Investigating the loss of work productivity due to symptomatic leiomyoma
Investigating the loss of work productivity due to symptomatic leiomyoma
Klara Hasselrot 0 1
Mia Lindeberg 1
Peter Konings 1
Helena Kopp Kallner 0 1
0 Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden, 2 Department of Clinical Sciences at Danderyd Hospital, Division of Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden , 3 Gedeon Richter Nordics AB, Stockholm, Sweden, 4 Parexel International, Stockholm , Sweden
1 Editor: Shannon M. Hawkins, Indiana University School of Medicine , UNITED STATES
Leiomyoma affects up to 50% of fertile women, leading to morbidity such as bleeding or pain. The effect of symptomatic leiomyoma on the productivity of employed women is understudied. The present study investigates productivity loss in a Swedish setting in women with symptomatic leiomyoma compared to healthy women.
Data Availability Statement: All relevant data files
are within the paper and its Supporting Information
Funding: The study was fully funded by Gedeon
Richter. The study was designed in collaboration
with the principal investigator Helena Kopp Kallner.
The decision to publish was a joint decision by the
investigators (KH, HKK, PK and ML) and the
company. Investigators received no compensation
for manuscript writing. ML is a current employee
of Gedeon Richter Nordics AB. PK was employed
by Parexel at the time of data analysis but not at
Material and methods
Women seeking care for leiomyoma and heavy menstrual bleeding (HMB) were recruited at
nine Swedish sites. Healthy controls with self-perceived mild to normal menstruation were
recruited at routine visits. Cases and controls were employed without option to work from
home. After recruitment, all women reported the work productivity and activity impairment
(WPAI) questionnaire, the pictorial blood assessment chart (PBAC) and pain on the visual
analog scale (VAS).
Women with symptomatic leiomyoma (n = 88) missed more working time during menses
compared to asymptomatic controls (n = 34): 7.6 vs 0.2% p = 0.003. The proportion of
impairment while working was also significantly higher in women with symptomatic
leiomyoma (43.8 vs 12.1% p<0.001). Moreover, cases reported greater activity impairment
outside office hours (43.9 vs 12.1%, p<0.001). Among healthy controls, 69.5% reported
symptoms of HMB (PBAC>100).
Symptomatic leiomyoma leads to loss of working hours as well as loss of productivity during
working hours, and affects women in other daily activities. Increased awareness of the
impact of leiomyomas on women's lives is needed, and timely and appropriate management
of the symptomatic leiomyomas could improve work productivity and quality of life.
the time of manuscript writing and received no
compensation for manuscript writing. KH has
received no compensation for manuscript writing,
nor does she receive any other honorariums from
Competing interests: Mia Lindeberg is an
employee of Gedeon Richter Nordics AB. Helena
Kopp Kallner has received honorariums for lectures
and participation in expert groups from Gedeon
Richter. She has also participated as principal
investigator in studies financed by Gedeon Richter.
HKK received no compensation for manuscript
writing. KH has received no compensation for
manuscript writing, nor does she receive any other
honorariums from Gedeon Richter. PK was
employed by Parexel at the time of data analysis
but not at the time of manuscript writing and
received no compensation for manuscript writing.
This does not alter our adherence to PLOS ONE
policies on sharing data and materials.
Leiomyoma (or uterine fibroids) are the most common benign pelvic tumor in women,
reaching lifetime incidences of up to 77% [
], and can be found via imaging in 50% of
reproductiveage women at any given time [
]. Although up to 50% of leiomyomas are estimated to be
asymptomatic, the main reasons to seek medical care are heavy menstrual bleeding (HMB),
pelvic pain, pressure symptoms or fertility disorders [
]. The symptomatology is clinically
relevant foremost in menstruating women, potentially causing difficulties during working hours
as well as in daily life. Symptomatology due to leiomyoma increases with age until menopause,
when the tumors most commonly stop proliferating and symptoms usually decline or
]. Treatment options for symptomatic leiomyoma are several and varying, ranging from
over the counter iron supplements to complicated abdominal surgery. Treatment modality
depends on the overall burden as well as the location of the tumors in the uterus. New
treatments are continuously emerging through pharmacological agents as well as developed
surgical procedures, although fertility sparing regimens are still in minority. Regardless of
menopausal status, leiomyoma is the leading cause of hysterectomy in the world .
The clinical definition of HMB is a menstrual blood loss (MBL) of >80mL per cycle . A
valid screening instrument for patient suffering from HMB, with a sensitivity of >80%, is the
pictorial blood assessment chart (PBAC) with a cut-off of 100[
]. Later studies by Zakerhah
et al confirm the use of PBAC as a diagnostic tool of HMB, however different cutoffs for heavy
menstrual bleeding with PBAC have been proposed [
Since menstruating women are often family providers, cyclic symptoms keeping them from
full professional capacity may have a great impact on productivity, both in personal and
professional settings. The sum of direct costs (such as surgery or medication) and indirect costs
(such as work productivity loss) have recently been reviewed by Soliman et al in the United
States. Costs were estimated to range from USD 11 000 to 25 000 per patient per year after
diagnosis and/or surgery[
]. The authors highlight a striking discrepancy between the United
States and the rest of the world regarding this research field, where 19 of 26 studies on
productivity loss emanate from the US and only five from Europe. Furthermore, most research
focuses on direct costs such as comparing different treatment strategies, or investigating the
costs from an employer's perspective, while the patient's perspective is often absent [
]. To our
knowledge there are no studies investigating whether leiomyoma is affecting working women
in a Nordic setting. We therefore sought to investigate work productivity loss due to
symptomatic leiomyoma in a multicenter study at nine Swedish sites.
All nine centers participating in the study provide specialized gynecological care, and although
referral is not mandatory, many patients are being referred from general practitioners,
outpatient gynecologists or midwives. Cases were recruited from patients seeking a gynecologist due
to symptoms related to leiomyoma. Controls were recruited at routine visits for various other
reasons such as cytology cervix cancer screening. Inclusion criteria for cases were: 1) known
leiomyoma and 2) self-perceived heavy menstrual bleeding. For controls, the inclusion criteria
were 1) self-perceived mild to normal menstrual bleeding and menstrual pain. For both
groups, the following inclusion criteria applied: 1) 30±55 years of age, 2) currently employed
without option to work from home, 3) sufficient knowledge of the Swedish language.
Each woman participating in the study signed a written informed consent form after oral and written information had been provided. Once included, each participant was further given a code, and all demographic information related to the patient were stored separately at
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each respective site, and was only used to send out reminders about study completion. All
study subjects could withdraw their participation at any given time at their own request.
Women received compensation of 20 Euro in the form of a gift card after they had filled in the online questionnaire.
The study was approved by the institutional review board at Karolinska Institutet with
To measure work loss and menstrual symptomsÐbleeding pattern as well as painÐin both
groups, we relied on the validated work productivity and activity impairment (WPAI)
questionnaire, the pictorial blood assessment chart (PBAC, range 0-1) for menstrual blood loss
and the visual analogue scale (VAS, range 0±100) for assessment of pain [
7, 10, 11
parameters were evaluated during the first menstrual period post enrollment. In addition, women
also recorded their burden of illness due to menstrual symptoms in a second questionnaire,
where they were asked if the menstruation limited them in different work-related or social
situations. At inclusion, all women were provided with a link to the online versions of the
questionnaires, as well as a paper version along with a pre-paid envelope, to complete during and
after the first menstrual period post enrollment. During the investigated menstrual period, no
new treatment for symptoms of leiomyomas was allowed. The investigator on site secured date
of birth and contact information for each participant.
The primary endpoint of this study was to investigate the difference in days of work
productivity between women with symptomatic uterine fibroids compared to asymptomatic
women (cases and controls), measured as the percent work time missed due to symptoms
related to menstruation (WPAI 1 = absenteeism). Secondary endpoints were: the difference
in impairment measured as the percent impairment while working due to symptoms related
to menstruation (WPAI 2 = presenteeism), the difference in overall work impairment
measured as the percent overall work impairment due to symptoms related to menstruation
(WPAI 3). In addition, the difference in activity impairment outside work between cases
and controls was measured as the percent activity impairment due to symptoms related
to menstruation (WPAI 4). The protocol defined mild to normal menstruation as PBAC
100 and VAS 30). For the per protocol analysis the cutoff for HMB was set to PBAC 100.
Thus, cases with PBAC 100 and controls with PBAC>100 were excluded in this specific analysis.
All controls reporting heavy bleeding defined as PBAC>100, were contacted by the designated investigator and provided with adequate counseling. The hypothesis was that only a minority of healthy controls with self-perceived ªmild to normalº menstruation would report a PBAC >100.
Statistical differences were considered significant at the 5% level; differences were assessed
using Fisher's exact test for categorical data and Wilcoxon's rank-sum test for continuous data.
Correlations between measures were measured using the Spearman rank coefficient.
A sample size calculation showed that a difference measured in hours of more than 9% between two groups could be shown by including 105 women in each group, at a significance level of 5% and power of 80%. We expected to recruit at least 150 women in each group to reach this number, to compensate for expected dropout due to ineligibility or non-response.
A total of 356 women (166 cases and 190 controls) were recruited from Jan 2015 to March
2017 at a total of nine sites in Sweden: Danderyds Hospital, Sabbatsbergs Hospital, The South
Hospital and SoÈdertaÈlje Hospital in Stockholm, Helsingborg Hospital, The University Hospital
in OÈ rebro, Gallerians private practice in JoÈnkoÈping, the Ingehammar private practice in
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Fig 1. PBAC versus maximum VAS for all included subjects.
GoÈteborg, the WennerstroÈm private practice in GoÈteborg and the Hofte private practice in
A total of 61 cases and 55 controls did not return any questionnaires. A total of 17 controls
and 17 cases did not fulfill inclusion or exclusion criteria and were therefore excluded. For the
final analysis 206 women remained whereof 91 cases and 118 controls, however some women
failed to return one or more questionnaires. The distribution of all included cases and controls
who reported PBAC and VAS are shown in Fig 1.
Out of 118 controls, 82 women (69.5%) were symptomatic according to the PBAC
questionnaire (PBAC >100) and thus suffered from HMB, despite regarding themselves as having
ªmild to normalº menstruations. The results are therefore presented both for per protocol
asymptomatic controls (reporting PBAC 100) and for all self-reported asymptomatic controls
(regardless of PBAC). The case group was significantly older than the control groups, had
significantly heavier menstruations and reported higher levels of menstrual pain. In the case
group, 3 of 91 (3%) women self-reported as having symptomatic despite PBAC 100, this
group was subsequently subdivided like the controls. The baseline characteristics of cases and
controls are shown in Table 1.
Results of primary and secondary outcomes are shown in Table 2. In the per-protocol anal
ysis, cases reported significantly more absenteeism than controls, missing 7.6% work time due
to menstrual problems compared to 0.2% (p = 0.003). In the self-reported groups cases missed
7.4% work time compared to 1.8% (p<0.001) work time missed by controls. There was also a significant difference between cases and controls in presenteeism, with cases reporting 43.8% impairment vs 12.1% among the controls (p<0.001). In the self-reported groups this difference
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Summary of patient demographics, PBAC-score, and VAS max by study group, p-values calculated by Wilcoxon sum-rank test. PBAC = pictorial blood assessment
chart, VAS = visual analogue scale, SD = standard deviation, IQR = interquartile range
remained (43.2 vs 22.6%; p<0.001). In the per-protocol asymptomatic control group only one
woman missed time at work during menses, while at the same period 22/88 (25%) of cases
missed time at work (data not shown). In addition, cases missed significantly more time at
work due to other reasons than menstrual problems than both control groups (p = 0.04 for per
protocol asymptomatic controls and p = 0.04 for self-reported asymptomatic controls,
analyzed by Wilcoxon rank-sum test, data not shown). Result from the burden of illness
questionnaire is shown in Fig 2. Cases were significantly more limited during menstruation than both
control groups, in work related activities as well as in their spare time.
The morbidity due to leiomyoma which affects women of reproductive age is substantial. This
has been acknowledged by research in the US, but only limited research has been published
from European countries. To our knowledge there are no such studies from the Nordic
countries, where health care is seldom financed by private or corporate health care insurance. The
present study shows that women with leiomyoma are indeed significantly affected professionally
and privately during menstruation. These women are missing a higher percentage of work time
every menstrual period, and show higher activity impairment while at work than healthy
controls. This is consistent with recent figures from Canada, which showed that women with
symptomatic leiomyomas missed significantly more working hours per month and scored lower on
the Uterine fibroids symptoms and health-related Quality of life (UFS-QOL) compared to
matched controls without leiomyomas [
]. Furthermore, women with leiomyoma are absent
from work more often than healthy controls due to other reasons. This has previously been
addressed in other studies which have shown a considerably lower health-related quality of life
and significantly higher depression severity score among women with leiomyoma [
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Summary of WPAI outcomes, difference in work time missed and activity impairment, p-values calculated by Wilcoxon sum-rank test. SD = standard deviation,
IQR = interquartile range
When recruiting controls for the present study, the main inclusion criteria was self-per
ceived ªmild to normal menstruationº. Our hypothesis was that the majority of these women
would report a PBAC 100. Interestingly, close to 70% of the controls suffered from HMB
measured as PBAC>100 [
]. The tendency to subjectively underestimate the menstrual blood
loss has been previously described. In a pioneer population based study from Gothenburg,
Sweden, 11% suffered from HMB with objective measurements. However 41% of these sub
jects considered their blood loss as moderate or scanty [
]. Even though the development and
the access of hormonal contraceptives have improved over the last decades, the presence of
HMB and/or misleading perceptions of MBL seem to hold true. In the present study, we underestimated the proportion of symptomatic women among controls. Interestingly, women underestimating their MBL, regarding themselves as having mild to normal menstruations in spite of PBAC>100, reported higher absence from work compared to controls with
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Fig 2. In what way do you feel limited during menstruation? Subjects were requested to agree or disagree with the above statements, the difference between the case
and control group is significant for all individual items, p-values 0.001. P-values calculated by Fisher exact tests.
PBAC 100 and VAS 30. A higher cut off of PBAC has been proposed by other investigators
and may have modified results [
There are limitations of the present study, including the relatively small sample size and the
lack of specific data on the leiomyomas of the symptomatic women. Furthermore, we did not
perform transvaginal ultrasound examinations of the healthy controls to rule out present
leiomyomas and thus the risk of undiagnosed leiomyomas in this group is evident. The high
proportion of controls with HMB, made us choose to subdivide the controls in two groups, in
order to strengthen the transparency. We do not know the proportion of hormonal
contraception use in either the cases or the control groups. Since the study design was focusing on
symptomatology, knowledge of such treatment would not have changed the planned analysis of
work impairment during menstruation. Symptoms related to menstruation were only
recorded during one menstruation, however the day-to-day evaluation of PBAC and VAS, and
the short recall period for WPAI (2±5 days) hopefully minimizes recall bias. The strengths of
the study are the multicenter approach, and the objective to investigate base-line
symptomatology of the participating women as most similar studies have investigated outcomes of different
treatment modalities for leiomyoma.
Since medical and surgical treatment options for leiomyoma as well as HMB are many and
increasing, today's general practitioners and gynecologists have an important task to identify
these patients, keep up with advances in the field, and choose appropriate treatments for each
patient. A recent study from the Netherlands evaluated changing guidelines for general
practitioners to treat HMB, showing that 40% of women seeking help for this condition received no
treatment within 6 months of diagnosis, and only 18% were referred to a gynecologist [
Thus, there is evident room for improvement in the medical care of these women.
7 / 9
Our study of loss of productivity in women suffering from symptomatic leiomyomas and
HMB in a Swedish setting shows that cases reported significantly more over all work
impairment than controls which does not only constitute a distress for the women but also an
expense for women and for society. We welcome further studies addressing these conditions
and their impacts on work productivity, and urge health care providers to routinely assess
women's menstrual pattern, to timely detect symptoms which should lead to a referral to a
S1 Dataset. Contains raw data files. There are no direct identifiers.
All participating sites.
Conceptualization: Helena Kopp Kallner.
Data curation: Mia Lindeberg.
Formal analysis: Klara Hasselrot, Peter Konings, Helena Kopp Kallner.
Funding acquisition: Mia Lindeberg.
Investigation: Helena Kopp Kallner.
Methodology: Peter Konings, Helena Kopp Kallner.
Project administration: Klara Hasselrot, Mia Lindeberg.
Supervision: Helena Kopp Kallner.
Writing ± original draft: Klara Hasselrot.
Writing ± review & editing: Klara Hasselrot, Mia Lindeberg, Peter Konings, Helena Kopp
8 / 9
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