Evaluation of menstrual blood loss (MBL) by self-perception and pictorial methods and correlation to uterine myometrial pathology

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Our study aimed to assess MBL using two methods: self-perception and pictograms (Pictorial Blood Assessment Chart -PBAC- and Menstrual Pictogram -MP-) in women undergoing transvaginal ultrasound (TVS). Methods: We enrolled 221 premenopausal women with spontaneous menstruation, no hormonal therapy, and no ongoing pregnancy. They were divided into four age groups (12-20, 21-30, 31-40, 41-55 years). Women self-reported normal (NMB) or heavy menstrual bleeding (HMB) and filled out PBAC and MP. A PBAC score ≥150 and MP score ≥80 ml indicated HMB. TVS was conducted on all patients, recording any pelvic pathologies. We compared self-perception with pictograms across the cohort, age groups, and ultrasound findings. Results: Of the cohort, 50.2% reported normal periods and 49.8% heavy periods. No significant differences were found between self-perception and pictograms in identifying NMB and HMB across all groups. However, significant differences were observed between PBAC and MP scores for NMB (56.1% vs 41.2%, p=0.001) and HMB (43.9% vs 58.8%, p=0.001), particularly in the 31-40 age group. Significant differences in PBAC and MP scores were noted between age groups 12-20 and 41-55, and 31-40 and 41-55. No significant differences were found between self-perception and pictograms regarding ultrasound findings like adenomyosis, fibroids, endometrial pathology, and uterine congenital malformations. Conclusion: Self-perception could be a reliable method for describing MBL across all age groups and ultrasound findings. Given the complexity and potential errors in using pictograms, clinicians should consider relying on self-perception for assessing menstrual cycle quantity. heavy menstrual bleeding pictorial blood loss assessment menstrual pictogram transvaginal ultrasound Figures Figure 1 Figure 2 What does this study add to the clinical work? This study aims to improve the clinician’s approach to the evaluation of menstrual blood loss in an outpatient setting. The use of self-perception alone could be a reliable method to describe the quantity of menstrual cycle in order to avoid errors due to the erroneous compilation of the visual pictograms. INTRODUCTION The evaluation of menstrual blood loss (MBL) during menstrual period is an important tool to determine how much gynecological pathologies, such as adenomyosis or uterine fibroids or hormonal disorders, could impact on women’s well-being. About 10–35% of women report heavy menstrual bleeding (HMB) in childbearing age, and among these, only 5% consult a medical practitioner to identify their possible causes. [ 1 ] In 2011, Munro et al. [ 2 ] described the causes of abnormal uterine bleeding (AUB) in non-pregnant women of reproductive age using the PALM-COEIN classification system, approved by the International Federation of Gynecology and Obstetrics (FIGO). In this classification the type of AUB and the normal or abnormal amount of MBL was not clearly defined. Only recently FIGO classification refers to HMB with a better definition. [ 3 ] In literature, HMB is defined as a blood loss > 80 ml per cycle [ 4 ]. HMB is known to be extensively under-reported [ 5 ]. This is largely due to inaccurate individual self-perception of MBL [ 6 ] and normalisation of symptoms [ 5 ]. HMB sometimes results in severe anemia and discomfort that interfere with the physical, emotional, social and women’s quality of life. It is therefore clear that under-reporting of HMB is of concern and improving identification methods may lead to timely diagnosis and treatment options. Over the years, several methods to evaluate the MBL have been developed. Semi-quantitative methods to assess MBL are the PBAC (Pictorial Blood loss Assessment Chart) and the menstrual pictogram (MP) [ 7 – 8 ]. The first PBAC was introduced in 1990 by Higham et al. [ 7 ] and it comprises a visual scoring system that depicts a graded series of soiled tampons and/or towels. The patient can directly record the number of her used feminine items and the degree to which they are bloodstained. PBAC is the most used method in literature to confirm HMB, and it showed the highest sensitivity and specificity using a cut off of 150 [ 7 ]. The menstrual pictogram (MP), introduced in 2001, includes five diagrams (icons) depicting a graduated series of stained towels or tampons. Women fill in the MP each time a sanitary pads changes, choosing a pictogram icon that corresponds with the degree of sanitary product staining. It showed the highest performance in evaluating HMB using a cut off of 80 ml. [ 8 ] The menstrual pictogram has subsequently been revalidated with superabsorbent polymer-c version -containing products that are now commonly used. [ 9 ] Nowadays, the evaluation of MBL is still a problem in primary healthcare; in literature self-perception not always correspond to the real blood loss [ 10 ] while, other authors showed good agreement between self-perceived MBL and objective evaluation [ 11 – 12 ]; moreover, currently available pictograms are not widely used in clinical practice. From one side, the relevance of the condition is based on a woman’s self-reported symptoms and their impact on quality of life (QoL); on the other side, self-perception of menstrual loss is unreliable. [ 13 ] Based on these considerations, the main aim of our study was to evaluate the amount of menstrual blood loss in a group of women with double evaluation: "Self-perception" or with the use of "Pictograms" (PBAC/revalidated MP) to evaluate whether personal perception alone is a reliable method to define the amount of blood flow. Secondary aim was to correlate the assessment of MBL by self-perception and with the use of pictograms in patients with pelvic gynecological pathologies detected by transvaginal ultrasound (TVS). MATERIAL and METHODS Setting and participants This is a prospective observational study carried out at the Department of Surgical Sciences, Gynecological Ultrasound Unit of the University of Rome “Tor Vergata”. From January to March 2023, 764 patients consecutively underwent transvaginal ultrasound evaluation (TVS). Inclusion criteria were premenopausal women with spontaneous menstruation, not on hormone therapy, with no ongoing pregnancy, and signed consent. Patients were excluded in case of postmenopause, pregnancy, ongoing hormonal treatment, and no signed consent. A total of 221 patients met finally the inclusion criteria ( Fig.1 ). Ethical approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University of Rome “Tor Vergata” (Date 20.09.2022/No.167/22). Informed consent was obtained from all individual participants included in the study. Clinical history and symptoms Patient information was recorded according to a pre-established format using the File maker pro® software Version 9.0. The collected data included: age at the time of the ultrasound, body mass index (BMI), age of menarche, parity, menstrual cycle characteristics, any current or previous medical or hormonal treatments, comorbidities. According to the last FIGO AUB System we expressed the normal variation in cycle length (regular cycle) as ±4 days. [3] Patients were asked to describe their menstrual periods, and according to their subjective evaluation were divided in two group: “ normal menstrual bleeding ” and “ heavy menstrual bleeding ”. Patients with a defined “ scarce ” amount of MBL were excluded. ( Fig.1 ) All participants, regardless of perceived menstrual flow, were instructed to fill in the two pictograms PBAC and revalidated MP. (Figure 2 A-B). [7,8] A PBAC score ≥150 [7] and a MP score ≥ 80 ml [8] were considered to describe heavy menstrual bleeding, whereas a PBAC score < 150 and a MP score<80 ml were considered to describe normal menstrual bleeding. Ultrasound examination All patients underwent transvaginal ultrasound examination in order to evaluate all possible pelvic pathologies. The ultrasound examination was performed by an experienced sonographer (C.E.) using a Voluson E6 or E8 device (GE Healthcare, Zipf, Austria) with a transvaginal probe. The ultrasound settings were standardised and identical for all subjects. The scan was first involved with a conventional two-dimensional (2D) ultrasound assessment of the pelvis. The uterus, endometrium and adnexa were evaluated. The 2D examination was followed by a 3D acquisition of volumes using the 3D volume mode. The TVS examination was performed at any phase of the menstrual cycle. All possible myometrial pathologies were described according to the Morphological Uterus Sonographic Assessment (MUSA) guidelines. [14-15] Uterine fibroid’s anatomical locations were classified according to the FIGO classification system [3]; to describe endometrial pathology, the International endometrial tumor analysis (IETA) terminology was used. [16] To describe ovarian pathologies, we used the International Ovarian Tumor analysis (IOTA) terminology. [17] Endometriosis and adenomyosis were recorded following the International Deep Endometriosis Analysis (IDEA). [18] Statistical analysis Statistical analysis was performed using SPSS V. 20.0 (SPSS. Chicago, IL, USA) and Prism software (GraphPad-9, San Diego, CA, USA). Categorical variables are reported as percentages and were analyzed by using the Chi-square test. Continuous variables are expressed in terms of median and interquartile range. Multiple comparisons were analyzed by using Kruskal–Wallis followed by Dunn’s test as post hoc test. For all the analyses, a p < 0.05 was considered statistically significant and all tests were 2-tailed, unless otherwise indicated. RESULTS Demographic and clinical characteristics of the 221 patients are described in Table 1. The patients mean age was 35.5±10.7-year-old (range 12-55 years). Patients were divided into 4 groups, according to ranges of age. (Table 1) In our study population, only 11% (24/221) of patients were adolescents (Age Group 12-20). The menarche’s mean age was 12.0±1.4year-old, with a rhythm of regular menstrual period for 42 patients (19%) and irregular for 179 patients (81%). In our study population 131/221 patients (60%) were nulliparous. In our cohort 60/221 (27.1%) patients had a normal TVS finding, while the most represented pathological TVS finding was endometriosis (34/221, 15.4%), followed by uterine fibroids alone (32/221, 14.5%) and adenomyosis alone (29/221, 13.1%). Table 2 showed the comparison between self-perception and pictograms and between both pictograms in the total population and in the different age groups; among the whole cohort, 111/221 (50.2%) patients considered their periods as normal and 110/221 (49.8%) as heavy. We observed no statistically significant differences between self-perception and the use of both pictograms in describing normal and heavy menstrual bleeding in the total population and also in the different age groups. (Table 2) Conversely, we noticed statistically significant difference in comparing the evaluation of MBL using the two pictograms (PBAC and MP) in the total population both for normal menstrual bleeding (124/221, 56.1% vs 91/221, 41.2%, p=0.001) and heavy menstrual bleeding (97/221, 43.9% vs 130/221, 58.8%, p=0.001). In particular, this statistical difference was observed in the age group 31-40 years, both for normal (38/67, 56.7% vs 25/67, 37.3%, p=0.02) and heavy menstrual bleeding (29/67, 43.3% vs 42/67, 62.7%, p=0.02). In Table 3 comparison between mean scores of PBAC and MP among the different age groups were described. We observed statistically significant differences in comparing mean scores of the two pictograms between the age groups 12-20 and 41-55, both for PBAC (118, range 50.5-205.75 vs 190, range 65-278.5, p<0.003) and MP (86.25, range 43.25-178.5 vs 131.5, range 55.5-189, p<0.003); statistically significant differences were also seen comparing the age groups 31-40 and 41-55 both for PBAC (127, range 74.5-247 vs 90, range 65-278.5, p<0.008 ) and MP (107, range 60.75-189.75 vs 131.5, range 55.5-189, p<0.008). Table 4 showed the comparison between self-perception and the use of pictograms according to the different TVS findings; we didn’t observe statistically significant differences between self-perception and the pictograms and also between both pictograms, in describing normal and heavy menstrual bleeding according to the ultrasound findings. (Table 4) DISCUSSION This study demonstrated that self-perception alone could be a reliable method to assess the amount of MBL in patients of different age and also according to the different ultrasound findings. The main objective was to evaluate the amount of MBL in a group of women with double evaluation: "self-perception" or with the use of "Pictograms" (PBAC/MP). The secondary aim was to correlate the assessment of MBL by self-perception and with the use of pictograms in patients with both normal ultrasound and pelvic gynecological pathologies. Nowadays, the evaluation of MBL represents a hot topic in literature, because of the variability of the studies in which self-perception or different pictograms have been used as the gold standard for the assessment of the problem. A correct evaluation of the MBL is crucial to improve the management of women with HMB and consequently their quality of life. PBAC and MP, are semi-quantitative methods used to determine MBL volume utilizing icon-based visual scoring systems for commonly used sanitary products; several recent papers have studied the accuracy of these methods in evaluating MBL and good results have been achieved in terms of sensitivity and specificity. [19] However, these methods showed some limitations, due to the large variety of commercially available sanitary products, and the consequent difficulties in fill them, that lead to a reduced accuracy. [20] In recent years, several papers have analyzed the reliability of self-perception in describing MBL, and the most representative result was that HMB is extensively under-reported because of an inadequate self-perception and normalization of symptoms. [5-6] On the other hand, other papers highlighted the importance of self-perception and how it could be used to assess the amount of blood loss. In 2003 Warner et al., showed that the volume of blood loss during the menstrual periods was significantly related to the patients subjective judgment; in particular, those women who rated their periods as ‘‘very heavy’’ had a mean blood loss that was 61% higher than the remainder of the women. [11] A recent paper of 2021, by KI Ko et al, demonstrated good associations of self-perceived symptoms with PBAC score and haemoglobin level in a group of Asian women; in particular, women with HMB had significantly higher total PBAC scores compared with women who had normal menstrual flow. [12] In our study no differences were found between the self-perceived MBL and the use of PBAC and MP among the whole cohort both regarding normal and heavy menstrual bleeding; this result was also confirmed by dividing patients in different age groups, from the adolescence to the perimenopause. While in comparing the use two pictograms PBAC and MP in the total population and in the different age groups, significant differences were observed, in particular among patients between 31 and 40 years old. This is crucial to understand that both adolescents and women in pre- or perimenopause, are able to describe their symptoms, if correctly evaluated. Furthermore, since statistically significant discrepancies have emerged in our population from the use of the two pictograms and since neither of the two has been considered superior to the other in the literature, we can assess that self-perception alone could be the only method to evaluate MBL. In this setting, the clinician plays an important role; an accurate investigation of the symptoms is fundamental to have a precise self-evaluation of MBL. By evaluating the mean scores of PBAC and MP among the different age groups, we observed that younger patients tend to have lower scores compared to older ones, as demonstrated by the differences found between the groups of patients between 12-20 years and 31-40 and the group of patients between 41 and 55 years. This result is in line with Barr et al., who developed in 1999 a different pictorial chart to evaluate the amount of blood loss in a cohort of Nigerian adolescents; [21] in this paper adolescents had a lower cutoff value for HMB (PBAC score > 50) compared to adults. However, this method resulted to have a low sensitivity and specificity and it was only used once in the literature. [22] Other papers in literature found that the mean PBAC score increased with age and days of bleeding. [23, 24] Moreover, by analyzing patients according to the ultrasound findings, we found that both groups of patients with normal or pathological pelvic findings didn’t show differences regarding the MBL assessment by using self-perception or pictograms. This is important in evaluating patients with common pelvic pathologies, such as adenomyosis and fibroids, thus, to consider self-perception also in these cases. Our study has some limitations; first, the population age groups are inhomogeneous: a higher adolescent’s sample size is needed to draw more robust conclusions on the analyzed endpoints. CONCLUSIONS In conclusion, our study demonstrated that self-perception alone could be a reliable method to describe MBL, showing no differences compared to the use of semi-quantitative pictograms. Women at different age can describe the amount of their blood flow, both in case of normal or pathological TVS findings. Since the use of pictograms could be confusing and sometimes difficult for patients to understand, and self-perception has proven to be accurate in evaluating the amount of menstrual flow, the role of the clinician is pivotal to carefully investigate patient’s symptoms. Further studies, including more homogeneous groups, are needed to confirm our data. Declarations Declaration of Interest The authors have no relevant financial or non-financial interests to disclose. Author Contribution Russo : Manuscript Writing and editing, Palumbo : Manuscript Writing, Reppuccia : Data collection, Iorio : Statistical analysis, Nocita : Data collection, Monaco : Data collection, Iacobini : Data collection, Soreca : Data collection, Exacoustos : Project development, Manuscript Writing and editing. References Pai M, Chan A, Barr R. How I manage heavy menstrual bleeding. Br J Haematol. 2013 Sep;162(6):721-9. https://doi: 10.1111/bjh.12447. 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Pictorial blood loss assessment chart for quantification of menstrual blood loss: a systematic review. Gynecol Surg 12, 157–163 (2015). https://doi.org/10.1007/s10397-015-0893-5. Barr F, Brabin L, Agbaje O. A pictorial chart for managing common menstrual disorders in Nigerian adolescents. Int J Gynaecol Obstet. 1999 Jul;66(1):51-3. https://doi: 10.1016/s0020-7292(99)00025-9. Özcan H, Burger NB, Dulmen-den Broeder EV, van Baal MW, den Boogaard EV, De Leeuw RA, Huirne JAF. Instruments to Identify Menstrual Complaints and Their Impact on Adolescents: A Systematic Review. J Pediatr Adolesc Gynecol. 2024 Apr;37(2):106-120. https://doi: 10.1016/j.jpag.2023.11.011. Barcelos RS, Zanini Rde V, Santos Ida S. Distúrbios menstruais entre mulheres de 15-54 anos de idade em Pelotas, Rio Grande do Sul, Brasil: estudo de base populacional [Menstrual disorders among women 15 to 54 years of age in Pelotas, Rio Grande do Sul State, Brazil: a population-based study]. 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Supplementary Files RussoetalTables.docx Cite Share Download PDF Status: Published Journal Publication published 30 Nov, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted Reviewers agreed at journal 16 Jun, 2024 Reviewers invited by journal 10 Jun, 2024 Editor invited by journal 09 Jun, 2024 Editor assigned by journal 05 Jun, 2024 First submitted to journal 04 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4528850","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":312475066,"identity":"a0fa701c-7d63-4fad-944d-6d705f83bf99","order_by":0,"name":"Consuelo Russo","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Consuelo","middleName":"","lastName":"Russo","suffix":""},{"id":312475067,"identity":"fc38ffc8-d472-49c7-a2f4-e1ac1471373f","order_by":1,"name":"Mario Palumbo","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Mario","middleName":"","lastName":"Palumbo","suffix":""},{"id":312475068,"identity":"843308f3-f4ef-4c0f-9425-4de2ef123206","order_by":2,"name":"Sabrina Reppuccia","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Sabrina","middleName":"","lastName":"Reppuccia","suffix":""},{"id":312475069,"identity":"503a5cd7-164a-4428-ab8e-dc017d4dd108","order_by":3,"name":"Giuseppe Gabriele Iorio","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Giuseppe","middleName":"Gabriele","lastName":"Iorio","suffix":""},{"id":312475070,"identity":"f18388bd-4d67-48fd-a8d9-fabad823988f","order_by":4,"name":"Elvira Nocita","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Elvira","middleName":"","lastName":"Nocita","suffix":""},{"id":312475071,"identity":"e223bd3e-9bb2-4dfa-9c9b-281f86058717","order_by":5,"name":"Giulia Monaco","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Giulia","middleName":"","lastName":"Monaco","suffix":""},{"id":312475072,"identity":"b021aed2-ea60-43a7-8240-387a43c4cba1","order_by":6,"name":"Federica Iacobini","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Federica","middleName":"","lastName":"Iacobini","suffix":""},{"id":312475073,"identity":"ea0d32ec-92ef-4907-9f83-ec9cbb2c9a33","order_by":7,"name":"Giorgia Soreca","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Giorgia","middleName":"","lastName":"Soreca","suffix":""},{"id":312475074,"identity":"c51ae2f8-13e8-4b71-9fe5-4aab36655d41","order_by":8,"name":"Caterina Exacoustos","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0003-3821-201X","institution":"University of Rome Tor Vergata: Universita degli Studi di Roma Tor Vergata","correspondingAuthor":true,"prefix":"","firstName":"Caterina","middleName":"","lastName":"Exacoustos","suffix":""}],"badges":[],"createdAt":"2024-06-04 14:39:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4528850/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4528850/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00404-024-07729-2","type":"published","date":"2024-11-30T15:58:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59292427,"identity":"4a56819f-ea13-4bb9-b3f2-e3056247b13a","added_by":"auto","created_at":"2024-06-28 18:53:02","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":92548,"visible":true,"origin":"","legend":"\u003cp\u003eFigure illustrates the study time frame, inclusion and exclusion criteria. A total of 221 patients were included in the analysis. TVS= transvaginal ultrasound.\u003c/p\u003e","description":"","filename":"Figure1Eligiblepatients.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4528850/v1/26fa2fc8ecd7100dc62c162d.jpg"},{"id":59292429,"identity":"9ab551fa-0f46-4c6c-8bf9-5036c0e26d36","added_by":"auto","created_at":"2024-06-28 18:53:02","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":262156,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA-B \u003c/strong\u003eGraphic illustration of the two visual pictograms. \u003cstrong\u003eA)\u003c/strong\u003e PBAC= Pictorial Blood Chart Assessment adapted from Higham et al., 1990. \u003cstrong\u003eB)\u003c/strong\u003e MP= Menstrual Pictogram adapted from Wyatt et al., 2011.\u003c/p\u003e","description":"","filename":"Figure2AdaptedPictograms.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4528850/v1/c4057616f69f1f8bc42b3988.jpg"},{"id":70382987,"identity":"cb41cd93-6cb4-4c8e-b4f4-cb88d0080953","added_by":"auto","created_at":"2024-12-02 16:36:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":688227,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4528850/v1/918a8ddf-d44b-4973-b29d-d7e10aa32af1.pdf"},{"id":59292428,"identity":"253db4e8-a714-4e10-93bc-6b1e91719297","added_by":"auto","created_at":"2024-06-28 18:53:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":34110,"visible":true,"origin":"","legend":"","description":"","filename":"RussoetalTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4528850/v1/7e689f64d24eb9aee6380bc3.docx"}],"financialInterests":"","formattedTitle":"Evaluation of menstrual blood loss (MBL) by self-perception and pictorial methods and correlation to uterine myometrial pathology","fulltext":[{"header":"What does this study add to the clinical work?","content":"\u003cp\u003eThis study aims to improve the clinician\u0026rsquo;s approach to the evaluation of menstrual blood loss in an outpatient setting. The use of self-perception alone could be a reliable method to describe the quantity of menstrual cycle in order to avoid errors due to the erroneous compilation of the visual pictograms.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eThe evaluation of menstrual blood loss (MBL) during menstrual period is an important tool to determine how much gynecological pathologies, such as adenomyosis or uterine fibroids or hormonal disorders, could impact on women\u0026rsquo;s well-being. About 10\u0026ndash;35% of women report heavy menstrual bleeding (HMB) in childbearing age, and among these, only 5% consult a medical practitioner to identify their possible causes. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn 2011, \u003cem\u003eMunro et al.\u003c/em\u003e [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] described the causes of abnormal uterine bleeding (AUB) in non-pregnant women of reproductive age using the PALM-COEIN classification system, approved by the International Federation of Gynecology and Obstetrics (FIGO). In this classification the type of AUB and the normal or abnormal amount of MBL was not clearly defined. Only recently FIGO classification refers to HMB with a better definition. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn literature, HMB is defined as a blood loss\u0026thinsp;\u0026gt;\u0026thinsp;80 ml per cycle [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. HMB is known to be extensively under-reported [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This is largely due to inaccurate individual self-perception of MBL [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and normalisation of symptoms [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. HMB sometimes results in severe anemia and discomfort that interfere with the physical, emotional, social and women\u0026rsquo;s quality of life. It is therefore clear that under-reporting of HMB is of concern and improving identification methods may lead to timely diagnosis and treatment options.\u003c/p\u003e \u003cp\u003eOver the years, several methods to evaluate the MBL have been developed. Semi-quantitative methods to assess MBL are the PBAC (Pictorial Blood loss Assessment Chart) and the menstrual pictogram (MP) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe first PBAC was introduced in 1990 by Higham et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and it comprises a visual scoring system that depicts a graded series of soiled tampons and/or towels. The patient can directly record the number of her used feminine items and the degree to which they are bloodstained. PBAC is the most used method in literature to confirm HMB, and it showed the highest sensitivity and specificity using a cut off of 150 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The menstrual pictogram (MP), introduced in 2001, includes five diagrams (icons) depicting a graduated series of stained towels or tampons. Women fill in the MP each time a sanitary pads changes, choosing a pictogram icon that corresponds with the degree of sanitary product staining. It showed the highest performance in evaluating HMB using a cut off of 80 ml. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe menstrual pictogram has subsequently been revalidated with superabsorbent polymer-c version -containing products that are now commonly used. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eNowadays, the evaluation of MBL is still a problem in primary healthcare; in literature self-perception not always correspond to the real blood loss [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] while, other authors showed good agreement between self-perceived MBL and objective evaluation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; moreover, currently available pictograms are not widely used in clinical practice.\u003c/p\u003e \u003cp\u003eFrom one side, the relevance of the condition is based on a woman\u0026rsquo;s self-reported symptoms and their impact on quality of life (QoL); on the other side, self-perception of menstrual loss is unreliable. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eBased on these considerations, the main aim of our study was to evaluate the amount of menstrual blood loss in a group of women with double evaluation: \"Self-perception\" or with the use of \"Pictograms\" (PBAC/revalidated MP) to evaluate whether personal perception alone is a reliable method to define the amount of blood flow.\u003c/p\u003e \u003cp\u003eSecondary aim was to correlate the assessment of MBL by self-perception and with the use of pictograms in patients with pelvic gynecological pathologies detected by transvaginal ultrasound (TVS).\u003c/p\u003e"},{"header":"MATERIAL and METHODS","content":"\u003cp\u003e\u003cem\u003e\u003cu\u003eSetting and participants\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis is a\u0026nbsp;prospective observational\u0026nbsp;study carried out at the Department of Surgical Sciences, Gynecological Ultrasound Unit of the University of Rome “Tor Vergata”. From\u0026nbsp;January to March 2023,\u0026nbsp;764 patients consecutively underwent\u0026nbsp;transvaginal ultrasound evaluation (TVS). Inclusion criteria were\u0026nbsp;premenopausal women with spontaneous menstruation, not on hormone therapy, with no\u0026nbsp;ongoing pregnancy,\u0026nbsp;and signed consent.\u0026nbsp;Patients were excluded in case of postmenopause, pregnancy, ongoing hormonal treatment, and no signed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA total of 221 patients met finally the inclusion criteria (\u003cstrong\u003eFig.1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of University of Rome “Tor Vergata” (Date 20.09.2022/No.167/22). Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eClinical history and symptoms\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePatient information was recorded according to a pre-established format using the File maker pro® software Version 9.0. The collected data included: age at the time of the ultrasound, body mass index (BMI), age of menarche, parity, menstrual cycle characteristics, any current or previous medical or hormonal treatments, comorbidities.\u003c/p\u003e\n\u003cp\u003eAccording to the last FIGO AUB System we expressed the normal variation in cycle length (regular cycle) as ±4 days. [3]\u003c/p\u003e\n\u003cp\u003ePatients were asked to describe their menstrual periods, and according to their subjective evaluation were divided in two group: “\u003cem\u003enormal menstrual bleeding\u003c/em\u003e” and “\u003cem\u003eheavy menstrual bleeding\u003c/em\u003e”.\u003c/p\u003e\n\u003cp\u003ePatients with a defined “\u003cem\u003escarce\u003c/em\u003e” amount of MBL were excluded. (\u003cstrong\u003eFig.1\u003c/strong\u003e)\u003c/p\u003e\n\u003cp\u003eAll participants, regardless of perceived menstrual flow, were instructed to fill in the two pictograms PBAC and revalidated MP. (Figure 2 A-B). [7,8] A PBAC score ≥150 [7] and a MP score ≥ 80 ml [8] were considered to describe heavy menstrual bleeding, whereas a PBAC score \u0026lt; 150 and a MP score\u0026lt;80 ml were considered to describe normal menstrual bleeding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eUltrasound examination\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll patients underwent transvaginal ultrasound examination in order to evaluate all possible pelvic pathologies.\u003c/p\u003e\n\u003cp\u003eThe ultrasound examination was performed by an experienced sonographer (C.E.) using a Voluson E6 or E8 device (GE Healthcare, Zipf, Austria) with a transvaginal probe. The ultrasound settings were standardised and identical for all subjects. The scan was first involved with a conventional two-dimensional (2D) ultrasound assessment of the pelvis. The uterus, endometrium and adnexa were evaluated. The 2D examination was followed by a 3D acquisition of volumes using the 3D volume mode. The TVS examination was performed at any phase of the menstrual cycle.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll possible myometrial pathologies were described according to the Morphological Uterus Sonographic Assessment (MUSA) guidelines. [14-15] Uterine fibroid’s anatomical locations were classified according to the FIGO classification system [3]; to describe endometrial pathology, the International endometrial tumor analysis (IETA) terminology was used. [16] To describe ovarian pathologies, we used the International Ovarian Tumor analysis (IOTA) terminology. [17]\u003c/p\u003e\n\u003cp\u003eEndometriosis and adenomyosis were recorded following the International Deep Endometriosis Analysis (IDEA). [18]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eStatistical analysis\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using SPSS V. 20.0 (SPSS. Chicago, IL, USA) and Prism software (GraphPad-9, San Diego, CA, USA). Categorical variables are reported as percentages and were analyzed by using the Chi-square test. Continuous variables are expressed in terms of median and interquartile range. Multiple comparisons were analyzed by using Kruskal–Wallis followed by Dunn’s test as post hoc test. For all the analyses, a p \u0026lt; 0.05 was considered statistically significant and all tests were 2-tailed, unless otherwise indicated.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eDemographic and clinical characteristics of the 221 patients are described in Table 1.\u003c/p\u003e\n\u003cp\u003eThe patients mean age was 35.5\u0026plusmn;10.7-year-old (range 12-55 years).\u003c/p\u003e\n\u003cp\u003ePatients were divided into 4 groups, according to ranges of age. (Table 1) In our study population, only 11% (24/221) of patients were adolescents (Age Group 12-20).\u003c/p\u003e\n\u003cp\u003eThe menarche\u0026rsquo;s mean age was 12.0\u0026plusmn;1.4year-old, with a rhythm of regular menstrual period for 42 patients (19%) and irregular for 179 patients (81%). In our study population 131/221 patients (60%) were nulliparous.\u003c/p\u003e\n\u003cp\u003eIn our cohort 60/221 (27.1%) patients had a normal TVS finding, while the most represented pathological TVS finding was endometriosis (34/221, 15.4%), followed by uterine fibroids alone (32/221, 14.5%) and adenomyosis alone (29/221, 13.1%).\u003c/p\u003e\n\u003cp\u003eTable 2 showed the comparison between self-perception and pictograms and between both pictograms in the total population and in the different age groups;\u0026nbsp;among the whole cohort, 111/221 (50.2%) patients considered their periods as normal and 110/221 (49.8%) as heavy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe observed no statistically significant differences between self-perception and the use of both pictograms in describing normal and heavy menstrual bleeding in the total population and also in the different age groups. (Table 2)\u003c/p\u003e\n\u003cp\u003eConversely, we noticed statistically significant difference in comparing the evaluation of MBL using the two pictograms (PBAC and MP) in the total population both for normal menstrual bleeding (124/221, 56.1% vs 91/221, 41.2%, p=0.001) and heavy menstrual bleeding (97/221, 43.9% vs 130/221, 58.8%, p=0.001).\u003c/p\u003e\n\u003cp\u003eIn particular, this statistical difference was observed in the age group 31-40 years, both for normal (38/67, 56.7% vs 25/67, 37.3%, p=0.02) and heavy menstrual bleeding (29/67, 43.3% vs 42/67, 62.7%, p=0.02).\u003c/p\u003e\n\u003cp\u003eIn Table 3 comparison between mean scores of PBAC and MP among the different age groups were described.\u003c/p\u003e\n\u003cp\u003eWe observed statistically significant differences in comparing mean scores of the two pictograms between the age groups 12-20 and 41-55, both for PBAC (118, range 50.5-205.75 vs 190, range 65-278.5, p\u0026lt;0.003) and MP (86.25, range 43.25-178.5 vs 131.5, range 55.5-189, p\u0026lt;0.003); statistically significant differences were also seen comparing the age groups 31-40 and 41-55 both for PBAC (127, range 74.5-247 vs 90, range 65-278.5, p\u0026lt;0.008 ) and MP (107, range 60.75-189.75 vs 131.5, range 55.5-189, p\u0026lt;0.008).\u003c/p\u003e\n\u003cp\u003eTable 4 showed the comparison between self-perception and the use of pictograms according to the different TVS findings; we didn\u0026rsquo;t observe statistically significant differences between self-perception and the pictograms and also between both pictograms, in describing normal and heavy menstrual bleeding according to the ultrasound findings. (Table 4)\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study demonstrated that self-perception alone could be a reliable method to assess the amount of MBL in patients of different age and also according to the different ultrasound findings.\u003c/p\u003e\n\u003cp\u003eThe main objective was to evaluate the amount of MBL in a group of women with double evaluation: \u0026quot;self-perception\u0026quot; or with the use of \u0026quot;Pictograms\u0026quot; (PBAC/MP). The secondary aim was to correlate the assessment of MBL by self-perception and with the use of pictograms in patients with both normal ultrasound and pelvic gynecological pathologies.\u003c/p\u003e\n\u003cp\u003eNowadays, the evaluation of MBL represents a hot topic in literature, because of the variability of the studies in which self-perception or different pictograms have been used as the gold standard for the assessment of the problem. A correct evaluation of the MBL is crucial to improve the management of women with HMB and consequently their quality of life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePBAC and MP, are semi-quantitative methods used to determine MBL volume utilizing icon-based visual scoring systems for commonly used sanitary products; several recent papers have studied the accuracy of these methods in evaluating MBL and good results have been achieved in terms of sensitivity and specificity. [19]\u003c/p\u003e\n\u003cp\u003eHowever, these methods showed some limitations, due to the large variety of commercially available sanitary products, and the consequent difficulties in fill them, that lead to a reduced accuracy. [20]\u003c/p\u003e\n\u003cp\u003eIn recent years, several papers have analyzed the reliability of self-perception in describing MBL, and the most representative result was that HMB is extensively under-reported because of an inadequate self-perception and normalization of symptoms. [5-6]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the other hand, other papers highlighted the importance of self-perception and how it could be used to assess the amount of blood loss.\u003c/p\u003e\n\u003cp\u003eIn 2003 Warner et al., showed that the volume of blood loss during the menstrual periods was significantly related to the patients subjective judgment; in particular, those women who rated their periods as \u0026lsquo;\u0026lsquo;very heavy\u0026rsquo;\u0026rsquo; had a mean blood loss that was 61% higher than the remainder of the women. [11]\u003c/p\u003e\n\u003cp\u003eA recent paper of 2021, by KI Ko et al, demonstrated good associations of self-perceived symptoms with PBAC score and haemoglobin level in a group of Asian women; in particular, women with HMB had significantly higher total PBAC scores compared with women who had normal menstrual flow. [12]\u003c/p\u003e\n\u003cp\u003eIn our study no differences were found between the self-perceived MBL and the use of PBAC and MP among the whole cohort both regarding normal and heavy menstrual bleeding; this result was also confirmed by dividing patients in different age groups, from the adolescence to the perimenopause.\u003c/p\u003e\n\u003cp\u003eWhile in comparing the use two pictograms PBAC and MP in the total population and in the different age groups, significant differences were observed, in particular among patients between 31 and 40 years old.\u003c/p\u003e\n\u003cp\u003eThis is crucial to understand that both adolescents and women in pre- or perimenopause, are able to describe their symptoms, if correctly evaluated.\u003c/p\u003e\n\u003cp\u003eFurthermore, since statistically significant discrepancies have emerged in our population from the use of the two pictograms and since neither of the two has been considered superior to the other in the literature, we can assess that self-perception alone could be the only method to evaluate MBL.\u003c/p\u003e\n\u003cp\u003eIn this setting, the clinician plays an important role; an accurate investigation of the symptoms is fundamental to have a precise self-evaluation of MBL.\u003c/p\u003e\n\u003cp\u003eBy evaluating the mean scores of PBAC and MP among the different age groups, we observed that younger patients tend to have lower scores compared to older ones, as demonstrated by the differences found between the groups of patients between 12-20 years and 31-40 and the group of patients between 41 and 55 years. This result is in line with Barr et al., who developed in 1999 a different pictorial chart to evaluate the amount of blood loss in a cohort of Nigerian adolescents; [21] in this paper adolescents had a lower cutoff value for HMB (PBAC score \u0026gt; 50) compared to adults. However, this method resulted to have a low sensitivity and specificity and it was only used once in the literature. [22]\u003c/p\u003e\n\u003cp\u003eOther papers in literature found that the mean PBAC score increased with age and days of bleeding. [23, 24]\u003c/p\u003e\n\u003cp\u003eMoreover, by analyzing patients according to the ultrasound findings, we found that both groups of patients with normal or pathological pelvic findings didn\u0026rsquo;t show differences regarding the MBL assessment by using self-perception or pictograms. This is important in evaluating patients with common pelvic pathologies, such as adenomyosis and fibroids, thus, to consider self-perception also in these cases.\u003c/p\u003e\n\u003cp\u003eOur study has some limitations; first, the population age groups are inhomogeneous: a higher adolescent\u0026rsquo;s sample size is needed to draw more robust conclusions on the analyzed endpoints.\u0026nbsp;\u003c/p\u003e"},{"header":" CONCLUSIONS","content":"\u003cp\u003eIn conclusion, our study demonstrated that self-perception alone could be a reliable method to describe MBL, showing no differences compared to the use of semi-quantitative pictograms. Women at different age can describe the amount of their blood flow, both in case of normal or pathological TVS findings. Since the use of pictograms could be confusing and sometimes difficult for patients to understand, and self-perception has proven to be accurate in evaluating the amount of menstrual flow, the role of the clinician is pivotal to carefully investigate patient\u0026rsquo;s symptoms. Further studies, including more homogeneous groups, are needed to confirm our data.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRusso\u003c/strong\u003e: Manuscript Writing and editing, \u003cstrong\u003ePalumbo\u003c/strong\u003e: Manuscript Writing, \u003cstrong\u003eReppuccia\u003c/strong\u003e: Data collection, \u003cstrong\u003eIorio\u003c/strong\u003e: Statistical analysis, \u003cstrong\u003eNocita\u003c/strong\u003e: Data collection, \u003cstrong\u003eMonaco\u003c/strong\u003e: Data collection, \u003cstrong\u003eIacobini\u003c/strong\u003e: Data collection, \u003cstrong\u003eSoreca\u003c/strong\u003e: Data collection, \u003cstrong\u003eExacoustos\u003c/strong\u003e: Project development, Manuscript Writing and editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePai M, Chan A, Barr R. How I manage heavy menstrual bleeding. Br J Haematol. 2013 Sep;162(6):721-9. https://doi: 10.1111/bjh.12447.\u003c/li\u003e\n\u003cli\u003eMunro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011 Apr;113(1):3-13. https://doi: 10.1016/j.ijgo.2010.11.011. \u003c/li\u003e\n\u003cli\u003eMunro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018 Dec;143(3):393-408. https://doi: 10.1002/ijgo.12666.\u003c/li\u003e\n\u003cli\u003eHallberg L, H\u0026ouml;gdahl AM, Nilsson L, Rybo G. Menstrual blood loss--a population study. Variation at different ages and attempts to define normality. Acta Obstet Gynecol Scand. 1966;45(3):320-51. https://doi: 10.3109/00016346609158455.\u003c/li\u003e\n\u003cli\u003eFraser IS, Mansour D, Breymann C, Hoffman C, Mezzacasa A, Petraglia F. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Int J Gynaecol Obstet. 2015 Mar;128(3):196-200. https://doi: 10.1016/j.ijgo.2014.09.027.\u003c/li\u003e\n\u003cli\u003eMagnay JL, O\u0026apos;Brien S, Gerlinger C, Seitz C. A systematic review of methods to measure menstrual blood loss. BMC Womens Health. 2018 Aug 22;18(1):142. https://doi: 10.1186/s12905-018-0627-8.\u003c/li\u003e\n\u003cli\u003eHigham JM, O\u0026apos;Brien PM, Shaw RW. Assessment of menstrual blood loss using a pictorial chart. Br J Obstet Gynaecol. 1990 Aug;97(8):734-9. https://doi: 10.1111/j.1471-0528.1990.tb16249.x. \u003c/li\u003e\n\u003cli\u003eWyatt KM, Dimmock PW, Walker TJ, O\u0026apos;Brien PM. Determination of total menstrual blood loss. Fertil Steril. 2001 Jul;76(1):125-31. https://doi: 10.1016/s0015-0282(01)01847-7. \u003c/li\u003e\n\u003cli\u003eMagnay JL, Nevatte TM, O\u0026apos;Brien S, Gerlinger C, Seitz C. Validation of a new menstrual pictogram (superabsorbent polymer-c version) for use with ultraslim towels that contain superabsorbent polymers. Fertil Steril. 2014 Feb;101(2):515-22. https://doi: 10.1016/j.fertnstert.2013.10.051.\u003c/li\u003e\n\u003cli\u003eMagnay JL, O\u0026apos;Brien S, Gerlinger C, Seitz C. A systematic review of methods to measure menstrual blood loss. BMC Womens Health. 2018 Aug 22;18(1):142. https://doi: 10.1186/s12905-018-0627-8.\u003c/li\u003e\n\u003cli\u003eWarner PE, Critchley HO, Lumsden MA, Campbell-Brown M, Douglas A, Murray GD. 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 May;190(5):1216-23. https://doi: 10.1016/j.ajog.2003.11.015. PMID: 15167821.\u003c/li\u003e\n\u003cli\u003eKo JKY, Lao TT, Cheung VYT. Pictorial Blood Loss Assessment Chart for evaluating heavy menstrual bleeding in Asian women. Hong Kong Med J. 2021 Dec;27(6):399-404. https://doi: 10.12809/hkmj208743.\u003c/li\u003e\n\u003cli\u003eVannuccini S, Jain V, Critchley H, Petraglia F. From menarche to menopause, heavy menstrual bleeding is the underrated compass in reproductive health. Fertil Steril. 2022 Oct;118(4):625-636. https://doi: 10.1016/j.fertnstert.2022.07.021.\u003c/li\u003e\n\u003cli\u003eVan den Bosch T, Dueholm M, Leone FP, Valentin L, Rasmussen CK, Votino A, Van Schoubroeck D, Landolfo C, Install\u0026eacute; AJ, Guerriero S, Exacoustos C, Gordts S, Benacerraf B, D\u0026apos;Hooghe T, De Moor B, Br\u0026ouml;lmann H, Goldstein S, Epstein E, Bourne T, Timmerman D. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound Obstet Gynecol. 2015 Sep;46(3):284-98. https://doi: 10.1002/uog.14806.\u003c/li\u003e\n\u003cli\u003eHarmsen MJ, Van den Bosch T, de Leeuw RA, Dueholm M, Exacoustos C, Valentin L, Hehenkamp WJK, Groenman F, De Bruyn C, Rasmussen C, Lazzeri L, Jokubkiene L, Jurkovic D, Naftalin J, Tellum T, Bourne T, Timmerman D, Huirne JAF. Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound Obstet Gynecol. 2022 Jul;60(1):118-131. https://doi: 10.1002/uog.24786.\u003c/li\u003e\n\u003cli\u003eLeone FP, Timmerman D, Bourne T, Valentin L, Epstein E, Goldstein SR, Marret H, Parsons AK, Gull B, Istre O, Sepulveda W, Ferrazzi E, Van den Bosch T. Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol. 2010 Jan;35(1):103-12. https://doi: 10.1002/uog.7487.\u003c/li\u003e\n\u003cli\u003eTimmerman D, Valentin L, Bourne TH, Collins WP, Verrelst H, Vergote I; International Ovarian Tumor Analysis (IOTA) Group. Terms, definitions and measurements to describe the sonographic features of adnexal tumors: a consensus opinion from the International Ovarian Tumor Analysis (IOTA) Group. Ultrasound Obstet Gynecol. 2000 Oct;16(5):500-5. https://doi: 10.1046/j.1469-0705.2000.00287.x.\u003c/li\u003e\n\u003cli\u003eGuerriero S, Condous G, van den Bosch T, Valentin L, Leone FP, Van Schoubroeck D, Exacoustos C, Install\u0026eacute; AJ, Martins WP, Abrao MS, Hudelist G, Bazot M, Alcazar JL, Gon\u0026ccedil;alves MO, Pascual MA, Ajossa S, Savelli L, Dunham R, Reid S, Menakaya U, Bourne T, Ferrero S, Leon M, Bignardi T, Holland T, Jurkovic D, Benacerraf B, Osuga Y, Somigliana E, Timmerman D. Systematic approach to sonographic evaluation of the pelvis in women with suspected endometriosis, including terms, definitions and measurements: a consensus opinion from the International Deep Endometriosis Analysis (IDEA) group. Ultrasound Obstet Gynecol. 2016 Sep;48(3):318-32. https://doi: 10.1002/uog.15955.\u003c/li\u003e\n\u003cli\u003eMagnay JL, Nevatte TM, Seitz C, O\u0026apos;Brien S. A new menstrual pictogram for use with feminine products that contain superabsorbent polymers. Fertil Steril. 2013 Dec;100(6):1715-21.e1-4. https://doi: 10.1016/j.fertnstert.2013.08.028.\u003c/li\u003e\n\u003cli\u003eEl-Nashar, S.A., Shazly, S.A.M. \u0026amp; Famuyide, A.O. Pictorial blood loss assessment chart for quantification of menstrual blood loss: a systematic review. Gynecol Surg 12, 157\u0026ndash;163 (2015). https://doi.org/10.1007/s10397-015-0893-5.\u003c/li\u003e\n\u003cli\u003eBarr F, Brabin L, Agbaje O. A pictorial chart for managing common menstrual disorders in Nigerian adolescents. Int J Gynaecol Obstet. 1999 Jul;66(1):51-3. https://doi: 10.1016/s0020-7292(99)00025-9.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zcan H, Burger NB, Dulmen-den Broeder EV, van Baal MW, den Boogaard EV, De Leeuw RA, Huirne JAF. Instruments to Identify Menstrual Complaints and Their Impact on Adolescents: A Systematic Review. J Pediatr Adolesc Gynecol. 2024 Apr;37(2):106-120. https://doi: 10.1016/j.jpag.2023.11.011.\u003c/li\u003e\n\u003cli\u003eBarcelos RS, Zanini Rde V, Santos Ida S. Dist\u0026uacute;rbios menstruais entre mulheres de 15-54 anos de idade em Pelotas, Rio Grande do Sul, Brasil: estudo de base populacional [Menstrual disorders among women 15 to 54 years of age in Pelotas, Rio Grande do Sul State, Brazil: a population-based study]. Cad Saude Publica. 2013 Nov;29(11):2333-46. Portuguese. https://doi: 10.1590/0102-311x00002813.\u003c/li\u003e\n\u003cli\u003eToxqui L, P\u0026eacute;rez-Granados AM, Blanco-Rojo R, Wright I, Vaquero MP. A simple and feasible questionnaire to estimate menstrual blood loss: relationship with hematological and gynecological parameters in young women. BMC Womens Health. 2014 May 30;14:71. https://doi: 10.1186/1472-6874-14-71.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"heavy menstrual bleeding, pictorial blood loss assessment, menstrual pictogram, transvaginal ultrasound","lastPublishedDoi":"10.21203/rs.3.rs-4528850/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4528850/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: Evaluating menstrual blood loss (MBL) in primary healthcare is challenging. Our study aimed to assess MBL using two methods: self-perception and pictograms (Pictorial Blood Assessment Chart -PBAC- and Menstrual Pictogram -MP-) in women undergoing transvaginal ultrasound (TVS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe enrolled 221 premenopausal women with spontaneous menstruation, no hormonal therapy, and no ongoing pregnancy. They were divided into four age groups (12-20, 21-30, 31-40, 41-55 years). Women self-reported normal (NMB) or heavy menstrual bleeding (HMB) and filled out PBAC and MP. A PBAC score ≥150 and MP score ≥80 ml indicated HMB. TVS was conducted on all patients, recording any pelvic pathologies. We compared self-perception with pictograms across the cohort, age groups, and ultrasound findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf the cohort, 50.2% reported normal periods and 49.8% heavy periods. No significant differences were found between self-perception and pictograms in identifying NMB and HMB across all groups. However, significant differences were observed between PBAC and MP scores for NMB (56.1% vs 41.2%, p=0.001) and HMB (43.9% vs 58.8%, p=0.001), particularly in the 31-40 age group. Significant differences in PBAC and MP scores were noted between age groups 12-20 and 41-55, and 31-40 and 41-55. No significant differences were found between self-perception and pictograms regarding ultrasound findings like adenomyosis, fibroids, endometrial pathology, and uterine congenital malformations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eSelf-perception could be a reliable method for describing MBL across all age groups and ultrasound findings. Given the complexity and potential errors in using pictograms, clinicians should consider relying on self-perception for assessing menstrual cycle quantity.\u003c/p\u003e","manuscriptTitle":"Evaluation of menstrual blood loss (MBL) by self-perception and pictorial methods and correlation to uterine myometrial pathology","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-28 18:52:57","doi":"10.21203/rs.3.rs-4528850/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2024-06-16T09:44:22+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-10T06:42:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Archives of Gynecology and Obstetrics","date":"2024-06-09T21:36:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-05T07:06:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2024-06-04T10:39:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"eb10f53e-296a-4758-bf84-a44cfd264a2a","owner":[],"postedDate":"June 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T16:05:04+00:00","versionOfRecord":{"articleIdentity":"rs-4528850","link":"https://doi.org/10.1007/s00404-024-07729-2","journal":{"identity":"archives-of-gynecology-and-obstetrics","isVorOnly":false,"title":"Archives of Gynecology and Obstetrics"},"publishedOn":"2024-11-30 15:58:13","publishedOnDateReadable":"November 30th, 2024"},"versionCreatedAt":"2024-06-28 18:52:57","video":"","vorDoi":"10.1007/s00404-024-07729-2","vorDoiUrl":"https://doi.org/10.1007/s00404-024-07729-2","workflowStages":[]},"version":"v1","identity":"rs-4528850","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4528850","identity":"rs-4528850","version":["v1"]},"buildId":"zG6E5Sm6oA1kbPE6fP8qF","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}