Reflections on access to care for heavy menstrual bleeding: Past, present, and in times of the COVID‐19 pandemic

Abstract

The symptom of heavy menstrual bleeding (HMB) affects at least a quarter of reproductive‐age menstruators. However, given the variance in diagnosing the underlying causes, barriers, and inequity in access to care for HMB, and therefore reporting of HMB, this figure is likely to be a gross underestimate. HMB can have a detrimental impact on quality of life. From the limited reports available it is estimated that around 50%–80% of people with HMB do not seek care for this debilitating symptom, and for those that do, it may take years until the first treatment action. Almost half of those with HMB believe their condition is unworthy of treatment, that there is no treatment available, or that it is “normal”. The term “medical gaslighting” has recently been used to describe how healthcare professionals disregard people's symptoms. This has the ensuing effect of negatively compounding self‐doubt and embarrassment around menstrual bleeding, creating a cycle of diminished experience inhibiting further seeking of care. There is a scarcity of intervention studies informing increased access to care. Multilevel approaches are needed to increase access to care and support for those with HMB. During the COVID‐19 global pandemic, barriers to care access and support for HMB have been exacerbated and, given the significant pressures that this pandemic has placed on healthcare services worldwide, it will take many years to recover. In the meantime, it is crucial to ensure that medically “benign” conditions such as the symptom of HMB are not overlooked.

Recommendations for diagnosis, treatment, and prevention of iron deficiency and iron deficiency anemia

“…For reproductive‐aged women, the most common causes of ID and IDA are the symptoms of HMB and unreplenished losses from previous pregnancy 36,38,39 . As discussed previously, HMB has a prevalence much higher than that generally perceived from healthcare system‐based data; survey‐based studies indicate that up to 53% of women of reproductive age may experience the symptom at any given time putting them at high risk for ID and IDA 40‐44 . This risk is exemplified by evaluating iron‐dependent erythropoiesis in women with and without HMB, 2 and a Finnish study of women with HMB showed that 27% of its participants had IDA, 90% with a serum ferritin less than 30 µg/L, and 60% with serum ferritin levels below 15 µg/L 45 .…”

“… 36 , 38 , 39 As discussed previously, HMB has a prevalence much higher than that generally perceived from healthcare system‐based data; survey‐based studies indicate that up to 53% of women of reproductive age may experience the symptom at any given time putting them at high risk for ID and IDA. 40 , 41 , 42 , 43 , 44 This risk is exemplified by evaluating iron‐dependent erythropoiesis in women with and without HMB, 2 and a Finnish study of women with HMB showed that 27% of its participants had IDA, 90% with a serum ferritin less than 30 µg/L, and 60% with serum ferritin levels below 15 µg/L. 45 Effective diagnostic and therapeutic strategies exist for the varying causes of the symptoms of HMB 46 , 47 ; failure to identify and address this issue will prolong or even prevent the sustained normalization of iron stores.…”

Tranexamic acid for management of heavy vaginal bleeding: barriers to access and myths surrounding its use

“…Due to the limited awareness on HMB among patients and health care providers, coupled with poorly defined methods to quantify blood loss, symptom dismissal is a core theme for women who suffer from HMB [ 1 , 15 , [56] , [57] , [58] ]. Lending literature from women with bleeding disorders, where HMB is the most commonly reported symptom, contributors to the normalization of HMB can be classified into individual, provider, and societal levels.…”

“…In fact, only 4 out of 10 women with HMB will seek medical care, leaving many to suffer silently [ 62 ]. The combination of these experiences, coupled with self-doubt and symptom dismissal, perpetuates a cycle of normalization in HMB [ 58 ]. Effective knowledge translation strategies are needed to increase HMB awareness, including diversifying the education curriculum to ensure that young women are better informed [ 58 ].…”

Antiplatelet period drama: a rush of blood or classic crimson tide?

“…While this may be due, in part, to a lower prevalence of individuals of reproductive age using these medications, perhaps an equal contributor to the lack of recognition is a historical and cultural aversion to discussing menstruation, even among health care professionals [ 11 ]. This stigma has led to systemic normalization of symptoms by society and even “medical gaslighting” or the disregard of symptoms by medical providers [ 11 , 12 ]. Large, population-based studies that have attempted to quantify the burden of HMB suggest that nearly half of the individuals experiencing these symptoms have not sought medical attention, and among those who do, evaluation and treatment are often inadequate [ 2 ].…”