Pictorial Blood Loss Assessment Chart

Pictorial Blood Loss Assessment Chart

Pictorial Blood Loss Assessment Chart (PBAC)

Higham JM, O’Brien PMS, Shaw RW


N.B.: These scores are posted with the permission of the developers.
  • Description
  • Utility
  • Administration
  • Psychometrics
  • References

The PBAC is a simple, pictorial tool used in women with menorrhagia to assess menstrual blood loss.

Contact person:
JM Higham:

Date of this review: August 25, 2013
Updated: April, 2014

Overall utility:

  • Useful in evaluating menorrhagia in the clinic setting between those with VWD versus other bleeding disorders
  • Can be used as a tool to measure response of menorrhagia to different forms of treatments
  • Also useful as a self-administered tool


  • Requires quite a bit of time for the patient to complete, not readily assessable during a first consultation (unless pre-filled by patient)
  • Studies show that cut off of ≥100 may not be sufficient to distinguish between those with and without a bleeding disorder8
  • Can be considered subjective

1.  Time to complete: Not identified

2.  Equipment/space required: Self-administered pictorial assessment; information pamphlet and scoring key

3.  Training required: A pamphlet is available to explain how the chart should be completed by the patient

4.  Cost: None

5.  Scoring/scaling/interpretation of results:

  • Using the scales below, the total score is calculated by adding up the sum of all scores for the tampons or sanitary napkin used in the next menstrual cycle

– For tampons: 1 for lightly stained, 5 for moderately soiled and 10 for completely saturated tampons.
– For sanitary napkins: 1 for lightly stained, 5 for moderately soiled and 20 for completely saturated pads.
– Clots were given a score of 1 for small and 5 for large clots.

  • Possible range of total score is completely dependent on quantitative and qualitative amount of bleeding during menstruation. Patient described range in original study was 5–456.1
  • Abnormal PBAC bleeding score (BS) ≥100, which correlates with menorrhagia, defined as >80 mL of menstrual blood loss.1

Psychometric properties:

1.  Construct validity:

Convergent validity

  • Good correlation between either physician or self-completed PBAC score and quantified menstrual blood loss (via alkaline haematin method).1
  • 14 of 34 adolescents diagnosed with menorrhagia had convergent scores on PBAC and HSC questionnaire.2
  • In a randomized trial between thermal balloon ablation (TBA) and laparascopic supracervical hysterectomy (LSH) for menorrhagia, the mean PBAC score was similar between the two groups.4
  • 57% of females with factor VII deficiency had an abnormal PBAC score vs. 17% of controls.5
  • Higher PBAC scores in adolescents was associated with adversely affected quality of life, also an abnormal PBAC score was likely to be associated with a perception of heavy periods.6

Divergent validity

  • In post-partum women, PBAC scores were similar between women who had a known bleeding disorder and those who did not.7

Group differences

  • PBAC scores were significantly higher in women with an inherited bleeding disorder than controls, however a cut-off of ≥185 was not sufficient to statistically differentiate between affected and controls. It did however differentiate between VWD and other bleeding disorders/controls.8

2.  Criterion validity:

  • Increasing PBAC was well correlated with quantified menstrual blood loss.1

3.  Reliability:

  • Reasonable agreement between physician-assessed and patient-assessed PBAC scores.1

4.  Responsiveness/sensitivity:

  • Sensitivity for a diagnosis of menorrhagia (estimated blood loss >80mL) was 86% and specificity 89% when self-assessed. When assessed by a physician, sensitivity was 86% and specificity 81%.1
  • Responsiveness was shown in women undergoing endometrial ablation for menorrhagia whereby the median PBAC scores decreased from 1208 to 0 post-operatively in one study and from >150 to <100 in 91.5% in another study.3,9
  • Responsiveness to LSH vs. TBA post-operatively showed that the mean PBAC score was significantly lower for both procedures, but that over time the low PBAC score was more consistent post-LSH4
  • Responsiveness was shown when using DDAVP (desmopressin) or oral contraception or tranexamic acid for menorrhagia, with an expected significant decrease in PBAC score post treatment.10,11,12 However, in another study when compared to placebo, no statistical difference was found, but this study had a very small sample size.13
  • Responsiveness was also shown to insertion of a levonorgestrel intra-uterine device (IUD) in two studies, and to oral ormeloxifene in another study, with a significant reduction in PBAC score pre- and post-placement to normal values.14,15,16

Languages studied: Because the PBAC is in the form of pictures, no specific languages were studied.

Groups tested:

  • Controls
  • Women taking part in a separate menstrual blood loss trial1
  • Adolescent schoolgirls who self-identified as having heavy menses2,6
  • Women with and without inherited bleeding disorders and menorrhagia3,4,8,9,10,12-16
  • Post-partum women with and without bleeding disorders7
  • Adolescents with VWD11
  • Women with factor VII deficiency5

Age: Children and adults

  1. Higham JM et al. Assessment of menstrual blood loss using a pictorial chart. Br J Obstet Gynaecol1990; 97: 734-739.
  2. Revel-Vilk S et al. Underdiagnosed menorrhagia in adolescents is associated with underdiagnosed anemia. J Pediatr 2012; 160: 468-472.
  3. Huq FY et al. The outcome of endometrial ablation in women with inherited bleeding disorders.Haemophilia 2012; 18: 413-420.
  4. Sesti F et al. Thermal balloon ablation versus laparoscopic supracervical hysterectomy for the surgical treatment of heavy menstrual bleeding: A randomized study J. Obstet. Gynaecol. Res. 2011; 37: 1650-1657.
  5. Kulkarni A et al. Disorders of menstruation and their effect on the quality of life in women with congenital factor VII deficiency. Haemophilia 2006; 12: 248-252.
  6. Pawar A et al. Perceptions about quality of life in a school-based population of adolescents with menorrhagia: implications for adolescents with bleeding disorders. Haemophilia 2008; 14, 579-583.
  7. Chi C, et al. Puerperal loss (lochia) in women with or without inherited bleeding disorders. Am J Obstet Gynecol 2010; 203: 56.e1-5.
  8. Siboni SM et al. Gynaecological and obstetrical problems in women with different bleeding disorders.Haemophilia 2009; 15: 1291-1299.
  9. Busund B et al. Endometrial ablation with NovaSureTM GEA, a pilot study. Acta Obstet Gynecol Scand2003; 82: 65-68.
  10. Mercorio F et al. Effectiveness and mechanism of action of desmopressin in the treatment of copper intrauterine device-related menorrhagia: a pilot study. HumReprod 2003; 18: 2319-2322.
  11. Amesse ML et al. Oral contraceptives and DDAVP nasal spray: patterns of use in managing vWD-associated menorrhagia. J Pediatr Hematol Oncol 2005; 27: 357-363.
  12. Kouides PA et al. Multisite management study of menorrhagia with abnormal laboratory haemostasis: a prospective crossover study of intranasal desmopressin and oral tranexamic acid. Br J Haematol2009; 145: 212-220.
  13. Kadir RA et al. DDAVP nasal spray for treatment of menorrhagia in women with inherited bleeding disorders: a randomized placebo-controlled crossover study. Haemophilia 2002; 8: 787-793.
  14. Cho S et al. Clinical effects of the levonorgestrel-releasing intrauterine device in patients with adenomyosis. Am J Obstet Gynecol 2008; 198: 373.e1-373.e377.
  15. Reid PC and Virtanen-Kari S Randomised comparative trial of the levonorgestrel intrauterine system and mefenamic acid for the treatment of idiopathic menorrhagia: a multiple analysis using total menstrual fluid loss, menstrual blood loss and pictorial blood loss assessment charts. BJOG 2005; 112: 1121-1125.
  16. Kriplani A et al. Efficacy and safety of ormeloxifene in management of menorrhagia: A pilot study. J Obstet Gynaecol Res 2009; 35: 746-752.