Heavy menstrual bleeding and its detection in clinical practice

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Questions asked by the doctor to the patient.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>" ] ] ] "textoCompleto" => "IntroductionHigh menstrual bleeding (HMB) is defined as excessive menstrual blood loss that interferes with quality of life which may occur alone or in combination with other symptoms.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> The overall prevalence is estimated to be 36%–38% of women of childbearing age.<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a> This prevalence varies according to the measurements used to quantify menstrual blood loss; the quantitative ones place it at up to 14% and the qualitative ones at 52%.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>The International Federation of Gynaecology and Obstetrics establishes 2 types of causes of abnormal uterine bleeding: those related to structural alterations in the uterus (polyps, adenomyosis, leiomyomas, malignancy, and hyperplasia) and those related to non-structural causes (coagulopathy, ovulatory dysfunction, endometrial dysfunction, iatrogenic injuries, and others). These can occur alone or in combination.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The possible concurrent conditions to HMB and their consequences go beyond the scope of gynaecology and may affect different specialties. HMB increases the risk of iron deficiency, which, if left untreated, can progress to anemia.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Depending on its importance, this deficit may be associated with significant morbidity that may require hospitalizations, blood transfusions, or intravenous iron administration.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Anaemia caused by HMB is a common problem, but often underestimated problem, particularly in adolescents.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> It has been established that 25% of women with a loss greater than 80 ml per cycle will develop anemia.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>It should be noted that the presence of HMB negatively influences the physical,<a class="elsevierStyleCrossRef" href="#bib0055">11</a> emotional<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a> and/or social<a class="elsevierStyleCrossRef" href="#bib0035">7</a> states of women. It is associated with lower quality of life and lower academic, occupational, or sporting productivity.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> However, HMB is an underdiagnosed and undertreated condition due to the poor correlation between patient perception and objective menstrual blood loss,<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a> as well as the limitations of diagnostic tools. This is compounded by other factors such as lack of information, lack of knowledge or stigma associated with menstruation.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>What really prompts women to seek treatment are the negative effects menstruation has on their quality of life.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Despite this, there are no recommendations on specific screening tools for HMB that take into account not only the amount of bleeding, but also its impact on a woman’s quality of life,<a class="elsevierStyleCrossRefs" href="#bib0005">1,18</a> and many of the validated techniques to detect it do not take this concept into account. Recently the National Institute for Health and Care Excellence (NICE) has published a new definition of HMB, which recognizes the importance of women’s perception of their menstrual bleeding and its impact on quality of life.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>For these reasons, history-taking of a woman of childbearing age should include an assessment of the amount of menstruation, regardless of the speciality treating the consultation.The objective of this work is to review the main tools available to detect HMB, their advantages and disadvantages, as well as their applicability in routine clinical practice, and to recommend those that have the best characteristics.Heavy menstrual bleeding screeningHMB can be detected using quantitative, semi-quantitative or qualitative techniques (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Methods for the objective quantification of menstrual losses are complex and are not often used in routine clinical practice. Semi-quantitative methods have been devised which, using pictograms showing different sized spots on sanitary pads (sanitary towels or tampons), provide a more objective approximation of the amount of menstrual bleeding reported by women. Finally, the questionnaires allow to know the perception of the patient about her menstrual bleeding and its impact on her quality of life.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>A literature review of the most relevant studies reveals the following types of assessments and tools.Quantitative assessment: alkaline haematinThe method most used in research to detect HMB has been that of alkaline hematin (AH). It consists of estimating menstrual blood loss by analysing all sanitary pads used during a menstrual period. They must be collected by the patient and sent to a laboratory for processing, where the blood is extracted from the collected blood material using a specific solution. All haemoglobin derivatives are converted to alkaline haematin, which is quantified spectrophotometrically; it is converted by calculation to millilitres of blood. For a case to be considered HMB, a woman must lose on average at least 80 ml of blood per cycle.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> The AH method is validated in terms of blood recovery efficiency from sanitary pads, including products containing superabsorbent polymers. It is considered the gold standard in terms of precision to assess the amount of bleeding.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>However, this method is costly, labour-intensive, and time-consuming for both the patient and the doctor. Furthermore, it does not assess the impact of bleeding on quality of life.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>Semi-quantitative assessment: Pictorial Blood Loss Assessment ChartMenstrual blood loss has also been measured with semi-quantitative methods such as menstrual diaries and the Pictorial Blood loss Assessment Chart (PBAC) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The PBAC, which combines the number of sanitary pads used and their degree of impregnation, is a commonly used tool in clinical research to assess menstrual blood loss.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Patients complete a chart during menstruation and score points for each sanitary product used (e.g., 1 point is added for a lightly soiled pad, 5 for a moderately soaked pad and 20 for a saturated pad).<a class="elsevierStyleCrossRef" href="#bib0110">22</a> A score above 100 has been associated with menstrual loss greater than 80 ml. The estimation of menstrual volume by PBAC does not require laboratory determinations and is relatively easy to use.<a class="elsevierStyleCrossRef" href="#bib0115">23</a><elsevierMultimedia ident="fig0010"></elsevierMultimedia>As drawbacks, PBAC requires a lot of time and perseverance from the patient collecting data and from the doctor evaluating the charts, in addition to an observation period of between one and 3 months.<a class="elsevierStyleCrossRefs" href="#bib0095">19,21</a> It is not valid for all types of menstrual pads (for example, the menstrual cup), its results may depend on the degree of absorption of the pads and, as with AH, it does not analyse the quality of life related to bleeding. Since the original PBAC, new diaries and pictograms have emerged that expand the impregnation options of the different sanitary pads and add newer, highly absorbent ones.<a class="elsevierStyleCrossRefs" href="#bib0120">24,25</a>Questionnaire-based assessmentQuantitative and semi-quantitative measures to detect SMA are complex and not easily applicable in clinical practice. Its use is limited to the evaluation of treatments in the context of clinical trials. For daily clinical practice, it is necessary to have validated questionnaires that make it possible to easily and quickly detect when a patient suffers HMB, taking into account not only the amount of bleeding, but also how it interferes with her quality of life. This makes it possible to decide to request diagnostic tests or therapeutic measures during the same appointment. Currently there are questionnaires that can evaluate: 1) HMB specifically; 2) quality of life (general or disease-specific); or 3) a combination of both. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows a selection of the main validated questionnaires to detect HMB, along with their characteristics.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Among the specific questionnaires developed, the Menorrhagia Evaluation Questionnaire<a class="elsevierStyleCrossRef" href="#bib0130">26</a> assesses menstrual symptoms and HMB. Women who complete it should rate symptoms based on their severity and how they influence seeking health care. Other questionnaires assess both HMB clinical parameters and the impact on quality of life. Among them are the Aberdeen Menorrhagia Severity Scale (AMSS)<a class="elsevierStyleCrossRef" href="#bib0135">27</a> and the Menorrhagia Multiattribute Scale,<a class="elsevierStyleCrossRef" href="#bib0140">28</a> which were the first to become available, the Menorrhagia Impact Questionnaire (MY Q),<a class="elsevierStyleCrossRef" href="#bib0145">29</a> the Menstrual Bleeding Questionnaire (MBQ)<a class="elsevierStyleCrossRef" href="#bib0090">18</a> and the SAMANTA questionnaire (Development and Validation of a Screening Questionnaire for the Detection of Heavy Menstrual Bleeding in Gynaecology)<a class="elsevierStyleCrossRef" href="#bib0075">15</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).The MIQ is notable for its brevity and measures both limitations in daily activities and women’s perception of changes in their menstrual losses.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> The MBQ expands the concepts included in the AMSS and MIQ questionnaires and, in a distinctive way, incorporates the concept of «social embarrassment», one of the main determinants of poor quality of life in these patients.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> One of its advantages is that it is not influenced by “recall bias”, i.e., the distortion of results when they are collected over time.Generic quality of life questionnaires have also been used in the context of HMB studies such as the Short Form-36 (SF-36),<a class="elsevierStyleCrossRef" href="#bib0160">32</a> the EQ5D<a class="elsevierStyleCrossRef" href="#bib0165">33</a> and the Short-Form-12,<a class="elsevierStyleCrossRef" href="#bib0170">34</a> which analyse health-related quality of life (HRQoL) in a general sense. Different studies have shown a low correlation between a specific HMB questionnaire, such as the MBQ, and the SF-36.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> However, these generic tools can be useful when used in combination with more specific questionnaires, as they facilitate the comparison of the effect of symptoms in different diseases.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> A characteristic of all of them is the interference with the course of the consultation since, even in the best of cases, they require dedication on the part of the patient to fill them in and of the clinician to assess them.SAMANTA questionnaireA simple screening tool for the identification of women with HMB in Spain was developed and validated in 2020 (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The SAMANTA questionnaire consists of six items that address both the symptoms of HMB and its interference with quality of life and daily activities. The total score ranges from 0 to 10 points, and a total score ≥3 indicates the presence of HMB that interferes with quality of life.<a class="elsevierStyleCrossRef" href="#bib0075">15</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>The peculiarity of this questionnaire resides in the participation of patients in the writing of the questions. To develop it, an exhaustive literature search was carried out in order to identify questionnaires and concepts previously used to detect HMB and its impact on HRQoL. Of the 46 resulting questions, a committee of HMB-expert gynaecologists selected 27 that were translated and adapted to the Spanish context. These were tested by cognitive interviews in 10 women with HMB (different age, sociocultural status, and origin) to determine their understanding. As a result, 9 questions were deleted, 8 were redefined and 3 more were added. After a new review by the scientific committee, a set of 21 items was obtained and subjected to study. The psychometric validation of the selected questions made it possible to establish which of them had the highest sensitivity and specificity to make up the questionnaire.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Taking as a criterion a PBAC greater than or equal to 100, the SAMANTA questionnaire presented high sensitivity (86.7%) and specificity (89.5%), with a positive predictive value of 92.0%, a negative predictive value of 83% and a discriminatory capacity of 87.9%. It had good internal consistency and its score showed significant correlations between the perceived intensity of menstrual bleeding and its impact on daily activities. The psychometric validation established significant correlations between the SAMANTA score and 2 general questionnaires of perceived quality of life, the EuroQoL questionnaire with 5 dimensions and 5 levels and the index of general psychological well-being. The simplicity of the SAMANTA questionnaire favours its integration into clinical routine, with results obtained immediately.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>An even more simplified alternative to the SAMANTA questionnaire is being studied, which consists of the use of 2 visual analogue scales that measure the perceived intensity of menstrual bleeding and the perception of the impact of menstrual bleeding on daily life, as self-assessed by the woman.Measurements based on digital questionnaires (mobile applications)In recent years, digital questionnaires have been developed that track the menstrual cycle through smart mobile phones (apps). Teenagers prefer this format, which collects data in real time,<a class="elsevierStyleCrossRef" href="#bib0180">36</a> is associated with greater compliance and better adaptation to routine. A study by Jacobson et al.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> demonstrated that a PBAC-based mobile app was the preferred method of recording menstrual bleeding among 25 adolescents (13–21 years) versus the paper PBAC diary. The app received higher satisfaction scores and most teens entered data on a daily basis.<a class="elsevierStyleCrossRef" href="#bib0185">37</a>But apps also have drawbacks. A systematic review of 108 apps designed to track the menstrual cycle and fertility periods highlighted that only 19% contained accurate information or specific menstrual bleeding parameters.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> These apps need to be evaluated and validated in the same way as the other tools,<a class="elsevierStyleCrossRef" href="#bib0180">36</a> which has not been done in any case so far. In addition, they require certain technical requirements, and their use is not universal.<a class="elsevierStyleCrossRef" href="#bib0185">37</a>Within the apps designed to follow the menstrual cycle, some allow quantifying the degree of bleeding and have been developed by scientific societies, as is the case of Me — Period Flow Assessment, made by the Canadian Hemophilia Society (<a href="https://apkpure.com/es/me-period-flow-assessment/com.sch.regles.android">https://apkpure.com/es/me-period-flow-assessment/com.sch.regles.android</a>), or Sisterhood app, by the Hemophilia Federation of America (<a href="https://www.sisterhoodapp.com/">https://www.sisterhoodapp.com/</a>). Only the former is specific to HMB and evaluates the level of blood permeation in pads and tampons in a similar way to PBAC. The second covers bleeding disorders in general and records both menstrual and non-menstrual blood losses. Both issue alerts in the event of abnormal values and allow information to be shared with the specialist. But, as mentioned above, none of them have been validated psychometrically. Their ability to alert the user in the event of HMB and to transfer this information to the clinician also remains to be assessed.DiscussionSince NICE<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> defined HMB as excessive menstrual bleeding that interferes with the physical, emotional, social, and material quality of life of women, it is essential to consider tools for its detection that not only consider the amount of bleeding, but also its quality-of-life interference.This literature review of the most relevant studies has highlighted that the measurement tools most used to detect HMB, both quantitative and semi-quantitative, are complex and do not reflect the patient’s perception of the effect of symptoms on her daily life, although they have played a relevant role in clinical research and the historical identification of these patients. On the other hand, many of the existing questionnaires to diagnose HMB, which could cover these deficiencies, have not been psychometrically validated, are nonspecific or do not assess quality of life. The SAMANTA questionnaire, recently developed and validated in Spain, responds to these unmet needs in the detection of HMB.Quality of life alterations are a clear clinical indicator of the negative effects of an abnormal menstruation.<a class="elsevierStyleCrossRefs" href="#bib0100">20,39</a> The analysis of the menstrual cycle should therefore be considered a vital sign.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> HMB affects quality of life, increases school and work absenteeism, and impairs social relationships, self-esteem, and physical performance. However, several studies have shown that the majority of women with HMB do not seek medical attention for this condition,<a class="elsevierStyleCrossRefs" href="#bib0205">41,42</a> perhaps due to a biased perception of what constitutes normal menstrual bleeding, particularly when women in the same setting have a similar menstrual pattern.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>Different scientific societies agree that any intervention against HMB should aim to improve quality of life rather than focus on menstrual blood loss.<a class="elsevierStyleCrossRefs" href="#bib0005">1,18,43–45</a> The consequences of HMB on quality of life have been described by various authors. In a study that analysed the menstrual cycle in 1575 women aged 20–39 years in Australia, menstrual flow was considered heavy or very heavy by 22.5% and 5.3% of them, respectively. Women with heavy or very heavy bleeding were significantly more likely to remain bedridden during menstruation than the others (prevalence of 1.58 and 1.53 in women with heavy or very heavy bleeding, respectively, versus 1.09 in women with moderate bleeding, p = 0.0002).<a class="elsevierStyleCrossRef" href="#bib0055">11</a> In addition to this, HMB involves a greater consumption of healthcare resources.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a> Between 2004 and 2006, in the UK, there were 51,664 women aged 25–59 years with HMB who underwent endometrial ablation or hysterectomy in the English National Health Service.<a class="elsevierStyleCrossRef" href="#bib0230">46</a>Measurement of patient-reported outcomes (PRO) is an active research area at the HMB.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> PRO is defined as any information about a patient’s health status that comes directly from the patient, without interpretation of the response by another person.<a class="elsevierStyleCrossRef" href="#bib0235">47</a> HRQoL is the PRO that has attracted most interest in recent decades, with various generic and disease-specific questionnaires developed to measure HRQoL. However, few validated questionnaires in the field of HMB include quality of life (specific to this condition) as an evaluable parameter.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>The measurement of HRQL in clinical practice requires questionnaires that can be administered quickly and easily and, at the same time, allow to obtain reliable and valid results.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> Generating a questionnaire is a time-consuming and resource-intensive process. Before using a new PRO measuring tool, it is essential to prove its measuring capabilities. In addition, its use in a cultural context different from the original one requires a standard process of cross-cultural adaptation, with subsequent validation for the target country.<a class="elsevierStyleCrossRef" href="#bib0240">48</a>The recently published SAMANTA study<a class="elsevierStyleCrossRef" href="#bib0075">15</a> has made it possible to have a simple questionnaire, validated in Spanish, to easily identify women with HMB with high sensitivity and specificity. The 6 items included address both the symptoms and interference with the quality of life and daily activities. Thanks to its internal consistency, discrimination capacity and ease of use, this screening tool provides the opportunity to identify women with HMB without the need for complex methods. The results are obtained immediately, which facilitates their incorporation into clinical practice, both in primary care and in hospitals,<a class="elsevierStyleCrossRef" href="#bib0075">15</a> without introducing delays in treatment.On the other hand, this review has highlighted the need for HMB awareness. Women need to seek medical attention before their quality of life is impaired. Due to the sensitive nature of the disease, healthcare professionals should endeavour to provide the necessary informational and emotional support to these patients on an individual basis. Beyond point-of-care consultation, newly diagnosed women could access educational materials to receive appropriate training.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>Multidisciplinary care is another cornerstone in the treatment of HMB. Menstruation and especially HMB is the single most common cause of iron deficiency anaemia in women of childbearing age.<a class="elsevierStyleCrossRefs" href="#bib0245">49,50</a> In a study of women with HMB, 63% of respondents reported iron deficiency at some time.<a class="elsevierStyleCrossRef" href="#bib0255">51</a> Low iron stores in adolescents with HMB, reflected by a low level of ferritin, even in the absence of anaemia, are associated with fatigue and impaired cognition, with particular impairment of verbal learning and memory,<a class="elsevierStyleCrossRef" href="#bib0260">52</a> and even symptoms of depression or anxiety.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> In this sense, initiatives have been carried out for the multidisciplinary care of patients with HMB, such as the Young Women’s Blood Disorders program from the University of Texas, in which the patient is cared for by a team that acts in a coordinated manner in the diagnosis, treatment and monitoring of HMB.<a class="elsevierStyleCrossRef" href="#bib0265">53</a> The consequences of HMB go beyond the gynaecological setting and can affect different specialties (haematology, dermatology, pneumology, digestive, emergency, psychiatry, nutrition, nursing, etc.), so a multidimensional view is essential.<a class="elsevierStyleCrossRef" href="#bib0265">53</a>ConclusionMost of the tools available to detect HMB have limitations in terms of their ease of use, validation, and holistic perspective of the disease. Assessing the impact on quality of life is essential in any tool designed to detect HMB. Any questionnaire, whether in written or digital format, should be validated and exhibit good reliability. The SAMANTA questionnaire meets these requirements and can be easily integrated into routine clinical practice. In view of its good results, a prospective study is being carried out to confirm the sensitivity to change in the questionnaire score. In addition, it seems appropriate that the SAMANTA questionnaire undergoes cultural and linguistic validation for extension to other countries, and that it is adapted to digital format so as to widen its accessibility. This, together with the awareness of the healthcare professional within a multidisciplinary perspective, will ultimately benefit the HMB patient.FundingThis review has been financed by Bayer Hispania S.L.by contracting the services of Adelphi, an independent company that provided medical editorial assistance and editorial support.Conflict of interestsJoaquin Calaf has received consulting fees, served on advisory committees, or given lectures on behalf of Bayer, MSD, Gedeon Richter and Theramex. Dr. Calaf has not received any type of compensation for the writing of the article and the prescription of any product is not mentioned, promoted, or favoured.Josep Perelló has received consulting fees, served on advisory committees, or given lectures on behalf of Bayer, MSD, Theramex, Exeltis and Gynea-Kern. Dr. Perelló has not received any type of compensation for the writing of the article and the prescription of any product is not mentioned, promoted, or favoured.Joan Rius works as a medical advisor for Bayer Hispania SL. The article does not mention, promote, or encourage the prescription of any product." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1582922" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1424664" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1582921" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1424665" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Heavy menstrual bleeding screening" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Quantitative assessment: alkaline haematin" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Semi-quantitative assessment: Pictorial Blood Loss Assessment Chart" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Questionnaire-based assessment" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "SAMANTA questionnaire" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Measurements based on digital questionnaires (mobile applications)" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-12-22" "fechaAceptado" => "2021-02-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1424664" "palabras" => array:6 [ 0 => "Heavy menstrual bleeding" 1 => "Abnormal uterine bleeding" 2 => "Screening" 3 => "Questionnaire" 4 => "Quality of life" 5 => "Anaemia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1424665" "palabras" => array:6 [ 0 => "Sangrado menstrual abundante" 1 => "Sangrado uterino anormal" 2 => "Cribado" 3 => "Cuestionario" 4 => "Calidad de vida" 5 => "Anemia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss that interferes with quality of life. It is an under-diagnosed and under-treated disorder due to the poor correlation between patient perception and objective menstrual blood loss, as well as the scarcity of validated diagnostic tools. Anaemia caused by HMB is a common problem, underestimated on many occasions and with consequences that go beyond the scope of gynaecology. Despite the condition’s negative effect on quality of life, most of the tools validated to detect HBM do not take this into account. The aim of this paper is to review the main instruments available to detect HMB, their advantages and disadvantages, their applicability in routine clinical practice, and to recommend those with the best characteristics." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El sangrado menstrual abundante (SMA) se define como una pérdida excesiva de sangre menstrual que interfiere con la calidad de vida. Se trata de una alteración infradiagnosticada e infratratada debido a la escasa correlación entre la percepción de la paciente y la pérdida hemática menstrual objetiva, así como a la escasez de herramientas diagnósticas validadas. La anemia causada por el SMA es un problema frecuente, infravalorado en muchas ocasiones y con consecuencias que van más allá del ámbito de la ginecología. A pesar de su efecto negativo sobre la calidad de vida, la mayoría de las herramientas validadas para detectar el SMA no tienen en cuenta este concepto. El objetivo de este trabajo es revisar los principales instrumentos disponibles para detectar el SMA, sus ventajas e inconvenientes, su aplicabilidad en la práctica clínica habitual, y recomendar aquellos que reúnen las mejores características." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Perelló J, Rius Tarruella J, Calaf J. Sangrado menstrual abundante y su detección en la práctica clínica. Med Clin (Barc). 2021;157:332–338." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1465 "Ancho" => 2507 "Tamanyo" => 239404 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Screening methods for heavy menstrual bleeding (HMB)." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1306 "Ancho" => 2508 "Tamanyo" => 262081 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Example of validated Pictorial Blood loss Assessment Chart. Source: Adapted from Magnay et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 929 "Ancho" => 1674 "Tamanyo" => 210006 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "SAMANTA questionnaire. Questions asked by the doctor to the patient.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AMSS: Aberdeen Menorrhagia Severity Scale; EQ-5D-5L: EuroQoL of 5 dimensions and 5 levels; AH: alkaline hematin; MBQ: Menstrual Bleeding Questionnaire; MEQ: Menstrual Evaluation Questionnaire; MY Q: Menorrhagia Impact Questionnaire; MMAS: Menorrhagia Multiattribute Scale; PBAC: pictorial blood loss assessment chart; PGWBI: psychological general well-being index; SAQ: Sexual Activity Questionnaire; HMB: heavy menstrual bleeding." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Questionnaire \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reference \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Description \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Validation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HMB diagnostic capacity \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HMB discriminatory capacity \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Other characteristics \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Evaluation of menstrual symptoms</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Menstrual MEQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Warner et al.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Includes items on bleeding symptoms and scores them according to their severity and degree of contribution to seeking medical attention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated against AH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes. Sensitivity and specificity of bleeding diagnosis >80 ml: 60% and 86%, respectively \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderately good prediction of bleeding patients >80 ml \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consistency between cycles \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated in English \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Disadvantage: more than one cycle must be analysed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="7" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Multidimensional evaluation: menstrual symptoms and quality of life associated with HMB</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MMAS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Shaw et al.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">It measures the effect of the HMB with 6 items relating to practical difficulties, social life, mental health, physical health, work life and family life. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated against SF-36 v2, EQ-5D, SAQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No. Assessment of HMB-specific quality of life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Demonstrated discriminatory capacity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High face validity and content validity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pattison et al.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Responses are scored and weighted to generate a score from 0 (most severe effect) to 100 (no effect) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated in English \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Internal consistency \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Test-retest reliability \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AMSS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ruta et al.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Measures bleeding-specific symptoms and quality of life associated with HMB with 13 items on the characteristics of the symptom, pain, staining of clothes due to bleeding, work life, leisure activities and sexual life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Widely validated and used \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No. Assessment of HMB-specific quality of life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">It does not establish a discriminatory cut-off point, only differences between women who report heavy menstruation and women who do not \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Internal consistency \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Item scores are added up and weighted, where 0 is the best possible score and 100 is the worst possible score. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Participation of patients in its validation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acceptable test-retest reliability \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated in English \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MBQ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Matteson et al.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Measures the impact of HMB with 20 items including perception of bleeding volume, bleeding pattern, pain, impact of symptoms, including social embarrassment, fear of social embarrassment, and behaviour changes to avoid social embarrassment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated against SF-36, PBAC, ferritin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">It does not establish a discriminatory cut-off point, only differences between women who report heavy menstruation and women who do not \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Internal consistency with good item-domain correlations \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adds up the answers to get a total score and multiplies the score by 1.32 (0: lowest possible impact, 100: highest possible impact). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Participation of patients in its validation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Content validity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated in English \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advantage: measures social embarrassment and is not affected by recall bias \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Disadvantage: unknown whether it can be generalized \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MY Q \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bushnell et al.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Six items on perceived menstrual loss, impact on work and physical and social activities, number of limited activities, and perceived effect of treatment on symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated against MIQ item 6 c, AH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes. Sensitivity 64% and 69%–79%; specificity 75% and 63%–82% in women who perceived normal flow or diagnosed with HMB, respectively \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Discriminatory power validated with respect to both statistical and clinical significance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prediction of variations perceived as significant by women in menstrual blood loss. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lukes et al.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated in the context of clinical trials with tranexamic acid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Test-retest reliability. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated in English \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reliability of individual items \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advantages: speed (answer in 2 min); in case of short observation period, a change in +1 point is easily interpretable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SAMANTA questionnaire \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Calaf et al.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Six items that address both the symptoms of HMB and its interference with quality of life and daily activities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated against PBAC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes. Sensitivity 86.7% and specificity 89.5%, positive predictive value 92.0%, negative predictive value 83%, discriminatory capacity 87.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated discriminatory power. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High internal consistency \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The total score ranges from 0 to 10 points. A total score ≥ 3 indicates the presence of HMB that interferes with quality of life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Participation of patients in its validation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Significant correlations with the EQ-5D-5L and PGWBI perceived quality of life questionnaires \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated in Spanish \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Advantages: speed and simplicity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Disadvantages: test-retest reliability not evaluated \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2711495.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparative analysis of different validated questionnaires in the assessment of heavy menstrual bleeding (HMB), according to the parameters evaluated." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:53 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "NICE. National Evidence Based Clinical Guidelines. Overview, heavy menstrual bleeding: assessment and management. NICE Guidance [Accessed 17 December 2020]. Available from: <a target="_blank" href="https://www.nice.org.uk/guidance/ng88">https://www.nice.org.uk/guidance/ng88</a>, 2018." ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.G. Munro" 1 => "H.O. Critchley" 2 => "I.S. 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Heavy menstrual bleeding and its detection in clinical practice

Sangrado menstrual abundante y su detección en la práctica clínica

Josep Perellóa,

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jcalaf@santpau.cat

Corresponding author.

, Joan Rius Tarruellab, Joaquim Calafa

a Hospital de Sant Pau, Universitat Autònoma, Barcelona, Spain

b Bayer Hispania, Barcelona, Spain

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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SAMANTA questionnaire&#46; Questions asked by the doctor to the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">High menstrual bleeding &#40;HMB&#41; is defined as excessive menstrual blood loss that interferes with quality of life which may occur alone or in combination with other symptoms&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> The overall prevalence is estimated to be 36&#37;&#8211;38&#37; of women of childbearing age&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> This prevalence varies according to the measurements used to quantify menstrual blood loss&#59; the quantitative ones place it at up to 14&#37; and the qualitative ones at 52&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The International Federation of Gynaecology and Obstetrics establishes 2 types of causes of abnormal uterine bleeding&#58; those related to structural alterations in the uterus &#40;polyps&#44; adenomyosis&#44; leiomyomas&#44; malignancy&#44; and hyperplasia&#41; and those related to non-structural causes &#40;coagulopathy&#44; ovulatory dysfunction&#44; endometrial dysfunction&#44; iatrogenic injuries&#44; and others&#41;&#46; These can occur alone or in combination&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The possible concurrent conditions to HMB and their consequences go beyond the scope of gynaecology and may affect different specialties&#46; HMB increases the risk of iron deficiency&#44; which&#44; if left untreated&#44; can progress to anemia&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Depending on its importance&#44; this deficit may be associated with significant morbidity that may require hospitalizations&#44; blood transfusions&#44; or intravenous iron administration&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Anaemia caused by HMB is a common problem&#44; but often underestimated problem&#44; particularly in adolescents&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It has been established that 25&#37; of women with a loss greater than 80&#160;ml per cycle will develop anemia&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It should be noted that the presence of HMB negatively influences the physical&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> emotional<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> and&#47;or social<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> states of women&#46; It is associated with lower quality of life and lower academic&#44; occupational&#44; or sporting productivity&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However&#44; HMB is an underdiagnosed and undertreated condition due to the poor correlation between patient perception and objective menstrual blood loss&#44;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> as well as the limitations of diagnostic tools&#46; This is compounded by other factors such as lack of information&#44; lack of knowledge or stigma associated with menstruation&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">What really prompts women to seek treatment are the negative effects menstruation has on their quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Despite this&#44; there are no recommendations on specific screening tools for HMB that take into account not only the amount of bleeding&#44; but also its impact on a woman&#8217;s quality of life&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;18</span></a> and many of the validated techniques to detect it do not take this concept into account&#46; Recently the <span class="elsevierStyleItalic">National Institute for Health and Care Excellence</span> &#40;NICE&#41; has published a new definition of HMB&#44; which recognizes the importance of women&#8217;s perception of their menstrual bleeding and its impact on quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">For these reasons&#44; history-taking of a woman of childbearing age should include an assessment of the amount of menstruation&#44; regardless of the speciality treating the consultation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The objective of this work is to review the main tools available to detect HMB&#44; their advantages and disadvantages&#44; as well as their applicability in routine clinical practice&#44; and to recommend those that have the best characteristics&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Heavy menstrual bleeding screening</span><p id="par0040" class="elsevierStylePara elsevierViewall">HMB can be detected using quantitative&#44; semi-quantitative or qualitative techniques &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Methods for the objective quantification of menstrual losses are complex and are not often used in routine clinical practice&#46; Semi-quantitative methods have been devised which&#44; using pictograms showing different sized spots on sanitary pads &#40;sanitary towels or tampons&#41;&#44; provide a more objective approximation of the amount of menstrual bleeding reported by women&#46; Finally&#44; the questionnaires allow to know the perception of the patient about her menstrual bleeding and its impact on her quality of life&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">A literature review of the most relevant studies reveals the following types of assessments and tools&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Quantitative assessment&#58; alkaline haematin</span><p id="par0050" class="elsevierStylePara elsevierViewall">The method most used in research to detect HMB has been that of alkaline hematin &#40;AH&#41;&#46; It consists of estimating menstrual blood loss by analysing all sanitary pads used during a menstrual period&#46; They must be collected by the patient and sent to a laboratory for processing&#44; where the blood is extracted from the collected blood material using a specific solution&#46; All haemoglobin derivatives are converted to alkaline haematin&#44; which is quantified spectrophotometrically&#59; it is converted by calculation to millilitres of blood&#46; For a case to be considered HMB&#44; a woman must lose on average at least 80&#160;ml of blood per cycle&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The AH method is validated in terms of blood recovery efficiency from sanitary pads&#44; including products containing superabsorbent polymers&#46; It is considered the gold standard in terms of precision to assess the amount of bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">However&#44; this method is costly&#44; labour-intensive&#44; and time-consuming for both the patient and the doctor&#46; Furthermore&#44; it does not assess the impact of bleeding on quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Semi-quantitative assessment&#58; <span class="elsevierStyleItalic">Pictorial Blood Loss Assessment Chart</span></span><p id="par0060" class="elsevierStylePara elsevierViewall">Menstrual blood loss has also been measured with semi-quantitative methods such as menstrual diaries and the <span class="elsevierStyleItalic">Pictorial Blood loss Assessment Chart</span> &#40;PBAC&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The PBAC&#44; which combines the number of sanitary pads used and their degree of impregnation&#44; is a commonly used tool in clinical research to assess menstrual blood loss&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Patients complete a chart during menstruation and score points for each sanitary product used &#40;e&#46;g&#46;&#44; 1 point is added for a lightly soiled pad&#44; 5 for a moderately soaked pad and 20 for a saturated pad&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> A score above 100 has been associated with menstrual loss greater than 80&#160;ml&#46; The estimation of menstrual volume by PBAC does not require laboratory determinations and is relatively easy to use&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">As drawbacks&#44; PBAC requires a lot of time and perseverance from the patient collecting data and from the doctor evaluating the charts&#44; in addition to an observation period of between one and 3 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;21</span></a> It is not valid for all types of menstrual pads &#40;for example&#44; the menstrual cup&#41;&#44; its results may depend on the degree of absorption of the pads and&#44; as with AH&#44; it does not analyse the quality of life related to bleeding&#46; Since the original PBAC&#44; new diaries and pictograms have emerged that expand the impregnation options of the different sanitary pads and add newer&#44; highly absorbent ones&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24&#44;25</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Questionnaire-based assessment</span><p id="par0070" class="elsevierStylePara elsevierViewall">Quantitative and semi-quantitative measures to detect SMA are complex and not easily applicable in clinical practice&#46; Its use is limited to the evaluation of treatments in the context of clinical trials&#46; For daily clinical practice&#44; it is necessary to have validated questionnaires that make it possible to easily and quickly detect when a patient suffers HMB&#44; taking into account not only the amount of bleeding&#44; but also how it interferes with her quality of life&#46; This makes it possible to decide to request diagnostic tests or therapeutic measures during the same appointment&#46; Currently there are questionnaires that can evaluate&#58; 1&#41; HMB specifically&#59; 2&#41; quality of life &#40;general or disease-specific&#41;&#59; or 3&#41; a combination of both&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows a selection of the main validated questionnaires to detect HMB&#44; along with their characteristics&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Among the specific questionnaires developed&#44; the <span class="elsevierStyleItalic">Menorrhagia Evaluation Questionnaire</span><a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> assesses menstrual symptoms and HMB&#46; Women who complete it should rate symptoms based on their severity and how they influence seeking health care&#46; Other questionnaires assess both HMB clinical parameters and the impact on quality of life&#46; Among them are the <span class="elsevierStyleItalic">Aberdeen Menorrhagia Severity Scale</span> &#40;AMSS&#41;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> and the <span class="elsevierStyleItalic">Menorrhagia Multiattribute Scale</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> which were the first to become available&#44; the <span class="elsevierStyleItalic">Menorrhagia Impact Questionnaire</span> &#40;MY Q&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> the <span class="elsevierStyleItalic">Menstrual Bleeding Questionnaire</span> &#40;MBQ&#41;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and the SAMANTA questionnaire &#40;Development and Validation of a Screening Questionnaire for the Detection of Heavy Menstrual Bleeding in Gynaecology&#41;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The MIQ is notable for its brevity and measures both limitations in daily activities and women&#8217;s perception of changes in their menstrual losses&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The MBQ expands the concepts included in the AMSS and MIQ questionnaires and&#44; in a distinctive way&#44; incorporates the concept of &#171;social embarrassment&#187;&#44; one of the main determinants of poor quality of life in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> One of its advantages is that it is not influenced by &#8220;recall bias&#8221;&#44; i&#46;e&#46;&#44; the distortion of results when they are collected over time&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Generic quality of life questionnaires have also been used in the context of HMB studies such as the <span class="elsevierStyleItalic">Short Form-36</span> &#40;SF-36&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> the EQ5D<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> and the <span class="elsevierStyleItalic">Short-Form-12</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> which analyse health-related quality of life &#40;HRQoL&#41; in a general sense&#46; Different studies have shown a low correlation between a specific HMB questionnaire&#44; such as the MBQ&#44; and the SF-36&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> However&#44; these generic tools can be useful when used in combination with more specific questionnaires&#44; as they facilitate the comparison of the effect of symptoms in different diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> A characteristic of all of them is the interference with the course of the consultation since&#44; even in the best of cases&#44; they require dedication on the part of the patient to fill them in and of the clinician to assess them&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">SAMANTA questionnaire</span><p id="par0090" class="elsevierStylePara elsevierViewall">A simple screening tool for the identification of women with HMB in Spain was developed and validated in 2020 &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The SAMANTA questionnaire consists of six items that address both the symptoms of HMB and its interference with quality of life and daily activities&#46; The total score ranges from 0 to 10 points&#44; and a total score &#8805;3 indicates the presence of HMB that interferes with quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The peculiarity of this questionnaire resides in the participation of patients in the writing of the questions&#46; To develop it&#44; an exhaustive literature search was carried out in order to identify questionnaires and concepts previously used to detect HMB and its impact on HRQoL&#46; Of the 46 resulting questions&#44; a committee of HMB-expert gynaecologists selected 27 that were translated and adapted to the Spanish context&#46; These were tested by cognitive interviews in 10 women with HMB &#40;different age&#44; sociocultural status&#44; and origin&#41; to determine their understanding&#46; As a result&#44; 9 questions were deleted&#44; 8 were redefined and 3 more were added&#46; After a new review by the scientific committee&#44; a set of 21 items was obtained and subjected to study&#46; The psychometric validation of the selected questions made it possible to establish which of them had the highest sensitivity and specificity to make up the questionnaire&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Taking as a criterion a PBAC greater than or equal to 100&#44; the SAMANTA questionnaire presented high sensitivity &#40;86&#46;7&#37;&#41; and specificity &#40;89&#46;5&#37;&#41;&#44; with a positive predictive value of 92&#46;0&#37;&#44; a negative predictive value of 83&#37; and a discriminatory capacity of 87&#46;9&#37;&#46; It had good internal consistency and its score showed significant correlations between the perceived intensity of menstrual bleeding and its impact on daily activities&#46; The psychometric validation established significant correlations between the SAMANTA score and 2 general questionnaires of perceived quality of life&#44; the EuroQoL questionnaire with 5 dimensions and 5 levels and the index of general psychological well-being&#46; The simplicity of the SAMANTA questionnaire favours its integration into clinical routine&#44; with results obtained immediately&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">An even more simplified alternative to the SAMANTA questionnaire is being studied&#44; which consists of the use of 2 visual analogue scales that measure the perceived intensity of menstrual bleeding and the perception of the impact of menstrual bleeding on daily life&#44; as self-assessed by the woman&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Measurements based on digital questionnaires &#40;mobile applications&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">In recent years&#44; digital questionnaires have been developed that track the menstrual cycle through smart mobile phones <span class="elsevierStyleItalic">&#40;apps&#41;</span>&#46; Teenagers prefer this format&#44; which collects data in real time&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> is associated with greater compliance and better adaptation to routine&#46; A study by Jacobson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> demonstrated that a PBAC-based mobile app was the preferred method of recording menstrual bleeding among 25 adolescents &#40;13&#8211;21 years&#41; versus the paper PBAC diary&#46; The app received higher satisfaction scores and most teens entered data on a daily basis&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">But <span class="elsevierStyleItalic">apps</span> also have drawbacks&#46; A systematic review of 108 <span class="elsevierStyleItalic">apps</span> designed to track the menstrual cycle and fertility periods highlighted that only 19&#37; contained accurate information or specific menstrual bleeding parameters&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> These apps need to be evaluated and validated in the same way as the other tools&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> which has not been done in any case so far&#46; In addition&#44; they require certain technical requirements&#44; and their use is not universal&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Within the <span class="elsevierStyleItalic">apps</span> designed to follow the menstrual cycle&#44; some allow quantifying the degree of bleeding and have been developed by scientific societies&#44; as is the case of <span class="elsevierStyleItalic">Me &#8212; Period Flow Assessment</span>&#44; made by the <span class="elsevierStyleItalic">Canadian Hemophilia Society</span> &#40;<a href="https://apkpure.com/es/me-period-flow-assessment/com.sch.regles.android">https&#58;&#47;&#47;apkpure&#46;com&#47;es&#47;me-period-flow-assessment&#47;com&#46;sch&#46;regles&#46;android</a>&#41;&#44; or <span class="elsevierStyleItalic">Sisterhood app</span>&#44; by the <span class="elsevierStyleItalic">Hemophilia Federation of America</span> &#40;<a href="https://www.sisterhoodapp.com/">https&#58;&#47;&#47;www&#46;sisterhoodapp&#46;com&#47;</a>&#41;&#46; Only the former is specific to HMB and evaluates the level of blood permeation in pads and tampons in a similar way to PBAC&#46; The second covers bleeding disorders in general and records both menstrual and non-menstrual blood losses&#46; Both issue alerts in the event of abnormal values and allow information to be shared with the specialist&#46; But&#44; as mentioned above&#44; none of them have been validated psychometrically&#46; Their ability to alert the user in the event of HMB and to transfer this information to the clinician also remains to be assessed&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Since NICE<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> defined HMB as excessive menstrual bleeding that interferes with the physical&#44; emotional&#44; social&#44; and material quality of life of women&#44; it is essential to consider tools for its detection that not only consider the amount of bleeding&#44; but also its quality-of-life interference&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">This literature review of the most relevant studies has highlighted that the measurement tools most used to detect HMB&#44; both quantitative and semi-quantitative&#44; are complex and do not reflect the patient&#8217;s perception of the effect of symptoms on her daily life&#44; although they have played a relevant role in clinical research and the historical identification of these patients&#46; On the other hand&#44; many of the existing questionnaires to diagnose HMB&#44; which could cover these deficiencies&#44; have not been psychometrically validated&#44; are nonspecific or do not assess quality of life&#46; The SAMANTA questionnaire&#44; recently developed and validated in Spain&#44; responds to these unmet needs in the detection of HMB&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Quality of life alterations are a clear clinical indicator of the negative effects of an abnormal menstruation&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;39</span></a> The analysis of the menstrual cycle should therefore be considered a vital sign&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> HMB affects quality of life&#44; increases school and work absenteeism&#44; and impairs social relationships&#44; self-esteem&#44; and physical performance&#46; However&#44; several studies have shown that the majority of women with HMB do not seek medical attention for this condition&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">41&#44;42</span></a> perhaps due to a biased perception of what constitutes normal menstrual bleeding&#44; particularly when women in the same setting have a similar menstrual pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Different scientific societies agree that any intervention against HMB should aim to improve quality of life rather than focus on menstrual blood loss&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;18&#44;43&#8211;45</span></a> The consequences of HMB on quality of life have been described by various authors&#46; In a study that analysed the menstrual cycle in 1575 women aged 20&#8211;39 years in Australia&#44; menstrual flow was considered heavy or very heavy by 22&#46;5&#37; and 5&#46;3&#37; of them&#44; respectively&#46; Women with heavy or very heavy bleeding were significantly more likely to remain bedridden during menstruation than the others &#40;prevalence of 1&#46;58 and 1&#46;53 in women with heavy or very heavy bleeding&#44; respectively&#44; versus 1&#46;09 in women with moderate bleeding&#44; p&#160;&#61;&#160;0&#46;0002&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In addition to this&#44; HMB involves a greater consumption of healthcare resources&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a> Between 2004 and 2006&#44; in the UK&#44; there were 51&#44;664 women aged 25&#8211;59 years with HMB who underwent endometrial ablation or hysterectomy in the <span class="elsevierStyleItalic">English National Health Service</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Measurement of <span class="elsevierStyleItalic">patient-reported outcomes</span> &#40;PRO&#41; is an active research area at the HMB&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> PRO is defined as any information about a patient&#8217;s health status that comes directly from the patient&#44; without interpretation of the response by another person&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> HRQoL is the PRO that has attracted most interest in recent decades&#44; with various generic and disease-specific questionnaires developed to measure HRQoL&#46; However&#44; few validated questionnaires in the field of HMB include quality of life &#40;specific to this condition&#41; as an evaluable parameter&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The measurement of HRQL in clinical practice requires questionnaires that can be administered quickly and easily and&#44; at the same time&#44; allow to obtain reliable and valid results&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> Generating a questionnaire is a time-consuming and resource-intensive process&#46; Before using a new PRO measuring tool&#44; it is essential to prove its measuring capabilities&#46; In addition&#44; its use in a cultural context different from the original one requires a standard process of cross-cultural adaptation&#44; with subsequent validation for the target country&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The recently published SAMANTA study<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> has made it possible to have a simple questionnaire&#44; validated in Spanish&#44; to easily identify women with HMB with high sensitivity and specificity&#46; The 6 items included address both the symptoms and interference with the quality of life and daily activities&#46; Thanks to its internal consistency&#44; discrimination capacity and ease of use&#44; this screening tool provides the opportunity to identify women with HMB without the need for complex methods&#46; The results are obtained immediately&#44; which facilitates their incorporation into clinical practice&#44; both in primary care and in hospitals&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> without introducing delays in treatment&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">On the other hand&#44; this review has highlighted the need for HMB awareness&#46; Women need to seek medical attention before their quality of life is impaired&#46; Due to the sensitive nature of the disease&#44; healthcare professionals should endeavour to provide the necessary informational and emotional support to these patients on an individual basis&#46; Beyond point-of-care consultation&#44; newly diagnosed women could access educational materials to receive appropriate training&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Multidisciplinary care is another cornerstone in the treatment of HMB&#46; Menstruation and especially HMB is the single most common cause of iron deficiency anaemia in women of childbearing age&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">49&#44;50</span></a> In a study of women with HMB&#44; 63&#37; of respondents reported iron deficiency at some time&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> Low iron stores in adolescents with HMB&#44; reflected by a low level of ferritin&#44; even in the absence of anaemia&#44; are associated with fatigue and impaired cognition&#44; with particular impairment of verbal learning and memory&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> and even symptoms of depression or anxiety&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In this sense&#44; initiatives have been carried out for the multidisciplinary care of patients with HMB&#44; such as the <span class="elsevierStyleItalic">Young Women&#8217;s Blood Disorders</span> program from the University of Texas&#44; in which the patient is cared for by a team that acts in a coordinated manner in the diagnosis&#44; treatment and monitoring of HMB&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> The consequences of HMB go beyond the gynaecological setting and can affect different specialties &#40;haematology&#44; dermatology&#44; pneumology&#44; digestive&#44; emergency&#44; psychiatry&#44; nutrition&#44; nursing&#44; etc&#46;&#41;&#44; so a multidimensional view is essential&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusion</span><p id="par0170" class="elsevierStylePara elsevierViewall">Most of the tools available to detect HMB have limitations in terms of their ease of use&#44; validation&#44; and holistic perspective of the disease&#46; Assessing the impact on quality of life is essential in any tool designed to detect HMB&#46; Any questionnaire&#44; whether in written or digital format&#44; should be validated and exhibit good reliability&#46; The SAMANTA questionnaire meets these requirements and can be easily integrated into routine clinical practice&#46; In view of its good results&#44; a prospective study is being carried out to confirm the sensitivity to change in the questionnaire score&#46; In addition&#44; it seems appropriate that the SAMANTA questionnaire undergoes cultural and linguistic validation for extension to other countries&#44; and that it is adapted to digital format so as to widen its accessibility&#46; This&#44; together with the awareness of the healthcare professional within a multidisciplinary perspective&#44; will ultimately benefit the HMB patient&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Funding</span><p id="par0175" class="elsevierStylePara elsevierViewall">This review has been financed by <span class="elsevierStyleGrantSponsor" id="gs0005">Bayer Hispania S&#46;L&#46;</span>by contracting the services of Adelphi&#44; an independent company that provided medical editorial assistance and editorial support&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of interests</span><p id="par0180" class="elsevierStylePara elsevierViewall">Joaquin Calaf has received consulting fees&#44; served on advisory committees&#44; or given lectures on behalf of Bayer&#44; MSD&#44; Gedeon Richter and Theramex&#46; Dr&#46; Calaf has not received any type of compensation for the writing of the article and the prescription of any product is not mentioned&#44; promoted&#44; or favoured&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Josep Perell&#243; has received consulting fees&#44; served on advisory committees&#44; or given lectures on behalf of Bayer&#44; MSD&#44; Theramex&#44; Exeltis and Gynea-Kern&#46; Dr&#46; Perell&#243; has not received any type of compensation for the writing of the article and the prescription of any product is not mentioned&#44; promoted&#44; or favoured&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Joan Rius works as a medical advisor for Bayer Hispania SL&#46; The article does not mention&#44; promote&#44; or encourage the prescription of any product&#46;</p></span></span>"
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            1 => "Abnormal uterine bleeding"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Heavy menstrual bleeding &#40;HMB&#41; is defined as excessive menstrual blood loss that interferes with quality of life&#46; It is an under-diagnosed and under-treated disorder due to the poor correlation between patient perception and objective menstrual blood loss&#44; as well as the scarcity of validated diagnostic tools&#46; Anaemia caused by HMB is a common problem&#44; underestimated on many occasions and with consequences that go beyond the scope of gynaecology&#46; Despite the condition&#8217;s negative effect on quality of life&#44; most of the tools validated to detect HBM do not take this into account&#46; The aim of this paper is to review the main instruments available to detect HMB&#44; their advantages and disadvantages&#44; their applicability in routine clinical practice&#44; and to recommend those with the best characteristics&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El sangrado menstrual abundante &#40;SMA&#41; se define como una p&#233;rdida excesiva de sangre menstrual que interfiere con la calidad de vida&#46; Se trata de una alteraci&#243;n infradiagnosticada e infratratada debido a la escasa correlaci&#243;n entre la percepci&#243;n de la paciente y la p&#233;rdida hem&#225;tica menstrual objetiva&#44; as&#237; como a la escasez de herramientas diagn&#243;sticas validadas&#46; La anemia causada por el SMA es un problema frecuente&#44; infravalorado en muchas ocasiones y con consecuencias que van m&#225;s all&#225; del &#225;mbito de la ginecolog&#237;a&#46; A pesar de su efecto negativo sobre la calidad de vida&#44; la mayor&#237;a de las herramientas validadas para detectar el SMA no tienen en cuenta este concepto&#46; El objetivo de este trabajo es revisar los principales instrumentos disponibles para detectar el SMA&#44; sus ventajas e inconvenientes&#44; su aplicabilidad en la pr&#225;ctica cl&#237;nica habitual&#44; y recomendar aquellos que re&#250;nen las mejores caracter&#237;sticas&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Perell&#243; J&#44; Rius Tarruella J&#44; Calaf J&#46; Sangrado menstrual abundante y su detecci&#243;n en la pr&#225;ctica cl&#237;nica&#46; Med Clin &#40;Barc&#41;&#46; 2021&#59;157&#58;332&#8211;338&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SAMANTA questionnaire&#46; Questions asked by the doctor to the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">AMSS&#58; <span class="elsevierStyleItalic">Aberdeen Menorrhagia Severity Scale</span>&#59; EQ-5D-5L&#58; EuroQoL of 5 dimensions and 5 levels&#59; AH&#58; alkaline hematin&#59; MBQ&#58; <span class="elsevierStyleItalic">Menstrual Bleeding Questionnaire</span>&#59; MEQ&#58; <span class="elsevierStyleItalic">Menstrual Evaluation Questionnaire</span>&#59; MY Q&#58; <span class="elsevierStyleItalic">Menorrhagia Impact Questionnaire</span>&#59; MMAS&#58; <span class="elsevierStyleItalic">Menorrhagia Multiattribute Scale</span>&#59; PBAC&#58; <span class="elsevierStyleItalic">pictorial blood loss assessment chart</span>&#59; PGWBI&#58; psychological general well-being index&#59; SAQ&#58; <span class="elsevierStyleItalic">Sexual Activity Questionnaire</span>&#59; HMB&#58; heavy menstrual bleeding&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Questionnaire&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Description&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Validation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HMB diagnostic capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HMB discriminatory capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Other characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Evaluation of menstrual symptoms</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Menstrual MEQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Warner et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Includes items on bleeding symptoms and scores them according to their severity and degree of contribution to seeking medical attention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated against AH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&#46; Sensitivity and specificity of bleeding diagnosis &#62;80&#160;ml&#58; 60&#37; and 86&#37;&#44; respectively&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderately good prediction of bleeding patients &#62;80&#160;ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consistency between cycles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated in English&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disadvantage&#58; more than one cycle must be analysed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead colgroup " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Multidimensional evaluation&#58; menstrual symptoms and quality of life associated with HMB</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MMAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Shaw et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It measures the effect of the HMB with 6 items relating to practical difficulties&#44; social life&#44; mental health&#44; physical health&#44; work life and family life&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated against SF-36 v2&#44; EQ-5D&#44; SAQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46; Assessment of HMB-specific quality of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Demonstrated discriminatory capacity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High face validity and content validity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pattison et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Responses are scored and weighted to generate a score from 0 &#40;most severe effect&#41; to 100 &#40;no effect&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated in English&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Internal consistency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Test-retest reliability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AMSS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ruta et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Measures bleeding-specific symptoms and quality of life associated with HMB with 13 items on the characteristics of the symptom&#44; pain&#44; staining of clothes due to bleeding&#44; work life&#44; leisure activities and sexual life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Widely validated and used&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&#46; Assessment of HMB-specific quality of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It does not establish a discriminatory cut-off point&#44; only differences between women who report heavy menstruation and women who do not&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Internal consistency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Item scores are added up and weighted&#44; where 0 is the best possible score and 100 is the worst possible score&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Participation of patients in its validation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acceptable test-retest reliability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated in English&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MBQ&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Matteson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Measures the impact of HMB with 20 items including perception of bleeding volume&#44; bleeding pattern&#44; pain&#44; impact of symptoms&#44; including social embarrassment&#44; fear of social embarrassment&#44; and behaviour changes to avoid social embarrassment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated against SF-36&#44; PBAC&#44; ferritin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">It does not establish a discriminatory cut-off point&#44; only differences between women who report heavy menstruation and women who do not&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Internal consistency with good item-domain correlations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adds up the answers to get a total score and multiplies the score by 1&#46;32 &#40;0&#58; lowest possible impact&#44; 100&#58; highest possible impact&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Participation of patients in its validation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Content validity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated in English&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advantage&#58; measures social embarrassment and is not affected by recall bias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disadvantage&#58; unknown whether it can be generalized&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MY Q&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bushnell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Six items on perceived menstrual loss&#44; impact on work and physical and social activities&#44; number of limited activities&#44; and perceived effect of treatment on symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated against MIQ item 6&#160;c&#44; AH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&#46; Sensitivity 64&#37; and 69&#37;&#8211;79&#37;&#59; specificity 75&#37; and 63&#37;&#8211;82&#37; in women who perceived normal flow or diagnosed with HMB&#44; respectively&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Discriminatory power validated with respect to both statistical and clinical significance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prediction of variations perceived as significant by women in menstrual blood loss&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lukes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated in the context of clinical trials with tranexamic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Test-retest reliability&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated in English&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reliability of individual items&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Advantages&#58; speed &#40;answer in 2&#160;min&#41;&#59; in case of short observation period&#44; a change in &#43;1 point is easily interpretable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SAMANTA questionnaire&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calaf et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Six items that address both the symptoms of HMB and its interference with quality of life and daily activities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated against PBAC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&#46; Sensitivity 86&#46;7&#37; and specificity 89&#46;5&#37;&#44; positive predictive value 92&#46;0&#37;&#44; negative predictive value 83&#37;&#44; discriminatory capacity 87&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Validated discriminatory power&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High internal consistency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">The total score ranges from 0 to 10 points&#46; A total score&#160;&#8805;&#160;3 indicates the presence of HMB that interferes with quality of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Participation of patients in its validation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Significant correlations with the EQ-5D-5L and PGWBI perceived quality of life questionnaires&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Validated in Spanish&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Advantages&#58; speed and simplicity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disadvantages&#58; test-retest reliability not evaluated&nbsp;\t\t\t\t\t\t\n
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                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comparative analysis of different validated questionnaires in the assessment of heavy menstrual bleeding &#40;HMB&#41;&#44; according to the parameters evaluated&#46;</p>"
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