In developing countries, like India, HMB is the leading cause of hysterectomy.[ 4 ] HMB is commonly characterized as menstruation with excessive flow (greater than 80 mL of blood loss per cycle or requiring more frequent than 2-hour changes of hygiene products) and/or duration (longer than 7 days).[ 5 ] Clinically, it is also defined as “excessive menstrual blood loss which interferes with a woman’s physical, emotional, social, or material quality of life.”[ 6 ] Iron metabolism is a tightly regulated process without an active excretion mechanism. Iron deficiency anemia primarily arises from decreased intake of iron in the diet, poor absorption, and chronic blood loss. Heavy menstrual bleeding is an important causative factor of chronic blood loss in women; hence, it is an important risk factor of iron deficiency anemia in women affected by the condition.[ 7 8 ] The Government of India launched the Anemia Mukt Bharat program in 2018 to mitigate the problem of anemia by acting on it comprehensively. The strategy of the program is “6 × 6 × 6,” which is six beneficiaries, six interventions, and six institutional mechanisms. The six interventions are as follows: a) prophylactic iron folic acid supplementation, b) deworming, c) intensified year-round behavior change communication and delayed cord clamping, d) testing of anemia using digital methods with point of care treatment, e) mandatory provision of iron fortified foods through public health program, and f) addressing non-nutritional causes of anemia with special focus on malaria, fluorosis, and hemoglobinopathies in endemic pockets. The AMB program currently does not screen and treat for heavy menstrual bleeding in women diagnosed with anemia. However, the stagnation in the decline of anemia prevalence (as shown in National Family Health Survey data[ 9 ]) [ Figure 1 ] suggests the need to consider this overlooked cause of anemia. Anemia prevalence in all women aged 15−49 yr (NFHS 3 to 5) We undertook a scoping review to compile the existing literature on the burden of heavy menstrual bleeding (HMB) and its association with anemia. We also identified and summarized the effect of HMB on the quality of life of affected women and reviewed available interventions for the management of HMB, and explored national health programs focusing on HMB for anemia prevention and control, particularly Anemia Mukt Bharat.

This scoping review adheres to the PRISMA-ScR (Preferred Reporting Items for Scoping Reviews. A literature search was conducted on databases of PubMed, Google Scholar, and Scopus to identify studies published in English from 2000 to 2024. The search strategy included a broad combination of Medical Subject Headings (MeSH) and keywords related to “heavy menstrual bleeding,” “menorrhagia,” “anemia,” “iron deficiency,” “management of HMB,” “public health interventions,” “quality of life.” The search was flexible, and studies were selected if they provided insights into the burden, consequences, and management of HMB in relation to anemia. Articles focusing on “coagulopathies” and “uterine disorder” were not included unless they contributed to the main theme of HMB and anemia. The search resulted in 4,500 articles, which was further made specific by adding filters of “NOT Coagulopathy”; “NOT uterine disorders,” which finally resulted in a total of 49 articles. After removing the duplicates,[ 10 ] 39 studies were included for review. The selected articles and their reference list were scanned. The full text of the shortlisted articles was accessed and studied. Quantitative, qualitative, and mixed methods studies, along with important policy documents, were included. The findings were mapped and summarized to provide an overview of existing evidence, identify gaps in research, and highlight implications for anemia control programs.

The prevalence of heavy menstrual bleeding varies globally, with estimates ranging widely in different study populations, study settings, and methodological approaches. In studies available from India, a high burden of HMB along with significant variation across states is reported. A systematic review by Pouralirodbaneh et al .[ 6 ] reported the prevalence of HMB between 4% and 63% (in Egypt and Morocco, respectively). The wide variation in the prevalence was attributed to substantial heterogeneity in diagnostic criteria and population characteristics. Sinharoy et al .[ 12 ] reported prevalence of HMB as 42.0% (Tiruchirapalli); 46.7% (Warangal); 44.9% (Narsapur), India; and 48.6% globally in adult menstruating women using the SAMANTA scale. The prevalence of HMB as reported in various studies is summarized in Table 1 . Summarizes the prevalence of heavy menstrual bleeding according to studies[ 6 11 12 13 14 15 16 17 18 ] Heavy menstrual bleeding (HMB) is now included in the International Federation of Gynecology and Obstetrics (FIGO) terminology of “Abnormal Uterine Bleeding.” The etiology of abnormal uterine bleeding is classified by FIGO as “PALM-COEIN”: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not yet classified.[ 19 ] The causes of HMB vary in different age groups and are broadly classified in Table 2 . In adolescents, the nonstructural causes of heavy menstrual bleeding are common. Anovulation due to an immature hypothalamic-pituitary ovarian axis is the leading cause in this age group. Bleeding disorders (approximately 20% of all adolescent females suffering from HMB have coagulopathies) are the second leading cause of HMB in this age group.[ 19 20 21 ] Common causes of HMB in different age group[ 9 10 11 12 13 ] In the women of reproductive age group, the common causes of HMB include fibroids, adenomyosis, intrauterine devices, and polyps.[ 19 22 ] However, in perimenopausal women, the most common reported causes are endometrial hyperplasia and carcinoma.[ 23 ] HMB is the most common cause of iron deficiency anemia (IDA) among women of reproductive age group in developed countries.[ 7 ] Iron deficiency with and without anemia is a common finding in young women with heavy menstrual bleeding.[ 24 ] A survey conducted among European women aged 18-57 yr revealed that 63.0% of women suffering from HMB were diagnosed with iron deficiency anemia.[ 25 ] Several studies have reported a significant association between decreased hemoglobin and ferritin levels and increased menstrual blood loss.[ 15 26 ] Nelson et al .[ 27 ] reported 86.3% of women suffering from heavy menstrual bleeding were found to have abnormally low levels of ferritin. Dugan et al .[ 28 ] and Bernardi et al .[ 29 ] reported significantly higher prevalence of heavy menstrual bleeding in women with a history of anemia and iron deficiency [ Table 3 ]. Studies reporting association between heavy menstrual bleeding and anemia[ 15 25 26 27 28 29 30 ] Heavy menstrual bleeding along with iron deficiency have significant clinical and economic consequences that are experienced by the individual, her family, the healthcare system, and society. The coexistence of heavy menstrual bleeding and iron deficiency, with or without concurrent anemia, has a detrimental impact on an individual’s quality of life.[ 4 ] Studies revealed that heavy menstrual bleeding negatively impacts physical and social functioning, leading to reduced quality of life. A multicentric study revealed a WHO-5 well-being index score of 63.0 ± 26.7 among female participants suffering from heavy menstrual bleeding.[ 6 ] HMB also contributes to work impairment, increased work-related expenses, and strained marital relationships. Those with heavy menstrual bleeding tend to utilize more protective hygiene products and report staining of household items, as well as disruptions to their daily routines and significant inconveniences in their lives. Studies have found that women with heavy menstrual bleeding experience a significantly lower quality of life, as measured by validated patient-reported instruments such as the 36-Item Short Form survey.[ 31 32 33 34 35 ] According to a study conducted in the United States, women with heavy menstrual bleeding experienced an annual loss of $1,692 per individual due to work absences related to their increased menstrual blood flow. Additionally, women with a heavier menstrual flow were 72% as likely to be employed compared to those with a lighter or normal flow [ Table 4 ].[ 36 ] Effect of HMB on productivity and quality of life[ 31 32 34 35 36 38 39 ] Heavy menstrual bleeding results in iron depletion and consequent iron-deficiency anemia[ 37 ] as the amount of iron lost per cycle in women with heavy bleeding averages 5-6 times more than in women with normal blood loss thereby indirectly causing fatigue, lethargy, breathlessness, cognitive dysfunction, and severe anemia.[ 27 ] Treatment of Iron Deficiency Anemia : Oral and parenteral iron preparations are the choice of treatment for iron deficiency anemia induced by heavy menstrual bleeding. Dietary interventions alone have a minimal role.[ 40 ] Parenteral iron may be used as a substitute for blood transfusion in the treatment of severe anemia in women suffering from HMB with cardiac decompensation.[ 41 42 43 ] Treatment of Heavy Menstrual Bleeding : Heavy menstrual bleeding is treated adequately by medical or surgical intervention. The hormonal contraceptives, in particular levonorgestrel-releasing intrauterine hormonal devices (LARCS—long-acting reversible contraception), are reported to have significant noncontraceptive benefits of reducing menstrual bleeding and dysmenorrhea in women suffering from HMB.[ 44 ] Bellizi et al .[ 45 ] reported a reduced risk of anemia (OR = 0.56) in women using oral contraceptives for at least 6 months [ Table 5 ]. Treatment of Iron Deficiency Anemia : Oral and parenteral iron preparations are the choice of treatment for iron deficiency anemia induced by heavy menstrual bleeding. Dietary interventions alone have a minimal role.[ 40 ] Parenteral iron may be used as a substitute for blood transfusion in the treatment of severe anemia in women suffering from HMB with cardiac decompensation.[ 41 42 43 ] Treatment of Heavy Menstrual Bleeding : Heavy menstrual bleeding is treated adequately by medical or surgical intervention. The hormonal contraceptives, in particular levonorgestrel-releasing intrauterine hormonal devices (LARCS—long-acting reversible contraception), are reported to have significant noncontraceptive benefits of reducing menstrual bleeding and dysmenorrhea in women suffering from HMB.[ 44 ] Bellizi et al .[ 45 ] reported a reduced risk of anemia (OR = 0.56) in women using oral contraceptives for at least 6 months [ Table 5 ]. Medical treatment for treatment of heavy menstrual bleeding[ 19 24 40 ] Currently, none of the national health programs in India focusing on reproductive and sexual health of adolescent girls and women have a component for heavy menstrual bleeding and anemia caused by it. Only menstrual hygiene is included as part of the adolescent health program, with minimal or no focus on screening and treatment of HMB and other abnormal uterine bleeding.

This review suggests a high burden of heavy menstrual bleeding among menstruating women. Heavy menstrual bleeding is an important causative factor of iron deficiency and anemia affected by the condition. HMB adversely affects the quality and productivity of females suffering from it, and there are medical interventions available to treat this prevalent but neglected cause of anemia. There is a need to include HMB screening, treatment, and appropriate referral in the Anemia Mukt Bharat program. GP, KY: Concept, design, manuscript writing. RK, MB, AK, NN: Manuscript writing

This scoping review mapped the existing literature on heavy menstrual bleeding and anemia, highlighting the key findings and identifying the research gaps for further policy support. The majority of studies assessing HMB prevalence are cross-sectional surveys, with substantial heterogeneity in diagnostic criteria (self-reported symptoms vs. standardized tools such as PBAC or SAMANTA scale). The global prevalence ranged from 4% to 63%, while Indian studies reported HMB prevalence from 17.6% to 46.7%, highlighting significant geographical and methodological variation. The studies reporting the burden of HMB were mostly based on self-reported complaints with a cross-sectional study design, thus introducing recall bias and failing to report the incidence of HMB. Also, the inconsistency in HMB diagnosis underscores the need for standardized screening methods in both research and clinical practice. The majority of studies reporting the relation between HMB and anemia revealed a strong association of the two, where both are vicious partners of each other. However, these evidences were mostly observational studies with variation in anemia diagnostic criteria (standalone hemoglobin vs. other iron markers). Therefore, the causality and temporality of iron deficiency anemia due to HMB cannot be established. Also, the studies reporting the causes of HMB, including hormonal imbalances, structural abnormalities, and hematological disorders, were mostly done in clinical settings, thus lacking generalizability. These studies do not reveal the causes and risk factors of HMB in a community setting. The consequences of heavy menstrual bleeding included reduced productivity, work loss, and limitations in daily, social, and sexual activities. Studies assessed the impact of HMB on quality of life (QoL), productivity loss, and healthcare costs, using tools like the SF-36 health survey and WHO-5 well-being index. Also, the economic burden due to HMB was assessed for high-income countries estimate an annual productivity loss of $1,692 per affected woman, but similar cost analyses are lacking for low- and middle-income countries (LMICs), including India. The research on treatment approaches for HMB primarily focuses on hormonal therapies (levonorgestrel intrauterine devices (long-acting hormonal contraceptives), oral contraceptives) and iron supplementation. The levonorgestrel-containing intrauterine devices has been shown to be efficacious in controlling heavy menstrual blood loss and dysmenorrhea, thus improving hemoglobin and anemia, along with the quality of life of affected women.[ 45 ] However, implementation research on the real-world feasibility of integrating HMB management into public health programs is largely absent. The strategy of the Anemia Mukt Bharat program does not include interventions related to heavy menstrual bleeding and anemia caused by it. The present review reveals a high burden of heavy menstrual bleeding and its significant association with iron deficiency and anemia. This implies that addressing heavy menstrual bleeding and anemia (taking HMB and anemia as cause and consequence both) would facilitate further reduction of the prevalence of anemia and its complications in women. We suggest a multifaceted approach to the management of HMB and anemia. The first step is conducting research reporting burden of HMB and its association with anemia using standardized reporting scales and laboratory investigations with longitudinal study designs. The prospective study design and standardized reporting scales and or definition will help in establishing the temporality of anemia due to HMB and anemia as an independent factor of HMB. There is also a need to assess the loss of productivity and work absenteeism due to HMB in low- and middle-income countries, especially India. As currently no health program addresses HMB and anemia associated with it, implementation research on integrating HMB into the AMB program is the need of the hour. Screening of anemia in women suffering from HMB or reporting to healthcare with complaints of HMB should be incorporated in Anemia Mukt Bharat program. Similarly, taking history of HMB in females who are screened as anemic will help in preventing future chronic blood loss due to the condition. The next step in the treatment of heavy menstrual bleeding includes adequate medical treatment by the primary care giver, which includes iron folic acid supplementation for the treatment of anemia and medical treatment for heavy menstrual bleeding. Under National Family Planning Program, oral and injectable contraceptives are given for family planning.[ 46 ] However, these interventions are not aimed for tackling HMB and anemia induced by it. The introduction of hormonal treatment for HMB under the national health program for women suffering from chronic blood loss due to HMB should be implemented. We also suggest the appropriate referral of anemic females with history of HMB at the grassroot level needs development and strengthening. Also, heavy menstrual bleeding should be incorporated as risk factor of anemia in the Anemia Mukt Bharat program and more implementation research on HMB and anemia and its treatment modalities.