Management of Abnormal Uterine Bleeding in Low- and High-Resource Settings: Consideration of Cultural Issues

Abstract

In non industrialized countries the incidence of heavy menstrual bleeding (HMB) appears to be similar to that of industrialized countries, although data is scanty. In low-resource settings, women with abnormal uterine bleeding (AUB) often delay seeking medical care because of cultural beliefs that a heavy red menstrual bleed is healthy. Efforts to modify cultural issues are being considered. A detailed history and a meticulous examination are the important foundations of a definitive diagnosis and management in low-resource settings but are subject to time constraints and skill levels of the small numbers of health professionals. Women's subjective assessment of blood loss should be combined, if possible, with a colorimetric hemoglobin assessment, if full blood count is not possible. Outpatient endometrial sampling, transvaginal sonography, and hysteroscopy are available in some non industrialized countries but not in the lowest resource settings. After exclusion of serious underlying pathology, hematinics should be commenced and antifibrinolytic or nonsteroidal anti-inflammatory drugs considered during menses to control the bleeding. Intrauterine or oral progestogens or the combined oral contraceptive are often the most cost-effective long-term medical treatments. When medical treatment is inappropriate or has failed, the surgical options available most often are myomectomy or hysterectomy. Hysteroscopic endometrial resection or newer endometrial ablation procedures are available in some centers. If hysterectomy is indicated the vaginal route is the most appropriate in most low-resource settings. In low-resource settings, lack of resources of all types can lead to empirical treatments or reliance on the unproven therapies of traditional healers. The shortage of human resources is often compounded by a limited availability of operative time. Governments and specialist medical organizations have rarely included attention to AUB and HMB in their health programs. Local guidelines and attention to training of doctors, midwives, and traditional health workers are critical for prevention and improvement in management of HMB and its consequences for iron deficiency anemia and postpartum hemorrhage, the major killer of young women in developing countries.

Severe anemia from heavy menstrual bleeding requires heightened attention

“…31,32 Some have suggested that there is a strong cultural component to this failure to recognize abnormal blood loss; some women believe that an ample flow of red blood indicates superior fertility or better cleansing. 39 Equally disturbing is the fact that even when women report years of excessive bleeding, they do not seek medical assistance for effective therapy; in our population more than two thirds reported more than 6 months of excessively heavy bleeding. Nearly 40% of women had previously required blood transfusion.…”

The burden of health associated with benign gynecological disorders in low‐resource settings

“…HMB is often associated with a complex of symptoms and the burden of the condition extends into many aspects of women's lives through the practical difficulties of excessive blood loss and having to curb normal social, cultural, and religious activities [15,16]. When neglected, HMB can lead to iron deficiency (with or without anemia) that results in chronic symptoms of fatigue, increased susceptibility to infections, and poor wound healing [17]. These symptoms may occur with iron deficiency on its own, even in the absence of anemia.…”

Potentially effective therapy of heavy menstrual bleeding with an oestradiol-nomegestrol acetate oral contraceptive: a pilot study

“…In women with no underlying structural pathology, medical therapy is considered the preferred treatment for HMB [14]. However, in order to determine the efficacy of a new treatment, it is necessary to measure the actual physical monthly blood loss both prior to and during treatment.…”