Opinion: Heavy periods should be treated as a global health priority

Anemia, caused by heavy periods, can lead to severe bleeding after childbirth, writes Ian Roberts of the London School of Hygiene & Tropical Medicine.

Heavy menstrual bleeding is killing women, but it is not being treated as a global health priority. This urgently needs to change.

There are three steps in this dance to death: heavy periods, anemia, and death during childbirth. Heavy menstrual bleeding causes anemia in young women, anemia increases the risk of severe bleeding after childbirth, and this bleeding is the leading killer of mothers worldwide.

Each year, 14 million women globally develop postpartum hemorrhage (PPH) or severe bleeding after childbirth and over 50,000 of these women die. Most of these deaths are in low- and middle-income countries where the prevalence of anemia is highest and many women lack access to healthcare and life-saving treatment.

Although women in low- and middle-income countries are worst affected, PPH is a problem everywhere and one that exposes deep health and societal inequalities as, in high-income countries, deaths from PPH are higher among black women and women of color.

This week (7-10 March), the World Health Organization (WHO) is convening a PPH Summit to bring together relevant stakeholders to prioritize the most urgent actions needed to reduce PPH deaths worldwide.

For the past 20 years, I have worked with Professor Haleema Shakur-Still from the London School of Hygiene & Tropical Medicine and colleagues from around the world, to coordinate a program of large clinical trials of a cheap drug called tranexamic acid (TXA) that cuts bleeding by stopping blood clots breaking down.

The drug has been around for 50 years but in 2017, we showed that timely TXA treatment cuts PPH deaths by a third. The summit should be a moment to step up and coordinate efforts to make this treatment available to women everywhere.

Monthly menstrual blood loss varies widely between women. Average loss is about 40 ml of blood, but some women lose many multiples of this.

Some women with excessive bleeding for many years consider their bleeding is "normal." Health information providers are often dismissive.

Researchers estimate that a quarter of young women may have heavy bleeding. Every cup of blood lost, leaches iron from the body and unless compensated by dietary iron intake, women inevitably become anemic.

Red blood cells are like buses, picking up oxygen molecules in the lungs and transporting them to the tissues. The oxygen passengers sit on an iron containing protein called hemoglobin, the red seats on the bus.

When the body is iron deficient it cannot produce enough hemoglobin. Anemia is present when the hemoglobin concentration of the blood is lower than normal. Repeated cycles of frequent heavy bleeding can drag down women below this threshold.

Anemia increases the chance that a baby will be born small, early and will die soon after birth.

In anemic women there are not enough red buses to carry oxygen around and so the heart pumps the blood around harder and faster. Her breathing is rapid. Her body is working out even when she's stock-still. And with the exertion of childbirth, her heart can fail. She is also more likely to bleed after giving birth.

Anemic blood is thinner and bleeds faster. Every 10-gram reduction in a woman's hemoglobin substantially increases her chance of a serious bleed. And if she does bleed, she is more likely to die.

The contribution of heavy menstrual bleeding to anemia and in turn to PPH is under-recognized by health professionals. A 2020 WHO report on global efforts to prevent anemia in women of reproductive age completely overlooked heavy menstrual bleeding.

Although research shows that a woman's iron stores depend more on her menstrual blood loss than on her dietary iron intake, global efforts to prevent anemia largely focus on nutrition and supplementation.

TXA is a commonly prescribed treatment for heavy menstrual bleeding in high-income countries. But in Sub-Saharan Africa and South Asia, most women don't have access to pads, tampons or menstrual cups, let alone treatments for heavy periods. Access to TXA can help tackle the issue before it becomes a matter of life and death.

Global health professionals tend to attribute PPH cases to the "failure" of the womb to contract. This diagnosis ignores other causes like anemia from heavy periods.

The WOMAN-2 Trial is currently looking into whether giving TXA can prevent PPH and other severe outcomes in women with moderate and severe anemia. The results will be published later this year and will provide the evidence needed to address this critical gap in healthcare.

Tens of thousands of women who die from PPH could be saved each year. It's time we stopped turning a blind eye to the causes and work together to make sure all women, wherever they are in the world, have access to their right to a safe childbirth.