Demographic, social and economic effects of hormonal therapy in endometriosis and abnormal uterine bleeding
Endometriosis and abnormal uterine bleeding (AUB) are diseases with very high prevalence which lead to serious negative outcomes. Prevalence of symptomatic endometriosis is 5% and AUB is 10% in women of 16–54 years old. One on most used method of treatment of both diseases is hormonal therapy. The goal of study is to define potentially preventable social, demographic and financial burden of endometriosis and AUB if hormonal therapy is used. Firstly, we assessed total social, demographic and financial burden from endometriosis (including related infertility) and AUB. The burden we calculated by days of absence from work [what need social payment and decrease the impact to gross domestic product (GDP)] and lower number of birth due to infertility (decrease of GDP). Then, the preventable burden due to hormonal therapy was calculated.
Potentially preventable burden from endometriosis and AUB was 93.2 bln rub. per year: 21.0 from endometriosis (due to days of absenteeism 0.65 thsd days and birth of 2.2 thsd children), and from AUB 72.2 bln rub. per year (due to days of absenteeism 4.7 mln days). However, in Russian Federation, only 24% of women with endometriosis take hormonal therapy and only 19% – with AUB. As a result, only part of burden is really prevented nowadays: 19.1 bln rub per year (5.1 bln rub. from endometriosis, including 0.3 bln rub. from infertility and 14,1 bln rub. from AUB). According to these facts, it is possible to prevent additional burden or get an additional effect of 74.0 bln rub. per year, when hormonal therapy is prescribed to all those in need of it. Return on investment, estimated through additional treatment costs, per 1 rub., it will amount to 1.34 rub. in case of endometriosis, and with AUB – 3.35 rub. The authors conclude that organizational measures should be taken to increase the number of women who are diagnosed and should be prescribed hormonal therapy for endometriosis and AUB. Among these measures: informing women, training doctors, actively identifying patients, timely diagnosis and start of therapy, follow-up on prescriptions, creating registers of women who need therapy. At the same time, it is advisable for these diseases to include hormonal therapy in the system of free provision by State on an outpatient basis, as is done in all developed countries.
Keywords:endometriosis, abnormal uterine bleeding (AUB); infertility; hormonal therapy; preventable burden from endometriosis, infertility due to endometriosis, to AUB; loss of gross domestic product; return on investment prescribing therapy
Funding. The study was carried out with the support of Abbott Laboratories LLC.
Conflict of interest. The authors declare no conflict of interest.
For citation: Ulumbekova G.E., Khudova I.Yu. Demographic, social and economic effects of hormonal therapy in endometriosis and abnormal uterine bleeding. ORGZDRAV: novosti, mneniya, obuchenie. Vestnik VSHOUZ [HEALTHCARE MANAGEMENT: News, Views, Education. Bulletin of VSHOUZ]. 2022; 8 (1): 82–113. DOI: https://doi.org/10.33029/2411-8621-2022-8-1-82-113 (in Russian)
1. Radzynsky V.E., et al. «Endocrinology» in obstetrics and gynecology in clinical practice. StatusPraesens. 2021; (9): 19–25. (in Russian)
2. Endometriosis. Clinical Guidelines. 2020 [Electronic resource]. URL: https://disk.yandex.ru/i/yYPwxWe4uTZcWg.pdf (date of access September 06, 2021) (in Russian)
3. Bernuit D., et al. Female perspectives on endometriosis: findings from the uterine bleeding and pain women’s research study. J Endometriosis. 2011. Vol. 3, N 2. P. 73–85. DOI: https://doi.org/10.5301/JE.2011.8525
4. Sarria-Santamera A., et al. Systematic review and meta-analysis of incidence and prevalence of endometriosis. Healthcare (Basel). 2020; 9 (1). DOI: https://doi.org/10.3390/healthcare9010029
5. Abnormal menstual bleedings. Clinical guidelines 2021 [Electronic resource]. URL: https://docviewer.yandex.ru/view/399219424/ (date of access August 18, 2021)
6. Marret H., et al. Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol. 2010; 152 (2): 133–7. DOI: https://doi.org/10.1016/j.ejogrb.2010.07.016
7. Fraser I.S., et al. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Int J Gynaecol Obstet. 2015; 128 (3): 196–200. DOI: https://doi.org/10.1016/j.ijgo.2014.09.027
8. Ding C., et al. Heavy menstrual bleeding among women aged 18–50 years living in Beijing, China: prevalence, risk factors, and impact on daily life. BMC Womens Health. 2019; 19 (1): 1–9. DOI: https://doi.org/10.1186/s12905-019-0726-1
9. NICE endometriosis guideline. NICE guideline [Electronic resource]. URL: https://www.guidelines.co.uk/womens-health/nice-endometriosis-guideline/453662.article (date of access August 19, 2021)
10. Dunselman G.A.J., et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014; 29 (3): 400–12. DOI: https://doi.org/10.1093/humrep/det457
11. Meuleman C., et al. High prevalence of endometriosis in infertile women with normal ovulation and normospermic partners. Fertil Steril. 2009; 92 (1): 68–74. DOI: https://doi.org/10.1016/j.fertnstert.2008.04.056
12. Santer M., et al. What aspects of periods are most bothersome for women reporting heavy menstrual bleeding? Community survey and qualitative study. BMC Womens Health. 2007; 7. DOI: https://doi.org/10.1186/1472-6874-7-8
13. Kim T., et al. Associations of mental health and sleep duration with menstrual cycle irregularity: a population-based study. Arch Womens Ment Health. 2018; 21 (6): 619–26. DOI: https://doi.org/10.1007/s00737-018-0872-8
14. Kurakina Т.Yu. Information about number of diseases, registered in patients by medical organizations. Form No. 12. 2019. (in Russian)
15. Form 14. Version from 18.12.2020. Conture.Normative [Electronic resource]. URL: https://normativ.kontur.ru/document?moduleId=44&documentId=42709 (date of access October 26, 2021)
16. Methodical instructions about information in obligatory medical insurance. Version 04.04.2011. Conture.Normative [Electronic resource]. URL: https://normativ.kontur.ru/document?moduleId=1&documentId=176323 (date of access October 26, 2021) (in Russian)
17. Ulumbekova G.E., Khudova I.Yu. Demographic, social and economic effects of menopause hormonal therapy. ORGZDRAV: novosti, mneniya, obuchenie. Vestnik VShOUZ [ORGZDRAV: News, Opinions, Training. Bulletin of VShOUZ]. 2020; 6 (4): 23–53. DOI: https://doi.org/10.24411/2411-8621-2020-14002 (in Russian)
18. Prozherina Yu., Shirokova I. Women healthcare in priority. Remedium. Zhurnal o Rossiyskom rynke lekarstv i meditsinskoy tekhnike [Remedium. Magazine About the Russian Market of Medicines and Medical Equipment]. 2021; Results of the year: 154–5. (in Russian)
19. ICD 10 – Endometriosis (N80) [Electronic resource]. URL: https://mkb-10.com/index.php?pid=13367 (date of access September 06, 2021) (in Russian)
20. Rolla E. Endometriosis: advances and controversies in classification, pathogenesis, diagnosis, and treatment. F1000Research. 2019; 8. DOI: https://doi.org/10.12688/f1000research.14817.1
21. Patel B.G., et al. Pathogenesis of endometriosis: interaction between endocrine and inflammatory pathways. Best Pract Res Clin Obstet Gynaecol. 2018; 50: 50–60. DOI: https://doi.org/10.1016/j.bpobgyn.2018.01.006
22. Eskenazi B., Warner M.L. Epidemiology of endometriosis. Obstet Gynecol Clin North Am. 1997; 24 (2): 235–58. DOI: https://doi.org/10.1016/s0889-8545(05)70302-8
23. Christ J.P., et al. Incidence, prevalence, and trends in endometriosis diagnosis: a United States population-based study from 2006 to 2015. Am J Obstet Gynecol. 2021; 225 (5): 500.e1–9. DOI: https://doi.org/10.1016/j.ajog.2021.06.067
24. Singh S., et al. Prevalence, symptomatic burden, and diagnosis of endometriosis in Canada: cross-sectional survey of 30 000 women. J Obstet Gynaecol Can. 2020; 42 (7): 829–38. DOI: https://doi.org/10.1016/j.jogc.2019.10.038
25. Han X.T., et al. [Analysis of characteristics and influence factors of diagnostic delay of endometriosis]. Zhonghua Fu Chan Ke Za Zhi. 2018; 53 (2): 92–8.
26. Hudelist G., et al. Diagnostic delay for endometriosis in Austria and Germany: causes and possible consequences. Hum Reprod. 2012; 27 (12): 3412–6. DOI: https://doi.org/10.1093/humrep/des316
27. Fuldeore M.J., Soliman A.M. Prevalence and symptomatic burden of diagnosed endometriosis in the United States: national estimates from a cross-sectional survey of 59,411 women. Gynecol Obstet Invest. 2017; 82 (5): 453–61. DOI: https://doi.org/10.1159/000452660
28. Culley L., et al. The social and psychological impact of endometriosis on women’s lives: a critical narrative review. Hum Reprod Update. 2013; 19 (6): 625–39. DOI: https://doi.org/10.1093/humupd/dmt027
29. Olive D.L., et al. Expectant management and hydrotubations in the treatment of endometriosis-associated infertility. Fertil Steril. 1985; 44 (1): 35–41.
30. Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility: a committee opinion. Fertil Steril. 2012; 98 (3): 591–8. DOI: https://doi.org/10.1016/j.fertnstert.2012.05.031
31. Tactics of doctor-gynecologist. Practical guidelines. In: L.V. Adamyan, L.V. Apolikhina, Abakarova P.R. Moscow: GEOTAR-Media, 2020. (in Russian)
32. Managing endometriosis – NICE Pathways [Electronic resource]. URL: https://pathways.nice.org.uk/pathways/endometriosis#path=view%3A/pathways/endometriosis/managing-endometriosis.xml&content=view-index (date of access September 20, 2021)
33. Johnson N.P., Hummelshoj L. Consensus on current management of endometriosis. Hum Reprod. 2013; 28 (6): 1552–68. DOI: https://doi.org/10.1093/humrep/det050
34. Sukhykh G.V., et al. Didrogesterone for the treatment of confirmed endometriosis: key results of an observational open multicenter study in real world data practice (ORCHID study) Akusherstvo i ginekologiya: novosti, mneniya, obuchenie [Obstetrics and Gynecology: News, Opinions, Training]. 2020; (4): 79–81. DOI: https://doi.org/10.24411/2303-9698-2020-14006 (in Russian)
35. Yarmolinskaya M.I., Frolova M.S. Possibilities of dienogest 2 mg therapy in patients with external genital endometriosis. Problemy reproduktsii [Problems of Reproduction]. 2017; 23 (1): 70–9. (in Russian)
36. Liang B., et al. Efficacy, safety and recurrence of new progestins and selective progesterone receptor modulator for the treatment of endometriosis: a comparison study in mice. Reprod Biol Endocrinol. 2018; 16 (1). DOI: https://doi.org/10.1186/s12958-018-0347-9
37. Dubrovina S.O., Berlin Yu.D. Medical treatment of pain associated with endometriosis. Akusherstvo i ginekologiya [Obstetrics and Gynecology]. 2019; (2): 34–40. DOI: https://doi.org/10.18565/aig.2019.2.34-40 (in Russian)
38. Bezenar’ V.F., Kruglov S.Yu., Kuz’mina N.S., Krylova Yu.S., Sergienko A.S., Adilbekova A.K., et al. Expediency of long-term hormonal therapy of endometriosis after surgical treatment. Akusherstvo i ginekologiya [Obstetrics and Gynecology]. 2021; (4): 134–42. DOI: https://doi.org/10.18565/aig.2021.4.134-142 (in Russian)
39. State Register of Medicines [Electronic resource]. URL: https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=55c96baf-e15d-4b4a-94ca-f9977cda845d&t = (date of access September 09, 2021) (in Russian)
40. Santulli P., et al. Oligo-anovulation is not a rarer feature in women with documented endometriosis. Fertil Steril. 2018; 110: 941–8. DOI: https://doi.org/10.1016/j.fertnstert.2018.06.012
41. Chapron C., et al. Oral contraceptives and endometriosis: the past use of oral contraceptives for treating severe primary dysmenorrhea is associated with endometriosis, especially deep infiltrating endometriosis. Hum Reprod. 2011; 26 (8): 187–97. DOI: https://doi.org/10.1093/humrep/der156
42. Casper R.F. Progestin-only pills may be a better first-line treatment for endometriosis than combined estrogen-progestin contraceptive pills. Fertil Steril. 2017; 107 (3): 533–6. DOI: https://doi.org/10.1016/j.fertnstert.2017. 01.003
43. Mirena. Instructions for use [Electronic resource]. URL: https://www.vidal.ru/drugs/mirena__440 (date of access August 08, 2021) (in Russian)
44. Becker C.M., et al. Reevaluating response and failure of medical treatment of endometriosis: a systematic review. Fertil Steril. 2017; 108 (1): 125–36.
45. Mathers C.D. History of global burden of disease assessment at the World Health Organization. Arch Public Health. 2020; 78 (1): 1–13. DOI: https://doi.org/10.1186/s13690-020-00458-3
46. Murray C., et al. Population and fertility by age and sex for 195 countries and territories, 1950–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018; 392: 1995–2051. DOI: https://doi.org/10.1016/S0140-6736(18)32278-5
47. Disability-adjusted life years (DALYs) [Electronic resource]. URL: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/158 (date of access September 23, 2021)
48. Wang H., et al. Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet. 2020; 396 (10 258): 1160–203. DOI: https://doi.org/10.1016/S0140-6736(20)30977-6
49. Disability from endometriosis in the United States Army – PubMed [Electronic resource]. URL: https://pubmed.ncbi.nlm.nih.gov/2965241/ (date of access September 17, 2021)
50. Economic burden of endometriosis – Search Results – PubMed [Electronic resource]. URL: https://pubmed.ncbi.nlm.nih.gov/?term=economic+burden+of+endometriosis (date of access September 23, 2021)
51. Nnoaham K.E., et al. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril. 2011; 96 (2). DOI: https://doi.org/10.1016/j.fertnstert.2011.05.090
52. Armour M., et al. The cost of illness and economic burden of endometriosis and chronic pelvic pain in Australia: a national online survey. PLoS One. 2019; 14 (10). DOI: https://doi.org/10.1371/journal.pone.0223316
53. Koltermann K.C., et al. Economic Burden of Endometriosis: A Systematic Review. 2017. P. 1–8.
54. Pokrzywinski R.M., et al. Achieving clinically meaningful response in endometriosis pain symptoms is associated with improvements in health-related quality of life and work productivity: analysis of 2 phase III clinical trials. Am J Obstet Gynecol. 2020; 222 (6): 592.e1–10. DOI: https://doi.org/10.1016/j.ajog.2019.11.1255
55. Fourquet J., et al. Quantification of the impact of endometriosis symptoms on health-related quality of life and work productivity. Fertil Steril. 2011; 96 (1): 107–12. DOI: https://doi.org/10.1016/j.fertnstert.2011.04.095
56. Simoens S., et al. The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres. Hum Reprod. 2012; 27 (5): 1292–9. DOI: https://doi.org/10.1093/humrep/des073
57. Klein S., et al. What is the societal burden of endometriosis-associated symptoms? A prospective Belgian study. Reprod Biomed Online. 2014; 28 (1): 116–24. DOI: https://doi.org/10.1016/j.rbmo.2013.09.020
58. Soliman A.M., et al. The effect of endometriosis symptoms on absenteeism and presenteeism in the workplace and at home. J Manag Care Spec Pharm. 2017; 23 (7): 745–54. DOI: https://doi.org/10.18553/jmcp.2017.23.7.745
59. Demographic challenge of Russia: rational solutions and readiness of the public health system [Electronic resource]. URL: https://www.vshouz.ru/journal/2018-god/demograficheskiy-vyzov-rossii-ratsionalnye-resheniya-i-gotovnost-sistemy-obshchestvennogo-zdorovya (date of access August 26, 2021) (in Russian)
60. Demographic potential: additional aspects. Part 1 [Electronic resource]. URL: https://www.vshouz.ru/journal/2019-god/demograficheskiy-potentsial-dopolnitelnye-aspekty/ (date of access August 26, 2021) (in Russian)
61. National ART Register [Electronic resource]. URL: https://rahr.ru/registr_otchet.php (date of access September 25, 2021) (in Russian)
62. Aganbegyan A.G. Demographic drama on the way of perspective development of Russia. Narodonaselenie [Population]. 2017; (3): 4–23. (in Russian)
63. Healthcare of Russia: diagnosis and treatment. Rector of HSE Ulumbekova G.E. Public organizations # dentistry. Dental Community [Electronic resource]. URL: https://dentalcommunity.ru/common/2708/ (date of access October 17, 2021) (in Russian)
64. Federal State Statistics Service [Electronic resource]. URL: https://rosstat.gov.ru/labour_force?print=1 (date of access September 24, 2021) (in Russian)
65. Women and Men of Russia. 2020. Rosstat. Statistical publications [Electronic resource]. URL: https://rosstat.gov.ru/folder/210/document/13215 (date of access October 17, 2021) (in Russian)
66. FSS – News. The FSS called the number of days of disability per person per year [Electronic resource]. URL: https://fss.ru/ru/news/567885/628114.shtml (date of access October 02, 2021) (in Russian)
67. Federal State Statistics Service [Electronic resource]. URL: https://rosstat.gov.ru/search?q=%D0%B2%D0%B2%D0%BF (date of access October 02, 2021) (in Russian)
68. Resolution No. 1610 of December 7, 2019 «On the Program of state guarantees of free provision of medical care to citizens for 2020 and for the planning period of 2021 and 2022» [Electronic resource]. URL: http://static.government.ru/media/files/KeKsCYhldsEbwaStnPQEqpuBAZMbobzg.pdf (date of access October 02, 2021) (in Russian)
69. Munro M.G., et al. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018; 143 (3): 393–408. DOI: https://doi.org/10.1002/ijgo.12666
70. Context. Heavy menstrual bleeding: assessment and management. Guidance. NICE [Electronic resource]. URL: https://www.nice.org.uk/guidance/ng88/chapter/Context (date of access September 27, 2021)
71. Sun Y., et al. Prevalence of abnormal uterine bleeding according to new International Federation of Gynecology and Obstetrics classification in Chinese women of reproductive age: a cross-sectional study. Medicine (Baltimore). 2018; 97 (31). DOI: https://doi.org/10.1097/MD.0000000000011457
72. Kuznetsova I.V. Hormonal contraception as a method of treatment of women with abnormal uterine bleeding. Meditsinskiy sovet [Medical Council]. 2017; (20): 182–7. DOI: https://doi.org/10.21518/2079-701X-2017-20-182-187 (in Russian)
73. Davies J., Kadir R.A. Endometrial haemostasis and menstruation. Rev Endocr Metab Disord. 2012; 13 (4): 289–99. DOI: https://doi.org/10.1007/s11154-012-9226-4
74. Context | Heavy menstrual bleeding: assessment and management | Guidance | NICE [Electronic resource]. URL: https://www.nice.org.uk/guidance/ng88/chapter/ Context date of access 27.09.2021).
75. Hennegan J., et al. Menstrual health: a definition for policy, practice, and research. Sex Reprod Health Matters. 2021; 29 (1). DOI: https://doi.org/10.1080/26410397.2021.1911618
76. Wilson L.C., et al. Seeking synergies: understanding the evidence that links menstrual health and sexual and reproductive health and rights. Sex Reprod Health Matters. 2021; 29 (1). DOI: https://doi.org/10.1080/26410397.2021.1882791
77. Critchley H.O.D., et al. Menstruation: science and society. Am J Obstet Gynecol. 2020; 223 (5): 624–64. DOI: https://doi.org/10.1016/j.ajog.2020.06.004
78. Quinn S.D., Higham J. Outcome measures for heavy menstrual bleeding. Womens Health (Lond). 2016; 12 (1): 21–6. DOI: https://doi.org/10.2217/whe.15.85
79. Matteson K.A. Menstrual questionnaires for clinical and research use. Best Pract Res Clin Obstet Gynaecol. 2017; 40: 44–54. DOI: https://doi.org/10.1016/j.bpobgyn.2016.09.009
80. El-Nashar S.A., Shazly S.A.M., Famuyide A.O. Pictorial blood loss assessment chart for quantification of menstrual blood loss: a systematic review. Gynecol Surg. 2015; 12 (3): 157–63.
81. Magnay J.L., et al. Pictorial methods to assess heavy menstrual bleeding in research and clinical practice: a systematic literature review. BMC Womens Health. 2020; 20 (1): 24.
82. Kocaoz S., Cirpan R., Degirmencioglu A.Z. The prevalence and impacts heavy menstrual bleeding on anemia, fatigue and quality of life in women of reproductive age. Pak J Med Sci. 2019; 35 (2): 365–70.
83. Recommendations. Heavy menstrual bleeding: assessment and management. Guidance. NICE [Electronic resource]. URL: https://www.nice.org.uk/guidance/ng88/chapter/Recommendations#management-of-hmb (date of access August 20, 2021)
84. Heikinheimo O., Fraser I. The current status of hormonal therapies for heavy menstrual bleeding. Best Pract Res Clin Obstet Gynaecol. 2017; 40: 111–20. DOI: https://doi.org/10.1016/j.bpobgyn.2017.01.001
85. Maybin J.A., Critchley H.O. Medical management of heavy menstrual bleeding. Womens Health (Lond). 2016; 12 (1): 27–34.
86. Lethaby A., et al. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2015; 4: CD002126. DOI: https://doi.org/10.1002/14651858.CD002126.pub3
87. Fraser I.S., et al. Effective treatment of heavy and/or prolonged menstrual bleeding with an oral contraceptive containing estradiol valerate and dienogest: a randomized, double-blind Phase III trial. Hum Reprod. 2011; 26 (10): 2698–708. DOI: https://doi.org/10.1093/humrep/der224
88. Micks E.A., Jensen J.T. Treatment of heavy menstrual bleeding with the estradiol valerate and dienogest oral contraceptive pill. Adv Ther. 2013; 30 (1): 1–13. DOI: https://doi.org/10.1007/s12325-012-0071-3
89. Plavinsky S.L., Barinova A.N., Ozolinya L.A. Undesirable consequences of the use of hormonal contraceptives. Analysis of pharmacoepidemiological studies and databases of spontaneous reports. Voprosy ginekologii, akusherstva i perinatologii [Problems of Gynecology, Obstetrics and Perinatology]. 2019; 18 (6): 92–9. DOI: https://doi.org/10.20953/1726-1678-2019-6-92-99 (in Russian)
90. Solov’yova A.V., Ermolenko K.S. Differentiated approach to the choice of therapy in women with abnormal uterine bleeding. Akusherstvo i ginekologiya [Obstetrics and Gynecology]. 2018; (3): 157–60. DOI: https://doi.org/10.18565/aig.2018.3.157-160 (in Russian)
91. Bofill Rodriguez M., et al. Cyclical progestogens for heavy menstrual bleeding. Cochrane Database Syst Rev. 2019; 8: CD001016.
92. Podzolkova N.M., Tatarchuk T.F., Doshchanova A.M., Eshimbetova G.Z., Sumyatina L.V. Normalization of the menstrual cycle with didrogesterone. Akusherstvo i ginekologiya [Obstetrics and Gynecology]. 2018; (6): 70–6. DOI: https://doi.org/10.18565/aig.2018.6.70-76 (in Russian)
93. Liu Z., et al. A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding. Value Health. 2007; 10 (3): 183–94. DOI: https://doi.org/10.1111/j.1524-4733.2007.00168.x
94. Tanaka E., et al. Burden of menstrual symptoms in Japanese women: results from a survey-based study. J Med Econ. 2013; 16 (11): 1255–66. DOI: https://doi.org/10.3111/13696998.2013.830974
95. Wasiak R., et al. Impact of estradiol-valerate/dienogest on work productivity and activities of daily living in European and Australian women with heavy menstrual bleeding. Int J Womens Health. 2012; 4: 271–8.
96. Schoep M.E., et al. Productivity loss due to menstruation-related symptoms: a nationwide cross-sectional survey among 32 748 women. BMJ Open. 2019; 9 (6): e026186.
97. PPP conversion factor, GDP (LCU per international $). Data [Electronic resource]. URL: https://data.worldbank.org/indicator/PA.NUS.PPP?end=2017&na me_desc=false&start=2009 (date of access October 27, 2021)