For Healthcare Professionals: Improving The Quality Of Life For Women With Endometriosis And Menorrhagia

Introduction

This white paper aims to describe some of the common features of endometriosis and menorrhagia (heavy menstrual bleeding), appreciating them both through the lens of iron deficiency. Understanding the social and personal context of these conditions and how women experience them is vital to offer satisfactory treatments. A recent survey by Active Iron on 1500 women across Ireland, the UK and USA, provides a contemporary insight into the impact of these conditions and iron deficiency on women’s lives.¹ While significant strides have been made to mitigate iron deficiency (via blood loss) associated with these conditions, the progress in the formulation of novel oral supplements to ameliorate iron deficiency, ensuring both effectiveness and tolerability, has been comparatively gradual.

Background

Endometriosis is a condition characterised by the abnormal growth of endometrial tissue outside of the uterine cavity. It is estimated to have a prevalence amongst women of around 10% and can take years to formally diagnose despite its impact on quality of life². It has a varied range of symptoms which do not always relate to the severity of the disease, and it has the potential to spread across the pelvic cavity and to extra-pelvic areas such as the bowel, diaphragm and even lungs.

Although the main symptom of endometriosis is pain, according to the survey menorrhagia was the second most common symptom, affecting 74% of respondents. As the most common cause of iron deficiency in women of childbearing age, menorrhagia is a key contributor to morbidity and poor quality of life. Menorrhagia can occur at any time in a woman’s reproductive life but is most common during the teenage years and when perimenopausal. 58% of perimenopausal women surveyed experienced heavier periods. Menorrhagia is a clinical diagnosis which is characterised by menstrual blood loss of >80mls. ³ Whilst this figure may be useful for research purposes, it is also important to consider the wider impact of heavy bleeding, and how normal life can become restricted due to menorrhagia.² Heavy periods can cause a considerable physical and mental burden, with 74% of survey participants feeling tiredness and fatigue, 46% experiencing lower productivity at work/school and 45% stating that they do not want to exercise.

Common themes and challenges between endometriosis sufferers and those experiencing menorrhagia are stigma, impact on quality of life and delay in diagnosis. Endometriosis sufferers wait an average of 7.5 years before being diagnosed, and many women with menorrhagia may not even seek medical help as they assume their heavy bleeding is normal.⁴ ⁵ As menstruation is the leading cause of iron loss worldwide, heavy menstrual bleeding is a major contributor to iron deficiency.⁶ The most common symptoms of iron deficiency are vague, which means it can and does go undiagnosed. Fatigue, shortness of breath, and brain fog are particularly common but may not be attributed to low iron levels.³ When you combine this with symptoms of menorrhagia such as flooding, and passing of large clots it’s not hard to understand how this may lead to withdrawal from normal activities, and negatively impact on interpersonal relationships and mental health.

Alongside physical symptoms, there is also a drop in haemoglobin levels and the oxygen carrying capacity of the blood is therefore reduced. Over time, repeated episodes of blood loss (such as with menstruation) can deplete iron stores and compound the symptoms experienced. Even if someone is not profoundly anaemic, they may complain of tiredness, irritability, problems with concentration and shortness of breath. This in turn may lead to a reduction in quality of life. Continued blood loss without adequate replacement (such as in menorrhagia) can lead to iron deficiency anaemia.⁷ In the longer term, untreated iron deficiency increases the risk of infections, cardiac abnormalities and paradoxically, increases the risk of bleeding.⁸

• The main symptom of endometriosis is pain. Menorrhagia is the second most common symptom, affecting 74% of respondents¹.
• Menorrhagia is most common during the teenage years and when perimenopausal. 58% of perimenopausal women surveyed experienced heavier periods.
• Heavy periods can cause a considerable physical and mental burden, with 74% of survey participants feeling tiredness and fatigue, 46% experiencing lower productivity at work/school and 45% stating that they do not want to exercise. •
• Over time, repeated episodes of blood loss (such as with menstruation) can deplete iron stores and compound the symptoms experienced.

Proposed Solution

Addressing the course of symptoms with a healthcare professional is always the first aim when assessing a patient. However, we know that over 50% of women with menorrhagia will be classified as having dysfunctional uterine bleeding, as no cause is found.

For women in this position, increasing iron levels in the blood is vital, and iron supplementation supports in achieving optimum iron levels. Traditional iron supplements are often poorly tolerated due to the myriad of side effects associated with them⁷,⁸, such as nausea, constipation and change in bowel habit. This may cause people to be poorly compliant with the treatment, reducing the chance of their iron stores improving. ⁹ Although iron supplements are one of the most commonly prescribed medications for women experiencing menorrhagia, for many the side effects of these can be off-putting. 

Active Iron is clinically proven to increase iron levels by 94% whilst avoiding troublesome side effects such as nausea and constipation,¹⁰ meaning people can improve their quality of life in the longer term and improve their overall health at the same time. Active Iron is also clinically proven to increase energy levels¹⁰ and can be used as a tool to support menstrual fatigue. The clinical studies completed by Active Iron target women with an unmet need for iron; the latest study was carried out in women of childbearing age with periods (including perimenopausal women).¹⁰

Conclusion

The significant impact of both endometriosis and menorrhagia on women’s health cannot be underestimated. The pervasive nature of these gynaecological conditions invades women’s lives, impacting on their social, emotional, and professional environments.

A holistic understanding of the interplay between physiological aspects and women’s experiences is vital. The range of symptoms alongside the often-underestimated burden of managing them, highlights the need for simple and well tolerated treatments like Active Iron.

As we continue to highlight inequities in women’s health, it is key to prioritise solutions that target symptomatic relief and also improve quality of life. This white paper is a further step towards continued collaboration between the stakeholders who can empower women to be at the forefront of taking control of their health and wellbeing. 

References

1. Active Iron Survey 2024. n=1500
2. https://www.bsge.org.uk/wp-content/uploads/2022/02/ ESHRE-GUIDELINE-ENDOMETRIOSIS-2022.pdf
3. https://cks.nice.org.uk/topics/menorrhagia-heavy-menstrual-bleeding/ background-information/definition
4.  NICE GUIDELINE NG88 Heavy Menstrual Bleeding, published 14th March 2018, Last updated May 2021
5. https://www.endometriosis-uk.org/getting-diagnosed-0 Munro et al. (2023). American Journal of Obstetrics and Gynecology. doi:https://doi.org/10.1016/j.ajog.2023.01.017.
6. Pasricha et al. (2021) Iron deficiency. Lancet 16;397(10270):233-248. doi: 10.1016/S0140-6736(20)32594-0.
7. https://www.nhs.uk/conditions/iron-deficiency-anaemia/
8. https://www.bsg.org.uk/clinical-resource/guidelines-for-the-management of-iron-deficiency-anaemia/
9. Ledwidge, M. et al. PRECISION Study. Int J Clin Pharm (2023) https://doi.org/10.1007/s11096-023-01640-7