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• W3025665418 abstract "The FIGO Committee on Menstrual Disorders (The Menstrual Disorders Committee, or MDC), established in 2012, is dedicated to addressing non-gestational abnormal uterine bleeding (AUB) in the reproductive years as well as associated morbidity. The MDC continues its efforts to standardize nomenclature for AUB symptoms (FIGO System 1) as well as potential causes of the spectrum of menstrual symptoms experienced by women (FIGO System 2, PALM-COEIN), with the most recent revisions published in IJGO in late 2018.1 These systems are increasingly used in education and clinical care as well as in the design and interpretation of basic, translational, and clinical research on women and girls with AUB symptoms. It has been recognized that each of the potential causes of AUB that comprise the PALM-COEIN categorization (System 2) may benefit from subclassification to facilitate disorder-specific research, education, and clinical care. The leiomyoma subclassification system has been developed and modified and has been used in numerous clinical trials and other types of research.1 The MDC is at an advanced stage in the development of a standardized reporting system for adenomyosis, a process conducted in concert with multiple gynecologic societies and organizations worldwide as well as with both gynecological and radiological experts in uterine imaging. These efforts are ongoing, with anticipated results to be recognized over the coming months and years. On the horizon is a subclassification system for endometrial polyps as well as subcategorization of other diagnostic categories yet to be determined. With this editorial, we would like to introduce a new MDC initiative—one designed to raise awareness of the relationship between the symptom of heavy menstrual bleeding (HMB) and both iron deficiency (ID) and iron deficiency anemia (IDA). It is hoped that focusing attention on this insidious and highly prevalent relationship will result in the deployment of measures designed to address this issue in a meaningful fashion. Anemia is one of the world’s five most common causes of disability, with a global prevalence in menstruating women of about 30%; reaching 60% in parts of South Asia and sub-Saharan Africa.2-4 Approximately half of these cases of anemia are secondary to ID, a proportion that has been estimated to result in an annual loss of 19.7 million disability-adjusted life years, 1.3% of the worldwide total.5 There is evidence that 25%—perhaps more—of women with the symptom of HMB have IDA,6 and if ID without anemia is included the total is inevitably more.7, 8 Every day, women with IDA experience adverse effects on their quality of life—fatigue and diminished exercise capacity to name two. Anemic women who become pregnant are less able to tolerate peripartum hemorrhage and risk delivering babies with impaired neurological development.9 There is also evidence that ID alone, absent anemia, is itself associated with fatigue, reduced exercise tolerance, and impaired cognition.8 For women and girls in low-resource countries in particular, the impact of HMB on anemia is amplified by nutritional deficiencies.5 Women with iron-deficient diets related to cultural or socioeconomic reasons are far more susceptible to the effect of HMB and seem less likely to receive appropriate therapy. The impact of HMB itself on job performance may be substantial, with increased rates of employment absenteeism as well as presenteeism, which are likely compounded by the insidious effects of ID and IDA that are experienced each and every day.10 Even when diagnosed with IDA, it is apparent that women frequently are intolerant of treatment with oral iron products, a circumstance that results in poor compliance and contributes to the chronicity of the condition.11 Finally, it is apparent that when women with even mild anemia (<11 g/dL) undergo surgery, perioperative morbidity and mortality are increased in a way that may not be mitigated by transfusion.12 So, women with HMB frequently experience symptoms related to two disorders—the episodic instances of excessive uterine bleeding and the daily symptoms of ID and IDA. Unfortunately, European survey studies have shown us that the symptom of HMB may actually be present in as many as half the population of reproductive-aged women.13, 14 Frequently, this symptom seems to be normalized, a circumstance that likely starts in the home, influenced by mothers and other caregivers unaware of the issue. The circumstance continues into adulthood, supported by healthcare providers who may not appreciate the quality of life impact of HMB or of the relationships between menstrual loss and daily ID- or IDA-related symptoms. Indeed, survey respondents indicate that presentation to a healthcare provider with the symptom of HMB frequently fails to result in any evaluation or interventions.13 Menstruating women have long occupied an unusual and prejudicial place in society, one that seems agnostic to the borders of nations, cultures, and religions. In the biblical book of Leviticus it states: “When a woman has her regular flow of blood…anyone who touches her will be unclean till evening.”15 In his highly respected and widely read 79 AD encyclopedia entitled “Natural History”, Gaius Plinius Secundus (Pliny the Elder), described the impact of a menstruating woman on her environment: “Young vines…are injured irremediably by the touch…”; medicinal plants “will die instantly”; ‘bees…will forsake their hives”; “the edge of a razor will become blunted”; and “a mare…with foal will be sure to miscarry”. Furthermore, sexual intercourse with a menstruating woman was described as “noxious and attended with fatal effects to the man.”16 Early in the 20th century, the prominent British gynecologist H. Beckwith Whitehouse in a 1914 Hunterian lecture presented to the Royal College of Surgeons in London, stated: “Periodic uterine haemorrhage is, in fact, one of the sacrifices which women must offer at the altar of evolution and civilization.”17 These examples provide the context in which menstruating women have lived throughout millennia and perhaps explain the societal naiveté and resulting normalization of HMB—rendering it a symptom that should be tolerated. It is apparent that the symptom of HMB, resulting from one or more of a spectrum of potential causes, and ID, with or without anemia, are inexorably linked, a relationship that contributes significantly to the worldwide prevalence of anemia. In high-resource countries, where necessary resources are generally present, what appears to be missing is a coordinated effort to diagnose and effectively treat both of these related disorders in a way that alleviates the adverse impact on quality of life and work productivity. For low-resource countries, the problem is amplified by issues related to nutrition, and to the relative paucity of diagnostic and therapeutic options. Regardless of socioeconomic status, it is also apparent that cultural and medical professional normalization of the symptom of HMB adversely impacts the lives of women everywhere. While the relationships among HMB, ID, anemia, and related symptoms seem simple, addressing the problem is complex, as it involves altering the perceptions of a wide variety of cultures that have been similarly suffused with misconception, a tendency to normalization, and the involvement of a spectrum of healthcare and other non-medical stakeholders and disciplines. However, one could conceive of a three-pronged approach that includes raising awareness, increased use of diagnostic techniques and tests, and the implementation of effective medical therapy for both HMB and ID. Efforts designed to raise awareness must be focused on the entire range of reproductive-aged groups as well as families, teachers, employers, and healthcare providers and their related public and private provider systems. Diagnostic strategies include translating increased awareness into the increased use of simple blood tests designed to detect ID and IDA, as well as the structured approach to characterizing the symptoms and diagnosing the cause of HMB based upon the two FIGO AUB Systems. Therapy must be aimed at both HMB and ID, understanding that approximately half of all women prescribed iron supplements have difficulty related to side effects that can adversely affect compliance, while others do not absorb iron secondary to medications, chronic diseases, or malabsorptive syndromes. Such women require careful review and either modification of the oral iron regimen or the appropriate use of parenteral iron formulations that can now be used safely and rapidly in low-resource environments. Over the next years, the MDC will participate in this important process by raising awareness in parents, women, and providers in a way that will improve the rate of diagnosis of ID and IDA, particularly that related to the various causes of HMB in the reproductive years. Such an approach should be designed to encourage the simultaneous use of effective therapies for abnormal bleeding and simultaneous repletion of iron stores in a way that improves the lives of affected women everywhere. We hope that you will join us in this important journey. Malcolm Munro is a consultant to Daiichi Sankyo. The rest of the authors have no conflicts of interest. Malcolm Munro, Sihyun Cho, Hilary Critchley, Rohana Haththotuwa, Alka Kriplani, Yutaka Osuga, Sukhbir Sony Singh. Dr. Munro is a Clinical Professor in the Department of Obstetrics and Gynecology of the David Geffen School of Medicine at UCLA, Co-Chair of the SEUD Abnormal Uterine Bleeding Task Force and Section Head of F1000Prime Faculty for Menstrual Disorders and Abnormal Uterine Bleeding. Dr. Munro is the current Chair of the FIGO Menstrual Disorders Committee (MDC), which he helped cofound with Professors Hilary Critchley and Ian Fraser. The MDC has been responsible for the development and publication of the two FIGO AUB systems and is currently developing and validating a subclassification system for adenomyosis." @default.
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• W3025665418 date "2020-06-13" @default.
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• W3025665418 title "Abnormal uterine bleeding: A well‐travelled path to iron deficiency and anemia" @default.
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