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ORIGINAL ARTICLE
Year : 2021  |  Volume : 20  |  Issue : 2  |  Page : 111-115  

Clinical screening for menorrhagia and other bleeding symptoms in Nigerian women


1 Department of Haematology and Immunology, College of Medicine, University of Nigeria, Ituku Ozalla Campus, Enugu, Nigeria
2 Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Ituku Ozalla Campus, Enugu, Nigeria

Date of Submission09-Apr-2020
Date of Acceptance07-Aug-2020
Date of Web Publication30-Jun-2021

Correspondence Address:
Helen Chioma Okoye
Department of Haematology and Immunology, College of Medicine, University of Nigeria, Ituku Ozalla Campus, Enugu
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_26_20

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   Abstract 


Objective: The objective of the study was to evaluate the prevalence of perceived bleeding symptoms in Nigerian women and the usefulness of a simple clinical screening tool for bleeding symptoms. Materials and Methods: A population-based cross-sectional survey of 1524 women of 16–50 years in Southeast Nigeria using a structured, prevalidated, pretested questionnaire was conducted. Results: A total of 1524 (85%) women responded with the mean age of 26 (10.6) years. Prevalence of bleeding symptoms was 24.6% and 11% of the women reported a positive family history of bleeding symptoms. There was a significant association between having a positive family history of bleeding disorder and experiencing bleeding symptoms (adjusted odds ratio: 0.12, 95% confidence interval: 0.06–0.22 P < 0.0001). Two hundred and six women experienced at least one bleeding symptom, 125 (8.2%) experienced at least two, whereas 43 (2.8%) experienced >3 bleeding symptoms. The most common perceived bleeding symptom was heavy menstrual bleeding (HMB) present in 83 women (22.2%), 141 (9.3%) reported a past history of HMB, 202 (13.3%) had heavy bleeds during most of their monthly cycle, and 351 (23%) requiring resuscitation with blood support. Conclusion: The prevalence of perceived bleeding symptoms among women is high, and HMB is the most common bleeding symptom. This clinical screening tool is easy and cost-effective in routinely identifying women with bleeding symptoms needing further hemostatic and obstetrics evaluation.

   Abstract in French 

Résumé
Objectif: L'objectif de l'étude était d'évaluer la prévalence des symptômes hémorragiques perçus chez les femmes nigérianes et l'utilité d'un outil de dépistage clinique simple des symptômes hémorragiques. Matériel et méthodes: enquête transversale auprès de la population auprès de 1 524 femmes de 16 à 50 ans dans le sud-est du Nigéria à l'aide d'un questionnaire structuré, prévalidé et prétesté. Résultats: Un total de 1524 (85%) les femmes ont répondu avec l'âge moyen de 26 (10,6) ans. La prévalence des symptômes hémorragiques était de 24,6% et 11% des femmes ont signalé un antécédents familiaux positifs de symptômes hémorragiques. Il y avait une association significative entre avoir des antécédents familiaux de saignement positifs trouble et présentant des symptômes hémorragiques (rapport de cotes ajusté: 0,12, intervalle de confiance à 95%: 0,06–0,22 P <0,0001). Deux cent et six femmes ont présenté au moins un symptôme de saignement, 125 (8,2%) en ont eu au moins deux, tandis que 43 (2,8%) ont eu> 3 saignements symptômes. Le symptôme de saignement perçu le plus courant était le saignement menstruel abondant (HMB) présent chez 83 femmes (22,2%), 141 (9,3%) ont signalé des antécédents de HMB, 202 (13,3%) ont eu des saignements abondants pendant la majeure partie de leur cycle mensuel et 351 (23%) ont dû être réanimés avec support sanguin. Conclusion: la prévalence des symptômes hémorragiques perçus chez les femmes est élevée et le HMB est le plus courant symptôme de saignement. Cet outil de dépistage clinique est simple et économique pour identifier systématiquement les femmes présentant des symptômes hémorragiques nécessitant évaluation hémostatique et obstétrique plus poussée.

Keywords: Bleeding symptoms, clinical screening, hemostasis, heavy menstrual bleed, women


How to cite this article:
Nwagha TU, Okoye HC, Ugwu AO, Ugwu EO. Clinical screening for menorrhagia and other bleeding symptoms in Nigerian women. Ann Afr Med 2021;20:111-5

How to cite this URL:
Nwagha TU, Okoye HC, Ugwu AO, Ugwu EO. Clinical screening for menorrhagia and other bleeding symptoms in Nigerian women. Ann Afr Med [serial online] 2021 [cited 2021 Sep 27];20:111-5. Available from: https://www.annalsafrmed.org/text.asp?2021/20/2/111/320039




   Introduction Top


Often, women of reproductive age seek care from gynecologists for bleeding symptoms, suggestive of an underlying bleeding disorder with heavy menstrual bleeding (HMB) being a very common reportable bleeding symptom. Irrespective of the age, bleeding disorder is about the most common cause of HMB.[1] Women may experience other symptoms such as easy and frequent bruising, heavy or prolonged bleeding episodes following a hemostatic challenge, and history of receiving treatment for anemia. Similarly, having a family history is an important risk factor for a bleeding disorder. Bleeding disorders in women are associated with increased obstetrics and gynecologic morbidity.[2] Furthermore, it can be detrimental to their physical, psychological, and social well-being with a negative impact on their quality of life.[3] Little is known about the prevalence of bleeding symptoms in Nigerian women despite the known impact across many aspects of health and quality of life. Knowing that HMB is one common symptom making affected individuals present to obstetricians and gynecologists most times, these health-care providers are less likely to consider bleeding disorder as a possible cause of unexplained HMB.[4],[5] In a US-based study, a 16-year period was reported as the average delay time from the onset of bleeding symptoms to the diagnosis of an underlying bleeding disorder.[6] It is worthy to note that not all cases of bleeding symptom are associated with a background bleeding disorder.

In view of all these, there is a need for a handy but detailed clinical screening tool to aid prompt identification of individuals with bleeding symptoms at risk of bleeding disorder needing further evaluation, especially in our resource-poor setting. Should a woman be identified to have a bleeding disorder, the clinician, therefore, would be better prepared to refer the patient to the appropriate portal, offer preconception counseling, manage the pregnancy, or treat any other conditions she may present with.


   Materials and Methods Top


This was a population-based, cross-sectional, observational study conducted in five states in the Southeast geographic zone in Nigeria, over a period of 6 months from March to September 2017. Women of all works of life between the ages of 16 and 50 years were surveyed using a structured, prevalidated questionnaire that contained all eight questions. The Philip et al.[7] screening tool for bleeding symptoms was used.

We distributed a total of 1800 self-administered, prevalidated, pretested, structured questionnaires in English and local language spoken in the southeast region. The tools were distributed in churches, market places, and other women gatherings in the community to women who gave their consents to participate in the study. There were also trained interviewers to administer the questionnaire for those who needed help. We had a response rate of 85%, with a total of 1524 complete responses (Enugu state – 430; Anambra state – 326; Ebonyi state – 290; Imo state – 254; and Abia state – 224). The questionnaire had two sections; the first section was on sociodemographic information from the participants, whereas the second section was a screening tool to assess the presence and severity of bleeding symptoms. The screening tool consisted of eight questions in the following four categories: (1) severity of HMB, (2) family history of a diagnosed bleeding disorder, (3) personal history of excessive bleeding after specific challenges, and (4) history of treatment for anemia.

The severity of HMB was defined as a duration of menses of ≥7 days and either passage of clots, flooding, or bleeding through a sanitary pad, and menstruation clot in ≤2 h. A positive family history of a diagnosed bleeding disorder or presence of bleeding symptoms such as epistaxis postcircumcision bleeds, HMB, and joint bleeds in a family member. A history of excessive bleeding after a challenge was based on the following specific challenges: delivery, miscarriage, surgery, tooth extraction, or dental surgery.

A screening tool was considered positive for a study participant if an affirmative response was obtained in any one of the four categories.

Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) software version 21 (SPSS Inc., Chicago, IL, USA). Descriptive data were computed for the primary analysis. Chi-square, t-tests, and χ2 analyses were used for inferential statistics; confidence interval (CI) was set at 95% such that P < 0.05 was considered statistically significant.


   Results Top


We received 1524 (84.6%) completed responses with a Cronbach's alpha value of 0.8%.

The majority of respondents were ages 18–30 years old (n = 662, 43.4%), while 11.5% fell between the ages of 41–50 years. Most were nulliparous (n = 1028, 67.5%), single (1025, 67.3%), and had tertiary education (n = 627, 41.1%) [Table 1].
Table 1: Sociodemographics and menstrual history of participants (n=1524)

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A total of 141 (9.3%) respondents reported a history of HMB, 202 (13.3%) respondents reported experiences of heavy bleeds (flooding and passage of clots) during most of their monthly cycle, and 351 (23%) required resuscitation with blood support.

One hundred and seventy-three (11.4%) respondents reported a positive family history of bleeding symptoms, with 172 (11.4%) reporting a family history of bleeding after tooth extraction. Sixty-four (4.3%) respondents reported bleeding after dental procedures. There was a significant association between having a family history of bleeding and experiencing bleeding symptoms (adjusted odds ratio: 0.12, 95% CI: 0.06–0.22 P < 0.0001) [Table 1] and [Table 2].
Table 2: Bleeding pattern reported by respondents

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The prevalence of bleeding symptoms was 24.6% (n = 375). Two hundred and six (13.5%) respondents had at least one bleeding symptom, 125 (8.2%) experienced at least two, whereas 43 (2.8%) experienced >3 bleeding symptoms. HMB was the most reported bleeding symptom (n = 83, 22.1%), whereas postsurgical bleeding was the least reported symptom (n = 28, 7.5%).

There is a significant association between sociodemographics; age (χ2: 221.0, P 0.001), parity (χ2: 227.6, P = 0.0001), marital status (χ2: 263.7, P = 0.001), education (χ2: 46.3, P 0001), and occupation (χ2: 123.3, P = 0.001) and reported history of bleeding symptoms [Table 3],[Table 4],[Table 5].
Table 3: Association between sociodemographics and history of bleeding symptoms

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Table 4: Association between the presence of bleeding symptoms

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Table 5: Association between family history of bleeding symptoms and presence of bleeding symptoms

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   Discussion Top


To the best of our knowledge, this is the first population-based study aimed to screen and estimate the prevalence of reported bleeding symptoms among women in five states in Southeast Nigeria. This study surveyed a female population aged 16–54 years. Before now, most studies about bleeding symptoms or bleeding disorders in Nigeria were small hospital-based studies, either profiling the perception of clinicians managing these symptoms,[8] congenital bleeding conditions such as hemophilia[9] or case studies of patients with bleeding symptoms or disorders.[9],[10],[11]

We found that a high proportion of women were between the ages of 18–30 years, and minority were in the older age range. This differs from a similar UK study, which showed a reversal of the age of respondents compared to our study.[12] Their study also showed that most respondents were either married or cohabiting, a big contrast from our study, which showed most of our respondents were single. An Iranian study that screened women for von Willebrand disease differed in ages of participants as the majority of study participants were between the ages of 31 and 40 years.[13]

Our study reported a prevalence of 25% of the presence of self-reported bleeding symptoms. This again slightly agrees with studies on the prevalence of bleeding disorders who reported a range of 29%–43% in women with HMB.[14],[15] Our study also considered other bleeding symptoms other than HMB, obstetric bleeding, tooth extraction, and surgical bleeds.

The most frequently reported bleeding symptom was HMB. This agrees with similar population studies done in the USA,[3],[7] the UK,[12] Iran,[13] and Europe.[1] A Saudi Arabian study screening adolescents and young adults for bleeding disorders reported epistaxis as the most common bleeding symptoms.[16] This could be that, in their study, they screened both males and females, with males being in the majority. In our survey, we studied only women in the reproductive age group.

Our study found a significant association between a positive family history of bleeding symptoms and the presence of bleeding symptoms as reported by the women. Many studies have equally reported the association between family history of bleeding symptoms and the presence of symptoms[1] though the absence does not completely rule it out.

The high number of women either experiencing flooding during menstruation or requiring resuscitation with blood components underscores the need to incorporate a cost-effective and user-friendly screening tool for bleeding symptoms in the clinical evaluation of women in reproductive age range, especially in the primary health-care center. Phillip et al. showed this screening tool to have high sensitivity and will be beneficial as a screening tool in settings with suspected high rates of bleeding symptoms and disorders.[7] The simplicity of this tool makes it cheap and useful in screening out women that may need more expensive and comprehensive laboratory evaluation. This may be useful to primary care providers, gynecologists, and hematologists in classifying those referred for further hemostatic evaluation.


   Conclusion Top


This survey is the first population-based epidemiological study for bleeding symptoms in Nigeria using a cost-effective screening tool with proven sensitivity. The prevalence rate of bleeding symptoms in the southeast region is high and underscores the need for a national survey with a representative sample from other regions in the country. With HMB and obstetric bleed still an important contributor to high morbidity and mortality rates, we recommend the use of this simple, sensitive cost-effective screening tool as a part of the initial protocol in clinical practice including gynecologic and obstetric assessment of women in Nigeria.

Acknowledgment

We thank Nneka Amu and Onochie Obodo for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Philipp CS, Faiz A, Dowling N, Dilley A, Michaels LA, Ayers C, et al. Age and the prevalence of bleeding disorders in women with menorrhagia. Obstet Gynecol 2005;105:61-6.  Back to cited text no. 1
    
2.
James AH. More than menorrhagia: A review of the obstetric and gynaecological manifestations of bleeding disorders. Haemophilia 2005;11:295-307.   Back to cited text no. 2
    
3.
Kirtava A, Drews C, Lally C, Dilley A, Evatt B. Medical, reproductive and psychosocial experiences of women diagnosed with von Willebrand's disease receiving care in haemophilia treatment centres: A case-control study. Haemophilia 2003;9:292-7.  Back to cited text no. 3
    
4.
Dilley A, Drews C, Lally C, Austin H, Barnhart E, Evatt B. A survey of gynecologists concerning menorrhagia: Perceptions of bleeding disorders as a possible cause. J Womens Health Gend Based Med 2002;11:39-44.  Back to cited text no. 4
    
5.
Chi C, Shiltagh N, Kingman CE, Economides DL, Lee CA, Kadir RA. Identification and management of women with inherited bleeding disorders: A survey of obstetricians and gynaecologists in the United Kingdom. Haemophilia 2006;12:405-12.  Back to cited text no. 5
    
6.
Kirtava A, Crudder S, Dilley A, Lally C, Evatt B. Trends in clinical management of women with von Willebrand disease: A survey of 75 women enrolled in haemophilia treatment centres in the United States. Haemophilia 2004;10:158-61.  Back to cited text no. 6
    
7.
Philipp CS, Faiz A, Dowling NF, Beckman M, Owens S, Ayers C, et al. Development of a screening tool for identifying women with menorrhagia for hemostatic evaluation. Am J Obstet Gynecol 2008;198:163.e1-8.  Back to cited text no. 7
    
8.
Okparaoka S, Nwagha TU, Anyaehie B. Frequency of hemophilia and hemostatic evaluation in persons with bleeding symptoms in Southeast, Nigeria. Int J Med Health Dev 2019;24:18-22.  Back to cited text no. 8
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9.
Okoye HC, Korubo KI, Nwogoh B, Efobi CC, Ugwu NI, Madu AJ. Challenges in the management of bleeding disorders in Nigeria. Niger J Clin Pract 2018;21:468-72.  Back to cited text no. 9
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Ezeama C, Ikechebelu J, Obiechina Nj, Ezeama N. Clinical presentation of uterine fibroids in Nnewi, Nigeria: A 5-year Review. Ann Med Health Sci Res 2012;2:114-8.  Back to cited text no. 10
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Alatise OI, Fischer SE, Ayandipo OO, Omisore AG, Olatoke SA, Kingham TP. Health-seeking behavior and barriers to care in patients with rectal bleeding in Nigeria. J Glob Oncol 2017;3:749-56.  Back to cited text no. 11
    
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Gabriel OT, Bamidele AO. Epistaxis in Ido Ekiti, Nigeria: A 5-year review of causes, treatment and outcome. Sahel Med J 2013;16:107-10.  Back to cited text no. 12
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Shapley M, Jordan K, Croft PR, Abnormal bleeding patterns associated with menorrhagia in women in the community and in women presenting to primary care. Fam Pract 2007;26:532-37.  Back to cited text no. 13
    
14.
Rahbar N, Faranoush M, Ghorbani R, Sadr Alsadat B. Screening of Von Willebrand Disease in Iranian women with menorrhagia. Iran Red Crescent Med J 2015;17:e18244.  Back to cited text no. 14
    
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Knol HM, Mulder AB, Bogchelman DH, Kluin-Nelemans HC, van der Zee AG, Meijer K. The prevalence of underlying bleeding disorders in patients with heavy menstrual bleeding with and without gynecologic abnormalities. Am J Obstet Gynecol 2013;209:202.e1-7.  Back to cited text no. 15
    
16.
Noone D, Skouw-Rasmussen N, Lavin M, van Galen KPM, Kadir RA. Barriers and challenges faced by women with congenital bleeding disorders in Europe: Results of a patient survey conducted by the European Haemophilia Consortium. Haemophilia 2019;25:468-74.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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