Human Reproduction Open, pp. 1–8, 2022 https://doi.org/10.1093/hropen/hoac048 OPINION Clinical perspectives on the menstrual pictogram for the assessment of heavy menstrual bleeding Sukhbir S. Singh1, Joaquin Calaf Alsina2, Silvia Vannuccini3, Kaori Koga4, Agnaldo Lopes Silva-Filho5, Xin Yang6, Jean-Philippe Estrade7, and William Catherino 8,* 1 University of Ottawa & Ottawa Hospital Research Institute, Ottawa, Ontario, Canada 2Hospital de la Santa Creu i Sant Pau, Universitat Autónoma, Barcelona, Spain 3Careggi University Hospital, Florence, Italy 4University of Tokyo, Tokyo, Japan 5Universidade Federal de Minas Gerais, Belo Horizonte, Brazil 6Peking University People’s Hospital, Beijing, China 7Clinique Bouchard-Elsan, Marseille, France 8 Uniformed Services University of the Health Sciences, Bethesda, MD, USA *Correspondence address. Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA. Tel: þ1 301 295-3126; E-mail: william.catherino@usuhs.edu https://orcid.org/0000-0002-8783-6999 Submitted on December 07, 2021; resubmitted on September 20, 2022; editorial decision on October 17, 2022 Abstract: Heavy menstrual bleeding (HMB) has an estimated prevalence of 18–32% but is known to be under-reported due to poor recognition and estimation of menstrual blood loss (MBL). HMB can negatively impact quality of life, affecting social interactions, work pro- ductivity and sexual life. Abnormal menstrual bleeding may have an underlying structural or systemic cause, such as endometrial and myo- metrial disorders; however, for some, there is no identified pathological cause. Several methods are available for assessing MBL, including the alkaline hematin (AH) method and the menstrual pictogram (MP). The AH method is considered to be the most accurate way to mon- itor MBL; however, it is associated with inconvenience and expense, therefore limiting its value outside of research. The MP requires the user to select an icon from a chart that reflects the appearance of a used sanitary product; the icon is associated with a blood volume that can be used to determine MBL. Validation studies have demonstrated that the results of the MP and AH method are well correlated, showing that the MP can measure MBL with sufficient accuracy. Additionally, the MP is more convenient for users, less expensive than the AH method, may be used in regions where the AH method is unavailable and may also be used as part of a digital application. Overall, the MP offers a convenient approach to monitor MBL both in research and clinical practice settings. Key words: heavy menstrual bleeding / menstrual blood loss / uterine fibroids / menstrual pictogram / alkaline hematin method / abnormal uterine bleeding .. sample population characteristics (e.g. parity, age) and is dependent Introduction .. .. on HMB definition (Karlsson et al., 2014; Fraser et al., 2015, Heavy menstrual bleeding (HMB) is defined as blood loss of >80 ml .. Hapangama and Bulmer, 2016; Ding et al., 2019). .. per menstrual cycle (Hallberg et al., 1966), or excessive menstrual .. HMB is known to be extensively under-reported, and potentially only blood loss (MBL) that interferes with a woman’s physical, emotional, .. .. 6% of women with HMB seek medical help (Fraser et al., 2015). This is social and material quality of life (QoL). HMB can occur alone or with .. largely due to inaccurate individual self-perception of HMB (Magnay .. other symptoms (National Institute for Health and Care Excellence, .. et al., 2018) and normalization of symptoms (Fraser et al., 2015). For 2018). .. example, one population study demonstrated poor correlation between .. .. women’s perception of and actual MBL: 37% and 4% of women with .. blood loss >80 ml considered their MBL to be moderate or scanty, re- HMB is under-recognized and .. .. spectively; 14% of women with blood loss <20 ml considered their under-reported .. .. MBL to be heavy (Hallberg et al., 1966). This is supported by studies in- There are sparse data on HMB global prevalence in the general popu- .. cluding self-reported data, which report a lower HMB prevalence than .. lation, although a prevalence of 18–32% at any time during reproduc- .. primary clinical studies (Fraser et al., 2015). HMB recognition is also tive life has been suggested. This can vary across regions according to .. influenced by cultural factors (Edelman et al., 2007; Bitzer et al., 2013): C The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. V This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 2 Singh et al. .. menstrual taboos can promote a culture of silence (Harlow and .. (Wyatt et al., 2001; Magnay et al., 2018). Based on current United Campbell, 2004) and some cultures consider menstrual blood to be .. States Food and Drug Administration guidance, the AH method is typ- .. ‘medically cleansing’ or a sign of health (Bitzer et al., 2013). .. ically used for the diagnosis and assessment of HMB in research set- The International Federation of Gynecology and Obstetrics ... tings (Magnay et al., 2018). The AH method was developed >50 years Working Group on Menstrual Disorders developed the PALM-COEIN .. ago and involves chemical extraction of hemoglobin from used sanitary .. (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagul- .. products. It was initially validated for use with cotton-based sanitary opathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet .. products and blood recovery was 96% after a 20 h incubation. .. classified) classification system for causes of abnormal uterine bleeding .. Following protocol modifications to simplify and improve the speed (AUB), defined as menstrual bleeding that is abnormal in duration, vol- .. (Wyatt et al., 2001), the efficiency of blood extraction from a selection .. ume and/or frequency for 3 months. The term AUB also encom- .. of sanitary products ranged from 75 to 107% (Magnay et al., 2018). passes HMB (Munro et al., 2011). Although, for some women, there is .. More than a decade ago, most sanitary towels (also referred to as .. no obvious pathological cause of their AUB, others may experience .. sanitary pads) contained cotton as the main component of the absor- .. one or more entities that can cause or contribute to AUB, including .. bent core, whereas today, the majority of products contain superab- structural causes (polyps, adenomyosis, leiomyoma [fibroids], malig- .. sorbent polymer (SAP) granules (Magnay et al., 2014; Woeller and .. nancies) or non-structural causes (coagulation, ovulatory, endometrial .. Hochwalt, 2015; P&G (Proctor and Gamble), 2019). The AH method iatrogenic disorders) (Munro et al., 2011; Hapangama and Bulmer, .. was subsequently adapted and revalidated for use with a selected .. 2016; Cheong et al., 2017). Depending on severity, HMB may also .. brand of SAP-containing towels (Magnay et al., 2011); recovery of at lead to anemia (Borah et al., 2013; Stewart et al., 2013; Salehi et al., .. least 90% (85% with automation) of simulated menstrual fluid vol- .. 2015; David et al., 2016; Soliman et al., 2017). It is therefore clear that .. umes was observed (Magnay et al., 2018). under-reporting of HMB is of concern and improving identification .. However, the AH method requires women to collect and send .. methods may lead to timely diagnosis and treatment options. .. used sanitary products for laboratory analysis, which presents some .. challenges: it can be impractical and inconvenient, and it requires labo- .. HMB negatively impacts QoL .. ratory expertise and costs to interpret and report results (The .. Menorrhagia Research Group et al., 2004; Schumacher et al., 2012; HMB has been shown to adversely affect QoL, including impacting .. .. Magnay et al., 2014, 2018). The AH method is subject to incomplete physical activities, social interactions, work productivity, well-being and .. sexual life (Lukes et al., 2012; Gokyildiz et al., 2013; Su et al., 2020). It .. patient compliance and collection variability, including variation in sani- .. tary products, with associated variability in recovered amount of AH is the impact on daily life that will often lead individuals to seek care .. from their healthcare providers (Lukes et al., 2012). .. and requirement for calibration curves for each product (El-Nashar .. et al., 2015). Underestimation of blood loss due to overflow from the Post-hoc analysis of data from two randomized, placebo-controlled .. studies of an oral tranexamic acid formulation in women with HMB .. sanitary product is exacerbated by non-blood components not being .. detected by the AH method (Fraser et al., 1985; Fraser et al., 2001; revealed that higher daily MBL was associated with worse ratings of .. .. Wyatt et al., 2001; The Menorrhagia Research Group et al., 2004; health-related QoL (Menorrhagia Impact Questionnaire) (Lukes et al., .. Magnay et al., 2014, 2018). 2012). Data from both a case–control study and a Swedish cross- .. .. These practical limitations prevent the AH method from being used sectional study found that scores on all eight domains of the Short .. beyond research settings. Furthermore, women may be deterred from Form-36 QoL scale (physical functioning, physical role, pain, general .. .. participating in clinical trials and complying with the study require- health, vitality, social role functioning, emotional role functioning and .. ments, due to the inconvenience of having to collect, store and send mental health) were significantly lower in women who reported HMB .. .. used sanitary wear (Magnay et al., 2018). than in women in the control group (either relatives of the participants .. without any specific health problems or women with normal MBL) .. .. Pictorial methods (Gokyildiz et al., 2013; Karlsson et al., 2014). To improve QoL in .. women with HMB, efforts to assess and reduce MBL should be a pri- .. As the focus of treatment must be the improvement of women’s .. ority for healthcare providers (Lukes et al., 2012). .. symptoms and QoL (Mohan et al., 2007; Cheong et al., 2017), it fol- This report presents the advantages and limitations of the most .. lows that the AH method of quantifying MBL has less relevance in clin- .. commonly used methods for MBL assessment, with a focus on the po- .. ical practice. Pictorial methods of measuring MBL, such as the original .. pictorial blood loss assessment chart (PBAC) and MP, are simple, tential use of the menstrual pictogram (MP), a tool with relevance for .. both research and routine clinical practice, compared with the alkaline .. quick to use, semi-quantitative, patient-reported outcome tools used .. hematin (AH) method. .. to determine MBL volume utilizing icon-based visual scoring systems .. for commonly used sanitary products (Higham et al., 1990; Janssen .. .. et al., 1995; Wyatt et al., 2001; Magnay et al., 2013, 2014). These .. tools may be beneficial in both adult and adolescent patients and are Quantitative assessment of .. .. particularly useful for monitoring treatment response (Mohan et al., MBL .. 2007; Magnay et al., 2018). .. .. Unfortunately, there are important drawbacks to the currently used AH method .. pictorial methods, including variable sensitivity and specificity versus .. The AH method was established for the quantitative assessment of .. the AH method, due to only three icons being used, contributing to MBL and is considered to be the ‘gold standard’ in terms of accuracy .. reduced accuracy. The MP also requires a paper diary record for every Validated pictogram to measure menstrual blood loss 3 .. used sanitary towel or tampon, a limitation associated with decreased .. et al., 2014., 2018). An overview of some of the recent original and accuracy (Magnay et al., 2013, 2018; El-Nashar et al., 2015). There is, .. revalidated PBAC and MP data, highlighting sensitivity and specificity, .. therefore, an unmet need for an accurate, semi-quantitative method of .. and correlation with the AH method is provided in Table I. A full re- MBL assessment that is acceptable for use in clinical trials and clinical .. view of the currently available data for these, and other methods used .. practice. .. to measure MBL, has been published (Magnay et al., 2018). .. The original PBAC and MP were validated for use with the cotton- .. containing sanitary products that were available more than a decade .. .. ago (Janssen et al., 1995; Wyatt et al., 2001; Magnay et al., 2018), and .. Development and validation of have subsequently been revalidated with SAP-containing products that .. .. the MP are now commonly used (although validation has only been conducted .. for a limited number of current products) (Magnay et al., 2014, 2018). .. The revalidated MP (for use with SAP-containing sanitary products; .. The revalidated PBAC and MP still both have the disadvantage of .. hereafter referred to as the MP) is a later modification of the PBAC women having to recall/record results (Magnay et al., 2018); however, .. .. developed to assess MBL in clinical trials (Magnay et al., 2014). The although the MP (which has the advantage of estimating MBL in millili- .. MP allows women to assess the visual appearance of used sanitary .. ters and being directly comparable with the AH method) (Magnay .. products (Magnay et al., 2013, 2014), and the pictograms are used to et al., 2018) can differentiate between sanitary product absorbency .. provide an estimation of MBL (Magnay et al., 2013). .. ratings, the PBAC (which uses a scoring system that is proportional, .. The MP comprises diagrams, with five icons that depict a graded se- but not equivalent to MBL) (Magnay et al., 2018) cannot. .. ries of stained towels or tampons (Fig. 1); each icon is associated with .. Furthermore, the PBAC has been shown to overestimate MBL in .. a blood volume derived from measurements taken by the AH method some women, thereby limiting its value in clinical practice (Magnay .. (Magnay et al., 2013, 2014). Women are asked to complete the MP Table I Overview of pictorial blood-loss assessment chart and menstrual pictogram data for assessing menstrual blood loss in clinical trials.a PBAC MP ............................................................................................................................................................................................................................. Sensitivity and specificity Diagnosis of MBL >80 ml (n ¼ 950) (Higham et al., 1990; Diagnosis of MBL >80 ml (Wyatt et al., 2001; Magnay et al., Deeny and Davis, 1994; Janssen et al., 1995; Barr et al., 2014) or identifying 50% decrease in MBL (n ¼ 314) 1999; Reid et al., 2000; Zakherah et al., 2011; Hald and (Larsen et al., 2013): Lieng, 2014): • Sensitivity: 82–96% • Sensitivity: 58–99% • Specificity: 88–94% • Specificity: 7.5–89% Diagnosis of self-perceived HMB • Sensitivity: 78.5% • Specificity: 75.8% (n ¼ 429) (Hald and Lieng, 2014) Predictive value Predictive value of diagnosing HMB with a PBAC score Predictive value of diagnosing HMB (n ¼ 170) (Larsen et al., cut-off of 100 (n ¼ 103) (Reid et al., 2000): 2013): • PPV: 62% • PPV: 91% • NPV: 60% • NPV: 83% Predictive value of diagnosing HMB with a modified PBAC score cut-off of 185 (n ¼ 288) (Janssen et al., 1995): • PPV: 85.9% • NPV: 84.8% Predictive value of diagnosing HMB with a complaint of heavy MBL (n ¼ 288) (Janssen et al., 1995): • PPV: 55.9% Correlation with MBL • Moderate-to-high (r ¼ 0.466–0.847) correlation with • High (r ¼ 0.81–0.86) correlation with MBL or change in assessed by AH method MBL or change in MBL from baseline assessed by the AH MBL from baseline (n ¼ 206) (Larsen et al., 2013; method (n ¼ 328) (Higham et al., 1990; Reid et al., 2000; Magnay et al., 2014) Zakherah et al., 2011) a Data shown are for different versions of the MP and PBAC, which may have been adapted for use for study purposes. A full review of these data has been published (Magnay et al., 2018). PBAC, pictorial blood-loss assessment chart; MP, menstrual pictogram; MBL, menstrual blood loss; HMB, heavy menstrual bleeding; AH, alkaline hematin; PPV, positive predictive value; NPV, negative predictive value. 4 Singh et al. Figure 1. The revalidated menstrual pictogram. The menstrual pictogram requires women to assess their sanitary product upon changing, by selecting the image that looks the most like the underside of their sanitary product. In Magnay et al. (2014), blood loss (ml) was assigned to each pic- togram: 0.5, 1.5, 4, 6.5 and 12.5 for icons 1–5 of the ‘normal’ sanitary products, 0.5, 1.5, 3.5, 6.5 and 12.5 for icons 1–5 for the ‘long’ sanitary prod- ucts, and 0.5, 2, 4.5, 8 and 14 for icons 1–5 of the ‘night’ sanitary products. Reprinted with permissions from Magnay et al. (2014). whenever a sanitary product is changed, by choosing a pictogram icon .. specificity (92% [197/213 normal cycles were identified as 80 ml]) in .. that corresponds with the degree of staining on the underside of the .. diagnosing HMB. Figure 2 shows the Bland–Altman analysis of partici- sanitary product (Magnay et al., 2014). .. pant MP estimate of MBL versus AH estimate of MBL, after revision of .. In the validation study of the MP for measuring MBL (with the AH .. icon blood volume. The expert ratings revealed a sensitivity of 95% method as the reference standard) (Magnay et al., 2014), the median .. (21/22 HMB cycles) and a specificity of 89% (190/213 normal cycles). .. blood loss for the 22 HMB cycles was 111 ml (range, 80.1–245 ml). In .. Furthermore, AH and MP scores were significantly correlated contrast, the median blood loss for the 213 normal cycles was 17 ml .. (r ¼ 0.81, P < 0.0001) (Magnay et al., 2014). .. (range: 1–80 ml). Information on patient compliance/adherence was .. A second validation study for a further adapted version of the MP not reported. Overall, of 3325 sanitary towels collected, only 10 were .. (MPv3) has been published (Haberland et al., 2020). The MPv3 (on an .. excluded from analysis due to missing participant icon data (Magnay .. electronic device given to patients) was included alongside the AH .. et al., 2014). Following correction for the incremental rise in blood .. method in a Phase 2 study of a novel medical treatment for uterine fraction with volume, the MP demonstrated high sensitivity (82% [par- .. fibroids. Comparison and quantitative assessment of the MPv3 was .. ticipant assessments identified 18/22 HMB cycles as >80 ml]) and .. performed based on participant use of sanitary pads or tampons Validated pictogram to measure menstrual blood loss 5 Figure 2. Bland–Altman analysis of menstrual blood loss based on participant estimates with the menstrual pictogram versus alkaline hematin method. Bland–Altman analysis of participant revalidated menstrual pictogram (MP) estimate of menstrual blood loss (MBL) versus alkaline hematin estimate of menstrual blood loss (A) before and (B) after revision of icon blood volume, in Magnay et al. (2014). Symbol in- terpretation: light blue diamond ¼ true negative; red circle ¼ true positive; green triangle ¼ false negative; black square ¼ false positive. Dotted lines indicate 95% limits of agreement. Reprinted with permissions from Magnay et al. (2014). .. (Haberland et al., 2020). Full details of comparisons and statistical anal- .. related to observed MBL (criterion validity) and responsiveness yses have been described (Haberland et al., 2020). The results demon- .. (Haberland et al., 2020). Correlation coefficients showed a strong as- .. strated that bleeding outcomes measured by the MPv3 strongly .. sociation between the MPv3 and the AH method with regard to test– correlated with those from the AH method. Outcomes were deter- .. retest reliability (ICC estimate [95% CI] of 0.93 [0.88–0.96] during .. mined by intraclass correlation coefficients (ICCs) for reliability of the .. screening and randomization periods, and 0.96 [0.94–0.97] during MPv3 to provide reproducible scores over time (test–retest), correla- .. treatment in AH-defined stable women); criterion validity (rs ¼ 0.72 at .. tion coefficients for the extent to which MBL measured by MPv3 is .. randomization and rs ¼ 0.97 at end of treatment); and responsiveness 6 Singh et al. .. (rs ¼ 0.86 for change in monthly sum scores) (Haberland et al., 2020). .. women on whether their MBL volume is abnormal and if it may indi- There was also a lower frequency of missing data for the MPv3, versus .. cate an underlying condition. It would allow physicians and women to .. the AH method, indicating improved compliance with the MPv3—a .. gauge the severity of HMB and facilitate personalized bleeding manage- key benefit (Haberland et al., 2020). ... ment, as well as evaluate the efficacy of treatment of any underlying Overall, currently available evidence suggests that the MP and MPv3 .. condition. Increasing awareness of HMB will, in turn, improve knowl- .. meet the unmet need for more accurate and patient-friendly methods .. edge around its impact on reproductive health, enabling the identifica- for quantitative MBL evaluation, potentially supporting improved clini- .. .. tion and management of any adverse effects on QoL and fertility. cal care and more informed decision-making. Although all methods for .. There is also a need to shift regional and cultural views around the assessment of MBL have limitations, pictorial methods (especially .. .. HMB (Harlow and Campbell, 2004; Edelman et al., 2007; Bitzer et al., the MP/MPv3) offer a good balance between ease of use and vali- .. 2013), making this a topic that women feel comfortable and confident dated accuracy (Magnay et al., 2018). .. .. discussing. Tools such as the MPv3 may help to empower women to .. openly discuss HMB with their physician. Self-reporting of symptoms .. .. and outcomes is strongly encouraged by many physicians, and helps .. Clinician opinion of the MPv3 .. women to play a more active role in their diagnosis and treatment. .. and opportunities for future .. .. use .. .. Conclusion The MPv3 is simple, user-friendly and inexpensive, and has demon- .. .. The MPv3 menstrual loss evaluation tool has been validated for the as- strated responsiveness and reliability during validation for use in clinical .. trials evaluating MBL (Magnay et al., 2014; Haberland et al., 2020). MP .. sessment of HMB and offers several opportunities for use both in re- .. data are available from a number of studies (Wyatt et al., 2001; Wyatt .. search and clinical practice to evaluate treatment response and disease et al., 2002; Larsen et al., 2013; Magnay et al., 2013, 2014) and, similar .. progression/patient follow-up. Based on these benefits, and its advan- .. to the AH method, the MPv3 can assess change in MBL over time to .. tages over the AH method, the MPv3 has the potential to broaden determine treatment response, as demonstrated in women with uter- .. the perception and awareness of HMB and its associated pathologies .. ine fibroids (Haberland et al., 2020). Advantages of the MPv3 over the .. in women and clinicians, resulting in improved outcomes for these AH method include: .. .. women. .. • it is easy to use (Magnay et al., 2014; Haberland et al., 2020), .. • it does not require women to mark, label, store and send used .. .. sanitary products for analysis (The Menorrhagia Research Group .. Data availability et al., 2004; Magnay et al., 2018), .. .. No new data have been generated or analyzed in support of this • it does not require a clinic to receive, store and analyze used sani- .. .. publication. tary products (The Menorrhagia Research Group et al., 2004), .. • it is used as part of a digital application, making recording data .. .. straightforward, and allowing data to be easily entered alongside .. .. Acknowledgements electronic medical records without a paper diary record for every .. Medical writing support was provided by Afsaneh Khetrapal at used sanitary towel or tampon (Haberland et al., 2020), .. • it can be used in areas where the AH method is not available and .. Huntsworth Health Ltd, with funding from Bayer AG. All authors .. • it is of lower cost (Schumacher et al., 2012; Magnay et al., 2014). .. attended a meeting to discuss the topics and develop the expert opin- .. ions included in this manuscript. This meeting was financially supported Positive results support an opportunity for using the MPv3 to moni- .. tor treatment response for HMB-associated conditions in clinical prac- .. by Bayer AG. The Menstrual Pictogram was originally developed at .. Keele University, UK, and refined in cooperation between Keele tice. Based on the convenience and ease of use versus the AH .. method, the MPv3 may support patient recruitment and retention in .. University and Bayer AG, Germany. Intellectual property in the instru- .. ment is jointly owned by Keele University and Bayer. clinical trials, and potentially improve compliance and increase the ac- .. curacy of reported results, ultimately facilitating research (Haberland .. .. et al., 2020). One drawback of paper pictorial methods is that patients .. Authors’ roles must record details of used sanitary products in a paper record; when .. .. used as a digital application (ideally available on any mobile device), .. The manuscript was formulated after extensive discussion over several .. months between all authors (J.C.A., W.C., J-.P.E., K.K., A.L.S-.F., S.S.S, physician and patient access to the MPv3, along with data storage and .. sharing, would be key advantages. Although it should be noted that .. S.V. and X.Y.). All authors provided equal substantial intellectual contri- .. bution during the writing and revising of the manuscript, and all authors not all patients may have access to a phone, be able to download the .. digital application or readily have access to an internet connection. .. approved the final version. .. Beyond clinical trials, the MPv3 may be a valuable diagnostic tool for .. HMB. Reports indicate that HMB is under-reported and under- .. .. Funding recognized, underlining the importance of de-normalizing this patholog- .. ical condition (Fraser et al., 2015). The MPv3 may also educate .. Funding was provided by Bayer AG. Validated pictogram to measure menstrual blood loss 7 .. Conflict of interest .. Fraser IS, Mansour D, Breymann C, Hoffman C, Mezzacasa A, .. Petraglia F. Prevalence of heavy menstrual bleeding and experien- .. J.C.A. is a member of the HELP group, which is financially supported .. ces of affected women in a European patient survey. Int J Gynaecol by Bayer, and has received honoraria from Gedeon Richter for devel- .. Obstet 2015;128:196–200. .. oping educational materials. W.C. is a member of the HELP group, .. Fraser IS, McCarron G, Markham R, Resta T. Blood and total fluid which is financially supported by Bayer. He has also acted as a consul- .. .. content of menstrual discharge. Obstet Gynecol 1985;65:194–198. tant at AbbVie, Allergan (now owned by AbbVie), Bayer, Myovant and .. Fraser IS, Warner P, Marantos PA. Estimating menstrual blood loss .. ObsEva. J.-P.E. is a member of the HELP group, which is financially sup- .. in women with normal and excessive menstrual fluid volume. ported by Bayer. K.K. is a member of the HELP group, which is finan- .. Obstet Gynecol 2001;98:806–814. .. cially supported by Bayer, and has received honorarium and support .. Gokyildiz S, Aslan E, Beji NK, Mecdi M. The effects of menorrhagia for travel to meetings for the study by Bayer. A.L.S.-F. is a member of .. on women’s quality of life: a case-control study. ISRN Obstet .. the HELP group, which is financially supported by Bayer, and has re- .. Gynecol 2013;2013:1–7. ceived honoraria for lecturing and acting in an advisory capacity for .. Haberland C, Filonenko A, Seitz C, Börner M, Gerlinger C, Doll H, .. Bayer. S.S.S. is a member of the HELP group, which is financially sup- .. Wessiepe D. Validation of a menstrual pictogram and a daily .. ported by Bayer, has participated in advisory boards, and provided .. bleeding diary for assessment of uterine fibroid treatment efficacy consulting services and educational presentations for AbbVie, Allergan, .. in clinical studies. J Patient Rep Outcomes 2020;4:97. .. Bayer, Myovant and Hologic. He has also been an investigator for trials .. Hald K, Lieng M. Assessment of periodic blood loss: interindividual related to endometriosis and uterine fibroids for AbbVie, EndoDiag .. and intraindividual variations of pictorial blood loss assessment .. and Bayer, for which his institution received funding. S.V. is a member .. chart registrations. J Minim Invasive Gynecol 2014;21:662–668. of the HELP group, which is financially supported by Bayer, and has re- .. Hallberg L, Hogdahl AM, Nilsson L, Rybo G. Menstrual blood loss— .. ceived honoraria and reimbursement for travel and accommodation. .. a population study. 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