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

Abstract Background Pictorial blood loss assessment charts (PBACs) represent the most widely used method to assess menstrual blood loss (MBL) in clinical trials. The aims of this review were to: (1) determine the diagnostic accuracy of PBACs that have been validated against the reference alkaline hematin technique; (2) categorize the pitfalls of using obsolete and nonvalidated charts; (3) provide guidelines for development of a new PBAC or use of an existing chart to measure MBL in clinical trials; and (4) consider the feasibility of using pictorial charts in primary care. Methods A literature review was conducted using Embase and MEDLINE databases. The review identified reports of women with self-perceived or actual heavy menstrual bleeding (HMB), bleeding disorders, abnormal uterine bleeding, leiomyomata (uterine fibroids) or endometriosis, and women undergoing treatment for HMB, as well as those with normal menstrual periods. Data were reviewed from studies that focused on the development and validation of PBACs and from those that used derivative noncertified charts to assess HMB. Results Nine studies reported validation of PBAC scoring systems against the alkaline hematin technique. Across these studies, the sensitivity was 58–97%, the specificity was 7.5–95.5%, the positive and negative likelihood ratios were 1.1–13.8 and 0.14–0.56, respectively, and the diagnostic odds ratio was 2.6–52.4. The cut-off score above which the diagnosis of HMB was made ranged from 50 to 185. Several modifications of these PBACs were used in other studies; however, objective confirmation of their validity was not reported. Overall, there was widespread inconsistency of chart design, scoring systems, diagnostic cut-off limits and post-treatment outcome measures. Conclusions PBACs are best suited to the controlled and specific environment of clinical studies, where clinical outcome parameters are defined. The current lack of standardization precludes widespread use of the PBAC in primary care. Review registration number PROSPERO international prospective register of systematic reviews: CRD42016030083.

Keywords: bleeding disorders; heavy menstrual bleeding; menstrual blood loss; menstrual pictogram; pictorial blood loss assessment chart EN bleeding disorders heavy menstrual bleeding menstrual blood loss menstrual pictogram pictorial blood loss assessment chart e632 e635 4 09/16/21 20210901 NES 210901 Uterine blood loss occurs normally in women between puberty and menopause as menstruation, and after childbirth during the postpartum period. The primary use of the PBAC is to quantify menstrual blood loss and menorrhagia, although it has also been used to quantify postpartum blood loss.6 Using this scoring system, 80 mL of menstrual blood loss results in a PBAC score of 100. [Extracted from the article]

Background: Pictorial blood loss assessment charts (PBACs) represent the most widely used method to assess menstrual blood loss (MBL) in clinical trials. The aims of this review were to: (1) determine the diagnostic accuracy of PBACs that have been validated against the reference alkaline hematin technique; (2) categorize the pitfalls of using obsolete and nonvalidated charts; (3) provide guidelines for development of a new PBAC or use of an existing chart to measure MBL in clinical trials; and (4) consider the feasibility of using pictorial charts in primary care.Methods: A literature review was conducted using Embase and MEDLINE databases. The review identified reports of women with self-perceived or actual heavy menstrual bleeding (HMB), bleeding disorders, abnormal uterine bleeding, leiomyomata (uterine fibroids) or endometriosis, and women undergoing treatment for HMB, as well as those with normal menstrual periods. Data were reviewed from studies that focused on the development and validation of PBACs and from those that used derivative noncertified charts to assess HMB.Results: Nine studies reported validation of PBAC scoring systems against the alkaline hematin technique. Across these studies, the sensitivity was 58-97%, the specificity was 7.5-95.5%, the positive and negative likelihood ratios were 1.1-13.8 and 0.14-0.56, respectively, and the diagnostic odds ratio was 2.6-52.4. The cut-off score above which the diagnosis of HMB was made ranged from 50 to 185. Several modifications of these PBACs were used in other studies; however, objective confirmation of their validity was not reported. Overall, there was widespread inconsistency of chart design, scoring systems, diagnostic cut-off limits and post-treatment outcome measures.Conclusions: PBACs are best suited to the controlled and specific environment of clinical studies, where clinical outcome parameters are defined. The current lack of standardization precludes widespread use of the PBAC in primary care.Review Registration Number: PROSPERO international prospective register of systematic reviews: CRD42016030083. [ABSTRACT FROM AUTHOR]

The article presents a study which validates the semiquantitative tool menstrual pictogram (MP) that assesses blood loss in women with leiomyomata associated with heavy menstrual bleeding (HMB) against alkaline hematin (AH) quantitation. It states that premenopausal women aged 18 years old and above with the said condition randomly taken placebo and asoprisnil. Results show 91% positive predictive value of MP in identifying women with HMB against AH.

Objective: To validate the menstrual pictogram (superabsorbent polymer-c version) for Always Ultra-slim feminine towels containing superabsorbent polymers. Design: Prospective, multicenter, evaluator-blinded study. Setting: Three gynecology research clinics in the United Kingdom. Patient(s): Women with self-perceived light, normal, or heavy menstrual periods who had not previously used a graphical method to assess their menstrual loss. Intervention(s): One hundred twenty-two women were asked to complete the menstrual pictogram throughout two menstrual periods and collect their feminine towels for measurements of menstrual blood loss (MBL) by the alkaline hematin method and total menstrual fluid loss (MFL) by fluid weight. Main Outcome Measure(s): Agreement of menstrual pictogram MBL and MFL scores with alkaline hematin and towel weight, respectively. The percentage blood fraction was determined at various volumes of menstrual discharge. Result(s): Alkaline hematin and fluid weight were highly correlated (r = .97). However, the percentage blood fraction progressively increased with total MFL and MBL score. After correction for this incremental rise in blood fraction, the menstrual pictogram gave a sensitivity of 82% and a specificity of 92% for a diagnosis of heavy menstrual bleeding. Conclusion(s): The menstrual pictogram (superabsorbent polymer-c version) provides a simple means of measuring MBL in the clinical setting. [Copyright &y& Elsevier]

Objective: To determine whether the menstrual pictogram (the superabsorbent polymer-c or SAP-c version) can reliably estimate blood and total menstrual fluid volumes on prestained Always Ultra slim feminine towels (Proctor & Gamble) that contain superabsorbent polymers. Design: Randomized blinded study using simulated menstrual fluid (SMF: 50% blood, 50% saline mixture). Setting: Gynecology research clinic. Patient(s): 12 premenopausal women with regular menstrual cycles who had not previously used a graphical method to assess menstrual loss. Intervention(s): None. Main Outcome Measure(s): Assignment of 135 prestained towels containing known volumes of 0.5–25.0 mL of SMF to five pictorial icons of the menstrual pictogram, and correlation of pictogram scores to blood recovered from towels by the alkaline hematin method and total fluid applied to towels by measurement of soiled towel weight. Result(s): There was a high level of agreement between individual scores. For 112 (83%) of 135 towels, the participants' readings either completely concurred or differed by only a single icon. There was a statistically significant correlation between the volume of blood applied (SMF/2) and that recovered by alkaline hematin, and volume of fluid applied and soiled towel weight. Conclusion(s): The menstrual pictogram (SAP-c version) is a potential diagnostic tool for heavy menstrual bleeding and would be suitable for testing in a clinical trial. [Copyright &y& Elsevier]

Abstract: Aim: To evaluate the efficacy and safety of Safoof Habis in Kasrate Tams (menorrhagia) with validated menstrual pictogram. Materials and methods: A single blind, randomized, standard controlled trial was conducted in the gynaecological outpatient of National Institute of Unani Medicine Hospital. Clinically diagnosed patients (n =52) were randomized to the test (n =35) and control (n =17) groups. In the test group, Safoof Habis (Ingredient are Silicate of alumina and Iron oxide, Hydrated magnesium silicate and Vateria indica L.) 5g twice daily and in the control group, tranexamic acid 500mg, thrice daily were administered from day 1 to day 5 of menstrual cycle and Qurs Kushta Faulad, one tablet twice daily was administered in both the groups for three consecutive months. The primary outcome measure was to assess the efficacy and safety of this Unani formulation in menorrhagia with menstrual pictogram. The secondary outcome measures were to assess the effectiveness of test drug formulation on dysmenorrhea and hemoglobin concentration. The results were analyzed by Student''s ‘t’ test and Fisher exact test. Results: The groups were homogenous in the terms of age, parity, socioeconomic status, marital status and biochemical parameters (P >0.05). Post treatment when compared to baseline in same group showed significant reduction in menstrual blood loss in both the groups (P <0.001). The comparison between test and control group showed that both groups were equally effective (P =0.265). There was improvement in hemoglobin concentration in the test group (P =0.04) and dysmenorrhea was reduced in both groups (P <0.001). Conclusion: Safoof Habis was found to be effective in reducing menstrual blood loss in menorrhagia. [Copyright &y& Elsevier]