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Abnormal uterine bleeding (AUB) may display several patterns, and descriptive terms have been updated to standardize nomenclature (Munro, 2011). For example, heavy menstrual bleeding (HMB) (formerly menorrhagia) defines prolonged or heavy cyclic menstruation. Objectively, menses lasting longer than 7 days or exceeding 80 mL of blood loss are determining values. The term intermenstrual bleeding replaces metrorrhagia. Frequently, women may complain of both patterns. The term breakthrough bleeding is a more informal term for intermenstrual bleeding that accompanies hormone administration. In some women, there is diminished flow or shortening of menses, hypomenorrhea. Women normally menstruate every 28 days ± 7 days. Cycles with intervals longer than 35 days describe a state of oligomenorrhea. The term withdrawal bleeding refers to the predictable bleeding that results from an abrupt decline in progesterone levels. Finally, postcoital bleeding is that prompted by vaginal intercourse.

Assessing HMB in a clinical setting has its limitations. First, patient perception of blood loss and objective measurement often fail to correlate (Chimbira, 1980b). As a result, objective methods to assess blood loss have been investigated. Hallberg and associates (1966) describe a technique to extract hemoglobin from sanitary napkins using sodium hydroxide. Hemoglobin is converted to hematin and can be measured spectrophotometrically. Although used in research, this approach in a clinical setting has obvious constraints.

Other tools used to estimate menstrual blood loss include hemoglobin and hematocrit evaluation. Hemoglobin concentrations below 12 g/dL increase the chance of identifying women with HMB. A normal level, however, does not exclude HMB, as many women with clinically significant bleeding have normal values.

Another method involves estimating the number and type of pads or tampons used by a woman during menses. Warner and colleagues (2004) found positive correlations between objective HMB and passing clots more than 1 inch in diameter and changing pads more frequently than every 3 hours. Attempts to standardize this type of evaluation have lead to development of the pictorial blood assessment chart (PBAC) (Fig. 8-1). With a scoring sheet, patients are asked to record daily the number of sanitary products that are lightly, moderately, or completely saturated. Scores are assigned as follows: 1 point for each lightly stained tampon, 5 if moderately saturated, and 10 if completely soaked. Pads are similarly given ascending scores of 1, 5, and 20, respectively. Small clots score 1 point, whereas large clots score 5. Points are then tallied for each day. Totals more than 100 points per menstrual cycle correlate with greater than 80 mL objective blood loss (Higham, 1990).


Scoring for the pictorial bleeding assessment chart. Patients are counseled to evaluate the degree of saturation for each sanitary product used during menstruation. The total number of points are tallied for each menses. Point totals greater than 100 indicate menorrhagia.


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