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
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 al.to 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.
Conclusion
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.’
