Validating a pencil-and-paper measure of perimenopausal menstrual blood loss

doi:10.1016/j.whi.2004.07.005

Women's Health Issues

Volume 14, Issue 6, November–December 2004, Pages 242-247

https://doi.org/10.1016/j.whi.2004.07.005 Get rights and content

In the study presented here, we describe our efforts to develop and validate a new measurement tool for perimenopausal menstrual blood loss. We validate this simple-to-use, subjective pencil-and-paper scale, the Mansfield-Voda-Jorgensen Menstrual Bleeding Scale (MVJ), against an objective measure, the weight of used menstrual products. Thirty-one women from the Minneapolis-St. Paul, MN region saved all their used products over three menstrual cycles, storing them in airtight zip bags, and rated their menstrual fluid volume loss using the MVJ. The overall correlation between MVJ scores and log discharge rate was quite high (r = 0.683); all MVJ categories were statistically unique with the exception of categories “1” and “2.” The overall fit, then, was particularly good at the heavy bleeding end of the scale. When five women with poor performance were removed, the correlations ranged from 0.480–0.894. The MVJ is a promising tool for identifying women with excessive menstrual bleeding. It is a simple-to-use, pencil-and-paper scale that offers an inexpensive and practical method to clinicians who work with perimenopausal women, the group most vulnerable to unnecessary worry and/or interventions when menorrhagia is incorrectly diagnosed.

Section snippets

Introduction and background

Irregular and heavy menstrual bleeding are common gynecological complaints of perimenopausal women (Mansfield & Boyer, 1990; Mansfield & Voda, 1997; Roy & Mattox, 2003; Warren, 2002). Too often, a woman’s report of “heavy bleeding” is transformed into a clinical diagnosis of menorrhagia, which, by definition, is menstrual blood loss of ≥80 mL per cycle (Fraser et al., 1985; Hallberg & Nilsson, 1966; Hallberg et al., 1966; Janssen, Scholten, & Heintz, 1997; Roy & Mattox, 2003; Warren, 2002). A

Sample

From a list of 180 participants of the TREMIN Research Program on Women’s Health (formerly Alan Treloar’s Menstrual and Reproductive History Program), 40 women were randomly chosen to participate in this special study and received invitations by phone. All of the eligible participants lived in the Minneapolis/St. Paul, Minnesota area, were between the ages of 35 and 55, were still menstruating, and were not using exogenous hormones. TREMIN is the oldest ongoing research program of women’s

Results

Thirty-one women completed the study. One participant dropped out because she had a hysterectomy. The mean age of the participants was 47.6 years (range 38–52). Women selected 28 different brands of tampons and pads for use during the three menstrual cycles of this study. If we include different absorbencies of those brands selected by the participants, that figure rises to 87. The average number of products used by participants was 48.3 (SD = 24.4)

Although our sample was selected randomly and

Discussion

In this study, we tested the validity of the MVJ by comparing the scale ratings selected by participants to describe the magnitude of blood loss against an objective measure, the weight of used menstrual products. Work by Fraser et al. (2001) confirmed that the weight of total menstrual volume is an accurate method to use to estimate the volume of blood lost. The findings of our study confirm that the MVJ is a valid way to estimate menstrual fluid volume loss. The overall fit is particularly

Acknowledgments

This research was funded in part by Tambrands, Inc. and Public Health Service Research Grant No. RR-64 from the Division of Research Resources, U.S. Public Health Service.

Phyllis Kernoff Mansfield, PhD, is a professor of Women’s Studies and Health Education, and senior scientist at the Population Research Institute at Penn State. Her research interests include women’s health, the reproductive concerns of midlife women, sexuality, and the psychology of health. She is the Director of the TREMIN Research Program on Women’s Health and co-director of the Midlife Women’s Health Survey and serves on the board of directors of the Society for Menstrual Cycle Research.

References (31)

I.S. Fraser et al.
A preliminary study of factors influencing perception of menstrual blood loss volume
American Journal of Obstetrics and Gynecology
(1984)
I.S. Fraser et al.
Estimating menstrual blood loss in women with normal and excessive menstrual fluid volume
Obstetrics and Gynecology
(2001)
C.A.H. Janssen et al.
A simple visual assessment technique to discriminate between menorrhagia and normal blood loss
Obstetrics and Gynecology
(1995)
C.A.H. Janssen et al.
Menorrhagia—a search for epidemiological risk markers
Maturitas
(1997)
J. Newton et al.
A rapid method for measuring menstrual blood loss using automatic extraction
Contraception
(1977)
K. Wyatt et al.
Determination of total menstrual blood loss
Fertility and Sterility
(2001)
C. Berken
In behalf of women over 40understanding the importance of the menopause
Social Work
(1986)
T. Chimbira et al.
Relation between measured menstrual blood loss and patients’ subjective assessment of loss, duration of bleeding, number of sanitary towels used, uterine weight and endometrial surface area
British Journal of Obstetrics and Gynaecology
(1980)
I.S. Fraser et al.
Blood and total fluid content of menstrual discharge
Obstetrics and Gynecology
(1985)
I.S. Fraser et al.
Efficacy of mefanamic acid in patients with a complaint of menorrhagia
Obstetrics and Gynecology
(1981)

L. Hallberg et al.

Menstrual blood lossa population study

Acta Obstetricia et Gynecologica Scandinavica

(1966)

L. Hallberg et al.

Constancy of individual menstrual blood loss

Acta Obstetricia et Gynecologica Scandinavica

(1964)

L. Hallberg et al.

Determination of menstrual blood loss

Scandinavian Journal of Clinical Laboratory Investigation

(1966)

P.T. Haynes et al.

Measurements of menstrual blood loss in patients complaining of menorrhagia

British Journal of Obstetrics and Gynaecology

(1977)

A.-L.M. Heath et al.

Validation of a questionnaire method for estimating extent of menstrual blood loss in young adult women

Journal of Trace Elements in Medical Biology

(1998)

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Exploratory factor analysis identified 18 domains (Cronbach’s α > 0.7) and 30 redundant items. Test-retest analysis found acceptable intra-class correlations of 0.6–0.9 (p < 0.05). Eight domains were compared with Menstrual Distress Questionnaire showing moderate or strong correlation in seven domains. Ten domains were compared with Women’s Health Questionnaire, six of which showed moderate correlation. Mean QQ-10 Value and Burden scores were 76 and 25, respectively (SD=15.8 and 15.5). The mean completion time for ePAQ-MPH was 31 min. CFA of the revised version 2 instrument with 15 domains showed good model fit.
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Ann Voda was the second director of the TREMIN Research Program on Women’s Health from 1984 to 1998 at the University of Utah. She is a former president of the North American Menopause Society.

Dr. Gary Allison focuses on computationally intensive analyses of large datasets in fields ranging from bioinformatics to ecology and conservation.

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Validating a pencil-and-paper measure of perimenopausal menstrual blood loss

Section snippets

Introduction and background

Sample

Results

Discussion

Acknowledgments

American Journal of Obstetrics and Gynecology

Obstetrics and Gynecology

Obstetrics and Gynecology

Maturitas

Contraception

Fertility and Sterility

In behalf of women over 40understanding the importance of the menopause

Social Work

Relation between measured menstrual blood loss and patients’ subjective assessment of loss, duration of bleeding, number of sanitary towels used, uterine weight and endometrial surface area

British Journal of Obstetrics and Gynaecology

Blood and total fluid content of menstrual discharge

Obstetrics and Gynecology

Efficacy of mefanamic acid in patients with a complaint of menorrhagia

Obstetrics and Gynecology

Menstrual blood lossa population study

Acta Obstetricia et Gynecologica Scandinavica

Constancy of individual menstrual blood loss

Acta Obstetricia et Gynecologica Scandinavica

Determination of menstrual blood loss

Scandinavian Journal of Clinical Laboratory Investigation

Measurements of menstrual blood loss in patients complaining of menorrhagia

British Journal of Obstetrics and Gynaecology

Validation of a questionnaire method for estimating extent of menstrual blood loss in young adult women

Journal of Trace Elements in Medical Biology