Under-Diagnosed and Under-Treated Menorrhagia in Young Women Produce Suboptimal Performance
Authors: Bauman Dvora , Sommer Adir , Noy Dar , Hammer Tal , Revel-Vilk Shoshana 
Published: November 2020

Background: Menorrhagia can have a significant impact on a woman's life. It can lead to anemia, fatigue, difficulty with physical activities, absence from work, and avoidance of social activities and may be the first sign of a bleeding disorder. We presumed that many young women with menorrhagia do not seek medical advice or are under-treated. This study aimed to document the prevalence of menorrhagia, by questionnaire, visual scores and self-assessment; its association with bleeding disorders, and the effect of menorrhagia on activity and quality of life (QoL) in young adults engaged in compulsory military service. The military service in Israel is obligatory for women as for men, making this cohort similar to the general population.
Method: In this cross-sectional study we gave a short oral lecture presenting the study objective and plan to female soldiers in combat and non-combat roles. Participants were asked to consent to complete a one page coded, unidentified, initial questionnaire. After providing an additional informed consent, study participants were asked to complete additional study questionnaires, including personal and family bleeding history, pictorial bleeding assessment chart (PBAC), dysmenorrhea questionnaire, and age-appropriate PedsQL™. All forms were coded with the same number as the initial questionnaire. PBAC scores above 100 were diagnostic for menorrhagia and above 200 signified severe menorrhagia.
Results: Of 422 women soldiers completing the initial questionnaire, 365 (86.5%) completed all study questionnaires. Characteristics of women not completing all study questionnaires were similar to those with complete study data except there were more soldiers in a combat role in the former (P=0.02). The median (range, 25th-75th interval) of the PBAC score was 100 (4-590, 55-189). PBAC scores &gt; 100 and 200 were reported by 181 (50%) and 81 (22%), respectively. Most participants correctly self-assessed menorrhagia; still, a high PBAC score was also recorded in some who answered "no" or "unknown" in the initial questionnaire (Figure 1). Diagnosis of menorrhagia was associated with a history of bleeding, specifically cutaneous and bleeding from the oral cavity (Figure 2), yet none of the participants reported a diagnosis of a known bleeding disorder. The use of NSAIDs during menstruation was associated with a higher rate of menorrhagia (Table 1). No association was found with the current army role. However, the diagnosis of menorrhagia was related to the pre-enrolment fitness ranking [a score reflecting the overall per-recruitment health status] (Table 1). Those with menorrhagia suffered from higher pain levels and moderate to severe negative effects on activity during the days of menstruation compared to those without menorrhagia (Table 1, Figure 3). A trend for lower QoL was found in those with menorrhagia (Table 1).
Discussion: Menorrhagia in young adults is a significant clinical problem effecting activity and quality of life. It is under-recognized and under-treated. The association with other bleeding manifestations may suggest an under diagnosis of bleeding disorders. In a world of women empowerment, any treatable cause, leading to suboptimal performance should be addressed. Thus, assessment for menorrhagia and dysmenorrhea should be part of well-being visit also in young adults to provide appropriate management to reduce the undesired effects of menorrhagia.

Disclosures
Revel-Vilk: Takeda: Honoraria; sanofi-Genzyme: Honoraria; Pfizer: Honoraria.