Pictorial Blood Loss Assessment Chart

Description

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

Contact person(s):
JM Higham: jenny.higham@imperial.ac.uk

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

Utility

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

Limitations:

• 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

Administration

1. Time to complete: 5–10 minutes
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

Psychometrics

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 menses^2,6
• Women with and without inherited bleeding disorders and menorrhagia^{3,4,8,9,10,12-16}
• Post-partum women with and without bleeding disorders⁷
• Adolescents with VWD¹¹
• Women with factor VII deficiency⁵

Age: Children and adults

Glossary of Psychometric Properties

References

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.