The hidden impact of heavy menstrual bleeding on Australian women

The under-recognition and undertreatment of heavy menstrual bleeding leads to delayed diagnosis, affecting the lives of women across Australia.

Around 25% of women of reproductive age are afflicted by heavy menstrual bleeding (HMB) – a serious, yet treatable, medical condition (here). The age at presentation can range from adolescence to the perimenopausal phase, and HMB may occur alone or in combination with other symptoms (here). Despite its prevalence, it is very much hidden from the public eye in Australia due to its stigma, lack of understanding, and the normalisation of its symptoms. This contributes to underdiagnosis and inadequate management of the condition.

HMB is excessive menstrual blood loss that interferes with the woman’s physical, emotional, social, and material quality of life. Research suggests approximately three in four Australian women have experienced HMB, a quarter of whom experience heavy periods often or always.

The research

The HMB Australian clinical care standard, released in 2017, includes eight statements that describe clinical care that a patient who experiences HMB should be offered. Six are relevant to general practitioners (GPs) (here). These statements are a good initiative intended to minimise variation in the provision of HMB care and, for suitable women, encourage non-invasive treatment options first.

A survey published earlier this year has revealed a concerning lack of understanding and dialogue around menstrual health in Australia (here), and this is supported by other studies (here and here).

Nearly half of the Australian women surveyed display little to no knowledge of HMB treatments, many of whom suffer in silence, mistakenly accepting their symptoms as a normal part of womanhood (here, here and here).

Menstrual health knowledge

A great deal of Australian women have inadequate knowledge of menstrual health, leaving them unsure about what is considered “normal” and when to seek medical help (here, here and here).

This knowledge gap keeps women trapped in a harmful cycle of ignorance and prevents them from seeking appropriate care (here, here and here).

A curious paradox may be seen as existing here, as we now live in a time when information is more readily at hand than it ever has been before. The phenomenon of “Dr Google” is a well known one, where “Australians are increasingly turning to Google for assistance with medical inquiries, with more than half (54%) using the search engine at least weekly to look up medical questions and symptoms, and almost 3 in 4 (72%) saying they have at least once used Google to address their health needs instead of visiting a doctor” (here).

The challenge here is ensuring correct and credible information is more prominent in these searches, rather than the type that may dissuade a patient to actually seek medical help by offering non-evidence-based advice that does not involve consulting a health care practitioner.

For HMB, sites such as the Jean Hailes organisation (here), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (here), and the Australian Commission on Safety and Quality in Health Care (here) offer excellent patient resources; however, they may not always be easily arrived at due to the nature of how commerce influences search-term algorithms.

Stigma and embarrassment

In Australia, a recent survey showed 41% of women aged 35–52 years who have had heavy periods for between two and five years have endured an embarrassing experience (here).

Much like in other countries, feelings of shame and a sense of secrecy towards menstruation are also common in Australian women (here and here). Like many hygiene issues, open discourse of its particulars may not only be seen as being inappropriate to voice but also culturally constrained.

The article The ongoing taboo of menstruation in Australia (here), explores the interesting idea of how the increase in effectiveness of menstruation products has led to the belief that women are negligibly impaired by their monthly cycle:

“Rather than embracing menstruation and talking openly about it, girls and women use modern products to hide their bleeding more effectively than ever.”

These negative attitudes and overall stigma may encourage and reinforce that not every woman’s periods are equal, this could lead to delays in accessing menstrual health information and contribute to late diagnoses.

It’s always shocking to see how long women have put up with HMB prior to seeking medical care and how much this treatable condition is normalised.

Impact on quality of life

The profound impact of HMB on daily life is evident.

Symptoms like weakness (59%), bleeding-related discomfort (48%), nocturnal disruptions (34%), and compromised social, professional, athletic or sexual lives (30%) are common (here, here and here).

The resultant iron deficiency or anaemia can also be debilitating (here). Importantly, Australians who have less knowledge and control over their menstrual health tend to experience a greater negative effect on their quality of life, compared with those who are more informed (here).

Treatment-seeking behaviour

Concerningly, research reveals that even when women recognise their symptoms as abnormal and significantly impacting their quality of life, many still choose not to seek medical help (here, here and here). Half of Australian women (55%) state they have never discussed their heavy periods with a medical professional, and 46% of women always experiencing heavy periods have not sought treatment (here). Similarly, to not discussing heavy periods with a HCP, half of Australian women (55%) also de-prioritise their health care, the main reason being they put other family members first (73%) (here).

Although clinicians are the number one trusted source of HMB information, a surprising 78% of Australian women have not visited a health care professional, with 40% waiting more than a year to broach the topic with their GP (here).

Recent data reveal only 46% of women aged 35–52 years have been asked questions about their general menstrual health in the past two years (here). Moreover, only 24% of surveyed women said their GP had asked them questions specifically relating to whether they had experienced HMB in the past two years, reinforcing the need for normalising conversations about menstrual bleeding in primary practice (here).

An analysis of the Bettering the Evaluation and Care of Health (BEACH) study, which uses data from Australian general practice from 2000 to 2016, revealed an increased number of GP–patient encounters for HMB. This may have been due to heightened awareness of HMB in women who require treatment, or an increase in the diagnosis and management of HMB by GPs, or both. There is certainly need for more research into this condition and how it affects women. There is also a need for research into the how women with these conditions interact with the primary care sector.

But what can we do?

I am always reflecting at work about how to bridge this gap, and how we need heightened awareness and open conversations to change this culture of secrecy. The line between normal and abnormal needs to be clearer to women, health care providers, and society in general, if we are going to create meaningful change in this HMB space.

To raise awareness around HMB and/or abnormal uterine bleeding, a public health awareness day, week and/or month could be established to help educate and inform the general public about these common, debilitating conditions.

Funding for awareness around HMB and abnormal uterine bleeding is crucial. Although the Commonwealth government has provided substantial funding for endometriosis to date, we also need to ensure we have a holistic view on treatment pathways that both support and are inclusive of all women, including those living with HMB.

For a condition that affects one in four Australian women (aged 35–52 years) and has a tremendous negative impact on productivity at work, given women will often miss work, it is a shame to see this was not a priority topic in the National Women’s Health Strategy produced by the federal Department of Health in its ten-year plan (here).

In addition, there must be more federal and state government initiatives designed to educate and train health care professionals on menstrual health, as the current strategy and funding focuses primarily on mental health in women, breast cancer detection, and osteoporosis. Concerningly, there is currently little-to-no educational material available that addresses periods and quality of life impact on women. We need urgent acknowledgement at both federal and state health levels, as well as open conversations and public health awareness campaigns that educate women about the condition and, importantly, empower them to seek timely care.

Increased education, resources, awareness and open conversations are crucial for timely diagnosis, effective care, and improved quality of like for those affected by HMB.

For GPs, proactively speaking with women about their menstrual health can play a significant role in ensuring more cases of HMB are identified and appropriately treated. These conversations would need to include empathetic questioning and listening that navigates around any patient shame and embarrassment barriers. The current Australian Clinical Care Standards on HMB (here) state that a woman with heavy menstrual bleeding should be “provided with consumer-focused information” which is also helpful in destigmatising the condition. This is where government investment can further help by building frameworks for menstrual health checks that enable resource-led productive consults on heavy menstrual bleeding.

The under-recognition and undertreatment of HMB leads to delayed diagnosis, causing prolonged, negative impacts on women’s social and academic lives, as well as relationships and fertility.

Furthermore, we require more open conversations, especially between women and their GPs. There is currently a gap in recourse that enables conversations and makes the topic less taboo. We women can be great talkers, but should we have this condition, are we sharing it with our loved ones, our friends, and our GPs for their professional advice and support?

GPs can play a huge part in enabling conversations by asking patients about their menstrual health using plain language and non-medical jargon, guided by the Heavy Menstrual Bleeding Clinical Care Standard.

Dr Talat Uppal is an Obstetrician and Gynaecologist, and Founder and Director of Women’s Health Road, Sydney.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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