November 14, 2012

Quantification of Menstrual Cycle Disorders

a report by
Tracy M Nevatte, PhD, Julia L Magnay, CSci and Shaughn O’Brien, MD, FRCOG
Keele Menstrual Disorders Laboratory, Institute for Science and Technology in Medicine, University Hospital North Staffordshire/Keele University

Disorders of the menstrual cycle include heavy menstrual bleeding (HMB), pre-menstrual syndrome (PMS), pre-menstrual dysphoric disorder (PMDD), and dysmenorrhea. There are numerous potential symptoms, making the diagnosis of these conditions difficult. Therefore, no single test exists for use in either the clinical or research setting, and feedback from the patient is sometimes the only information available. Quantification of a disorder helps to confirm or refute diagnosis, and thus the appropriate treatment regimen can be instigated. This article will present a brief overview of the current methods available for diagnosis or quantification of these menstrual disorders.

Heavy Menstrual Bleeding

For many years HMB was defined as a blood loss of more than 80ml per cycle, and this definition is still used for research purposes.1 Recently, National Institute for Health and Clinical Excellence (NICE) guidelines redefined HMB as “excessive menstrual blood loss that interferes with a woman’s physical, emotional, social, and material quality of life, and can occur alone or in combination with other symptoms.”2 Even with this qualitative definition, it is still necessary to quantify menstrual fluid loss, whether in the research setting to investigate the efficacy of a drug designed to reduce menstrual fluid loss or in the clinical setting to provide reassurance to a woman that her periods are in fact ‘normal.’3 A patient’s opinion of her own menstrual fluid loss is not reliable for diagnostic purposes.4 Neither duration of menstruation nor the number of tampons/sanitary towels used are reliable diagnostic markers for quantifying menstrual loss.3 A colorimetric biochemical technique, the alkaline hematin method developed in the 1960s, is still used in the research setting to measure total menstrual blood loss.5 This procedure involves treating soiled sanitary towels with sodium hydroxide solution, which converts hemoglobin to hematin. The alkaline hematin method is not used in the clinical setting due to several limitations.

First, it is a cumbersome, labor-intensive, and time-consuming technique. Second, there are health and safety implications due to the large volumes of sodium hydroxide required and the risk for blood-borne viral infections. Third, because all towels/tampons are processed together, the data are unable to provide any information regarding the patient’s menstrual bleeding pattern over her menstrual period. Lastly, the technique was originally developed using towels and tampons composed of cotton–cellulose fibers, which readily release hemoglobin into the sodium hydroxide solution; however, the current generation of sanitary products now includes ultra-slim sanitary towels that use superabsorbent polymers as the absorptive agent. These slimline towels are more acceptable to patients, but the reliability of using the alkaline hematin method with these new sanitary products has not yet been validated. Furthermore, although the alkaline hematin method is considered to be the ‘gold standard,’ it measures menstrual blood loss only, not total menstrual fluid loss.

Menstrual fluid is a combination of whole blood (30–50%) and endometrial transudate, although there is evidence to suggest that when bleeding is heavy the ratio of blood to menstrual fluid increases.6,7 However, it is the total menstrual fluid loss that is of most concern to the patient. For a menstrual fluid loss assessment to become widely used both clinically and for research purposes, a robust, simple protocol is required that does not involve the collection of soiled sanitary towels/tampons and technical expertise or equipment. One such methodology was published in 1990, and was called the Pictorial Blood Loss Assessment Chart (PBAC).8 It consisted of three pictorial icons depicting sanitary towels with progressively increasing stained areas that represented known volumes of menstrual fluid loss.8 However, with only three icons, the range of interpretation was too wide and inaccurate for practical use. In 2001, the PBAC was replaced by the Menstrual Pictogram, with the addition of two further icons.9 Like the alkaline hematin method, the Menstrual Pictogram was developed using cotton–cellulose sanitary towels.

The current generation of ultra-slim towels are different sizes and shapes from the old-style cotton products, so the icons are no longerre preventatives of current towel technology. Therefore, both the Menstrual Pictogram and the alkaline hematin method require revalidation before use with towels containing super-absorbent properties.


Dysmenorrhea is lower abdominal or pelvic pain that can also radiate to theback and thighs, and occurs before, at the onset of, or during menstruation.10The disorder is usually classified as primary or secondary dysmenorrhea. Primarydysmenorrhea is seen predominantly in adolescent females, and is notassociated with any pelvic disease. Secondary dysmenorrhea usually has anunderlying pathology such as endometriosis, and is more common in womenafter their mid- to late 20s.10,11 It can also be iatrogenic (linked tointrauterine contraception device use). With secondary dysmenorrhea, alaparoscopy is frequently required for clarification of the diagnosis and thecause of the pain. However, there is currently no consensus concerningthe methods that should be used for quantification of symptoms or diagnosisof dysmenorrhea. Published quantification methods of this disorder, either bya clinician or for research purposes, generally involve some form of categoricalscale. Typically, at the beginning of a dysmenorrhea study such a scale isdevised by each individual research team.12 Consequently, there is nomethodical consensus or standardized technique available.

Pre-menstrual Syndrome and Pre-menstrual

PMS is characterized by a combination of somatic and psychological changesthat occur during the luteal phase of the menstrual cycle and terminate duringmenses.13 Over 200 pre-menstrual symptoms have been described, withvarying severity, resulting in a spectrum ranging from minimal to disabling.14PMDD represents the extreme of this continuum, with predominantlypsychological symptoms. These can produce such distressing emotional andbehavioral manifestations that they disrupt daily routines and interpersonalrelationships.15,16 When assessing a woman for PMS/PMDD, it is important toverify that the symptoms are not a pre-menstrual exaggeration of anunderlying psychiatric condition.17 The characteristic ‘on–off’ cyclic pattern ofsymptoms is a strong diagnostic indicator of PMS/PMDD, in contrast to thoseof a general psychiatric disorder in which the symptoms are non-cyclic. Severalmethods exist to quantify PMS (see Dhingra and O’Brien, 2007, for acomprehensive review).17 The Daily Record of Severity of Problems (DRSP) isbased on the symptoms documented in the Diagnosis and Statistical Manualof Mental Disorders, Fourth Edition (DSM-IV) criteria,18 and is therecommended diagnostic method for PMS by the Royal College ofObstetricians and Gynaecologists (RCOG) in the recent Green-top GuidelineNo. 48 for the management of PMS.19 Data must be collected prospectivelyover at least two cycles. This will identify the cyclical nature of the symptoms,the effect on functioning, and the level of underlying psychopathology.Recently, Endicott and Harrison reformatted the DRSP, in which data areplotted graphically on a daily basis as the record sheet is completed. In this way,the patient and clinician can rapidly ascertain any developing patterns ofsymptoms as the cycle progresses.20 One limitation of the DRSP is the lengthof time required before a diagnosis/measurement is finalized. ThePre-menstrual Symptoms Screening Tool (PSST) was developed by Steiner et provide a quicker method of identifying severe PMS/PMDD.21 Like the DRSP,the PSST is based on the DSM-IV criteria. It has not been validated against theDRSP, but has the potential to be a useful diagnostic tool for PMS. If the PSSTsuggests that a woman has severe PMS/PMDD, a DRSP could then beundertaken to confirm the diagnosis.Ovarian suppression could theoretically be used as a test to distinguish therelative contributions of underlying psychopathology and hormones.22Gonadotropin-releasing hormone (GnRH) agonist analogs have the ability tocompletely suppress ovarian endocrine activity and the post-ovulatory releaseof progesterone, and hence the underlying cause of the symptoms.15 The‘GnRH test’ has been used extensively in the clinical setting, although it hasnot been scientifically validated.


To ensure patient compliance, any method used to diagnose or quantify amenstrual disorder must be rapid and simple to use, and must not useretrospective data recording or require any technical expertise. A correctdiagnosis is imperative in avoiding unnecessary procedures and prescriptions,all of which have inherent risks. Quantification of symptoms is also crucial indetermining the efficacy of a drug or therapy. Some authorities may considerthat the patient and clinician’s impression of quality of life is more importantthan the actual quantification of PMS/PMDD, dysmenorrhea, or heavymenstrual bleeding;2 however, we consider quantification equally important,even if just to reassure a patient that her menstrual fluid loss is ‘normal.’