Prevalence and knowledge of heavy menstrual bleeding among gynecology outpatients by scanning a WeChat QR Code.

Heavy menstrual bleeding (HMB), or excessive menstrual blood loss, can seriously affect the quality of life of women since it interferes with the physical, emotional, social, and material quality of life. HMB can occur alone or in combination with other symptoms [ 1 ]. It is a specific type of abnormal uterine bleeding (AUB) that may result from structural and non-structural abnormalities defined within the PALM-COEIN classification [ 2 ]. Most women with HMB do not have any structural or histologically identifiable abnormalities. HMB management is justified when HMB has an impact on quality of life. Menstrual blood loss (MBL) of >80 mL has traditionally been used as the criterion for HMB [ 3 ] along with the menstrual period lasting >7 days. These symptoms may occur either individually or together with other symptoms. Long-term HMB may lead to anemia, which in turn may cause a series of unfavorable consequences such as shortness of breath, tiredness, weakness, emotional fluctuation, and impaired knowledge [ 4 ]. In the United States, about 45% of the women have had a hysterectomy was because of menorrhagia [ 5 ]. The prevalence of HMB depends on the assessment, clinical setting, and cultural and social ideas of ‘normal’ menstruation [ 6 , 7 ]. Investigation and management are hampered by confusing and inconsistent nomenclature and the lack of a standardized investigation approach [ 2 , 3 , 7 ]. There is a low level of awareness and understanding of HMB amongst women, which often leads to acceptance of the condition, without seeking the medical help [ 7 ]. Currently, there are no data in China that could help us understand how often women suffer from HMB and how many women know that HMB could severely jeopardize their health. The physical assessment of MBL is difficult to achieve outside clinical research settings [ 1 , 3 , 8 ]. For healthcare professionals, volume and accuracy of data is impeded by confusing and inconsistent nomenclature [ 3 , 7 ], difficulty with traditional approaches to measurement of MBL [ 3 , 6 , 7 ], lack of a standardized investigation approach [ 2 , 7 ], and poor awareness and understanding of the impact of HMB amongst women [ 9 , 10 ]. Hence, the aim of this study was to determine MBL using a mobile phone or tablet to scan a WeChat (a social media application software developed by Tencent) QR Code in order to enter the mobile questionnaire survey system, and to examine the level of awareness and knowledge of HMB among the gynecology outpatients treated at Peking University People’s Hospital.

Among a total of 1736 patients who were invited to participate in the questionnaire survey, 584 patients were excluded from the study: 352 patients were excluded because they refused to fill the questionnaire and 232 patients were excluded because they had incomplete data. In total, 1152 patients completed the survey and were analyzed. The percentage of patients with normal menstrual cycle (assessed by the patients) was 77.4% (892/1152) ( Table 1 ). The mean number of pregnancies was 1±1 (range, 0–7). The mean number of childbirth was 1±1 (range, 0–3). There was no patient taking oral contraceptive. Normal menstrual cycle was assessed by the patients. BMI, body mass index; SD, standard deviation. In total, 739 patients described their reasons for visiting the hospital. The major reason for visit was reproductive tract infection (36.1%, 267/739) including pelvic inflammation, cervicitis, cervical polyp, vaginitis, and vulvitis. The percentage of AUB (including all kinds of HMB) was 24.9% (184/739), the percentage of gynecological tumor (including ovary tumor, leiomyoma, endometrial cyst, adenomyosis, mesosalpinx cyst) was 14.3% (106/739) ( Table 1 ). A total of 1152 patients assessed their own menstrual flow volume. The patient self-assessment of menstrual blood volume showed that HMB accounted for 15.6% (180/1152). After assessing menstrual blood volume using the PBAC, the percentage of PBAC ≥100 was 58.0% (668/1152) ( Table 2 ). Among patients with PBAC ≥100, only 26.8% (179/668) reported HMB through self-assessment, and 7.0% (26/374), 35.8% (63/176), and 76.3% (90/118) patients self-reported as HMB among patients with PBAC 100–199, 200–299 and ≥300, respectively ( Fig 1 ). Table 3 presents the PBAC scores of patients with according to the self-assessed menstrual blood volume. HMB, heavy menstrual bleeding; MBL, menstrual blood loss; PBAC, Pictorial Blood Loss Assessment Chart; SD, standard deviation. HMB, heavy menstrual bleeding; PBAC, Pictorial Blood Loss Assessment Chart; SD, standard deviation. In total, 60.8% (449/739) patients were diagnosed with AUB. According to the PBAC scores, 422 patients suffered from HMB, accounting for 94.0% of all AUB patients; 121 patients had a period >7 days, accounting for 26.9% of all AUB patients (121 patients had both PBAC ≥100 and a period >7 days). The MMAS total scores are shown in Table 2 . There was significant difference in MMAS total score among patients with different volume of MBL by self-assessment or PBAC assessment (P<0.001). A total of 152 patients who provided blood routine examination results were divided into two groups based on the PBAC score; 96 patients who scored PBAC ≥100 were assigned to the HMB group and 56 patients with PBAC <100 to the normal blood loss group. Regarding its impact on daily life, the MMAS scores of HMB patients were significantly lower compared to those with normal blood loss (P<0.001, Table 4 ). Among these patients, 64.6% (62/96) of patients from the HMB group suffered from anemia, compared to 3.6% (2/56) of patients from the normal blood loss group (P<0.001) ( Table 4 ). MMAS, menorrhagia multi-attribute quality-of-life scale; PBAC, Pictorial Blood Loss Assessment Chart; SD, standard deviation. According to the HMB knowledge questionnaire, 63.2% (728/1152) of the patients knew nothing about HMB, while 34.5% (397/1152) had limited knowledge of HMB. With regard to the medical treatment (multiple choices), 47.2% (544/1152) of the patients believed that profuse menstruation is a kind of disease that requires medical treatment, 48.2% (555/1152) believed that scanty menstruation is a kind of disease that requires medical treatment, 42.0% (484/1152) believed that consistent profuse menstruation without any other disease or without affecting the quality-of-life requires no medical treatment, and 18.1% (208/1152) believed that consistent scanty menstruation without any other disease or without affecting the quality-of-life requires no medical treatment. Regarding the connection between HMB and anemia, only 45.5% (524/1152) patients believed that the two are related, while 54.5% (628/1152) believed that there was no connection between the two or had no idea at all ( Table 5 ). HMB, heavy menstrual bleeding.

HMB is frequently found among women consulting to a gynecological clinic, and is a common manifestation of AUB. Among the subgroup of patients who underwent routine laboratory tests, HMB affects a woman’s physical and emotional quality of life. There is a low level of awareness and understanding of HMB amongst women. We suggest an effective approach where patients can use their mobile phones or tablets to assess blood loss using PBAC, which they can send to hospital via WeChat. This tool may help health care providers and patients easily and accurately ascertain whether the patient suffers from HMB.

This cross-sectional study included all consecutive outpatients who visited the Peking University People’s Hospital from September 2016 to November 2016 for various gynecological diseases or for a routine medical examination. The inclusion criteria were: 1) an intact uterus; 2) with at least one ovary; 3) having menstruation; and 4) keeping a period diary or capable of recalling their menstruation-related facts. The exclusion criteria were: 1) pregnant women; 2) preadolescent or postmenopausal bleeding; 3) hormone replacement therapy due to primary amenorrhea or premature ovarian failure; 4) uterus/ovary removed on both sides; 5) use of steroid hormones in the past 3 months due to AUB; or 6) levonorgestrel-releasing intrauterine system (such as levonorgestrel intrauterine device) or implanted subdermal contraceptive. AUB was diagnosed based on the FIGO criteria [ 11 ]. The patients used a mobile phone or tablet to scan a WeChat QR Code to access the mobile questionnaire survey system. The study complied with the terms of service for the WeChat social media application software. All participants filled up the questionnaires and scales: general information questionnaire, period diary questionnaire, Menorrhagia Multi-Attribute Quality-of-Life Scale (MMAS), and menorrhagia knowledge questionnaire. The investigators were responsible for monitoring the results, and the physicians received training on the functions of the questionnaire system, the items included in the questionnaire, and the meaning of each item for implementing the survey. This questionnaire included items related to reasons for visiting the hospital, age, gestational history, menstrual cycle, self-assessment of menstrual blood volume, history of gynecological diseases (leiomyoma, adenomyosis, endometrial polyp, and endometrial hyperplasia), and history of gynecological surgery. The patients were requested to use the Pictorial Blood Loss Assessment Chart (PBAC), a self-administered pictorial assessment chart that allocates scores reflecting the degree of staining of tampons and cotton-based sanitary pads during a menstrual cycle [ 8 , 12 , 13 ], to assess their menstrual blood volume, and upload the information by WeChat for 2 months. The PBAC has been validated [ 12 , 13 ]. They were instructed by their physicians regarding the use of the PBAC. PBAC scoring ≥100 for 2 months was considered as HMB, PBAC <10 was considered as hypomenorrhea, and PBAC scoring 10–99 was considered as normal menstrual flow [ 13 ]. All the sanitary products used were cotton-based. The PBAC score was automatically calculated by the mobile questionnaire survey system. Patients with hemoglobin (Hb) <115 g/L were diagnosed with anemia. The MMAS [ 14 , 15 ] was used to measure the impact of HMB on the daily life of patients during menstruation. The MMAS includes six dimensions: practical difficulties, social life, family life, work and daily routine, psychological well-being, and physical health. Each patient was asked to construct a series of statements for each domain, and the final score was obtained based on the weighted score for each dimension and the weighted score for severity level. The score ranged from 0 (all dimensions in the worst state) to 100 (all dimensions in the best possible state). It was considered that daily life was affected when MMAS reached <100. The HMB knowledge questionnaire was designed by the study authors and included three questions ( S1 Material ). (1) How much do you know about HMB: no knowledge, limited knowledge, partial knowledge, moderate knowledge, or adequate knowledge. (2) Which of the following do you agree with (multiple choices): profuse menstruation is a kind of disease that requires medical treatment; scanty menstruation is a kind of disease that requires medical treatment; consistent profuse menstruation without any other disease requires no medical treatment; consistent profuse menstruation without affecting the quality-of-life requires no medical treatment; consistent scanty menstruation with (without) any other disease requires no medical treatment; and consistent scanty menstruation without affecting the quality-of-life requires no medical treatment. (3) Do you believe that HMB is related to anemia: yes, no, or don’t know. If patients did not answer a question, the question was not included in the statistical analysis. This questionnaire was not validated. SPSS 17.0 (SPSS Inc., Chicago, IL) was used to perform the statistical analyses of the questionnaire data. Continuous data were expressed as means ± standard deviations (SD) and the differences between groups were analyzed using the Student’s t-test. Categorical data were expressed as frequency (percentage) and analyzed using the chi-square test. P-value <0.05 was considered statistically significant. This study was approved by the ethics committee of Peking University People’s Hospital (No. 2015PHB087-01). All procedures were in accordance with the ethical standards of the institutional and national research committees, and in line with the 1964 Helsinki declaration and its later amendments or with comparable ethical standards. Informed consent was obtained from all participants included in the study. Because this survey did not involve interventions or supplementary medical procedures/testing, the patients provided their consent verbally to their physician. Then, completing the questionnaires was considered as a de facto consent. The ethics committee approved this consent procedure.

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