In the gynecological patient, features of heavy menstrual bleeding (HMB) include (1) a subjective complaint of significant menstrual blood loss (MBL) resulting in impaired quality of life (QoL) across not only physical but also emotional, social, and economic domains; (2) an objective measurement indicating MBL greater than 80 mL per cycle or bleeding above the 95th percentile of the women with similar clinical features; (3) association with anemia, evidenced by hemoglobin levels falling below 10 g/dL; and (4) classification as a prominent symptom presenting in nonpregnant women of reproductive age within the broader spectrum of abnormal uterine bleeding (AUB) [1, 2, 3, 4, 5]. HMB can primarily be a consequence of structural or functional disturbances within the reproductive system, but it may also be linked to structural and functional ailments of other bodily systems. The exact global prevalence of HMB varies from 4% to 51% across different countries and racial groups, with estimates suggesting that approximately one-third of reproductive-age women experiences HMB [1, 3]. Research in Turkey reveals that around 37.9% of reproductive-age women experience HMB, a condition closely linked to anemia and significant reductions in QoL [6, 7, 8]. Furthermore, among Turkish women who underwent surgery for abnormal uterine bleeding, HMB-related symptoms were reported in 26.6% as hypermenorrhea and 14.4% as menorrhagia, particularly in multiparturients, highlighting the substantial burden of this condition in the Turkish healthcare system [6, 7, 8, 9].

The discrepancy in HMB prevalence reports is attributable to underreporting, stemming from both patients’ limited recognition and inconsistent reporting protocols among healthcare professionals. Cultural and societal norms significantly influence patient reporting behavior and medical consultation patterns, with less than half of women suffering from HMB seeking medical consultation [3, 10]. While various assessment tools exist, including the Menorrhagia Multi-Attribute Scale (MMAS) [11] and Pictorial Blood Loss Assessment Chart (PBAC) [12] as well as the alkaline hematin method [3], each has limitations in clinical settings. Recently, the SAMANTA questionnaire, a 6-item screening instrument developed in Spain, has shown considerable success in classifying women with HMB, demonstrating strong correlation with Visual Analog Scale scores for both bleeding intensity and impact on daily activities [3, 13]. In Turkey, the clinical issue for HMB is marked by a significant gap in screening and predictive diagnostics [14]. While HMB is a common condition, often leading to secondary health issues such as anemia, the lack of specific tools for its assessment complicates its effective management.

The existing methods for evaluating HMB in Turkey are not designed to address the unique aspects of this condition, particularly in terms of screening and predicting its presence and severity and its moderating effects on QoL. The SAMANTA questionnaire was chosen for Turkish adaptation due to its validated sensitivity (86.7%) and specificity (89.5%) in measuring MBL impact on QoL, its concise 6-item structure optimized from 46 initial items, its proven responsiveness to treatment changes, and its strong correlation with both patient-reported outcomes and clinical assessments [10, 13, 15]. This deficiency underscores the necessity for a specific, culturally adapted diagnostic tool like the SAMANTA questionnaire. This study aimed to develop a culturally and linguistically appropriate Turkish version of the SAMANTA questionnaire, ensuring its reliability and validity as a diagnostic tool for HMB. By addressing the unique cultural and medical aspects of the Turkish population, this research sought to fill the gap in effective HMB screening and diagnostics, ultimately improving gynecological care and patient outcomes in Turkey. The adaptation of the SAMANTA questionnaire to Turkish healthcare practices involved a meticulous process of translation, cultural adaptation, and validation to ensure its effectiveness in accurately identifying and predicting HMB.

This study employed a two-stage methodological and observational approach to culturally and linguistically adapt the SAMANTA questionnaire for use in the Turkish context and to comprehensively examine its psychometric characteristics, including reliability and validity. The two stages of the study included translation and cross-cultural adaptation, followed by psychometric testing. The methodological framework was adapted from our prior research on the Turkish adaptation of the antenatal risk questionnaire-revised [16], ensuring consistency with established protocols while incorporating adjustments tailored specifically to the SAMANTA questionnaire. The translation and cross-cultural adaptation process adhered to standard steps. These steps included forward translation by bilingual experts, synthesizing translations to resolve inconsistencies, backward translation into English, and a review by a multidisciplinary expert panel. Additionally, a pilot study was conducted to refine the pre-final Turkish SAMANTA questionnaire based on feedback from participants. Specific adaptations were made to culturally sensitive items, such as those addressing “social gatherings and leisure-time plans”, to ensure their relevance for Turkish women.

Psychometric testing was carried out with a sample of 148 adult women aged 18–45 years who applied to an outpatient gynecological service at a tertiary care institution between January and June 2023. Reliability was assessed through a test-retest analysis involving 30 participants, who completed the questionnaire twice with a two-week interval. Validity was evaluated using exploratory and confirmatory factor analyses, and internal consistency was measured with Cronbach’s alpha. The sample size was calculated to meet the requirement of 20 participants per scale item, with additional participants recruited to account for potential attrition.

The study adhered rigorously to the ethical standards set forth in the Declaration of Helsinki [17]. The study protocol, including both pilot and main study phases, received approval from the Human Ethics Committee of the University of Health Sciences (Ethical approval number 20/3 and dated December 1, 2023). The original authors of the SAMANTA questionnaire granted permission via email for its translation, cultural adaptation, and validation in Turkish.

Table 1 lists the demographic profile of the 148 female participants analyzed in the study. The median age was 30.9 years, with an age range of 18–45 years, indicating a sample well within the reproductive and economically active stages of life. A substantial majority of the participants (91.9%) attained higher education, which may reflect a higher propensity for health awareness and access to healthcare resources. Regarding occupational status, 67.6% of participants were employed, while 18.9% were students, indicating a largely economically active population with potential impacts on healthcare engagement and access. In terms of relationship status, of the participants, 58.8% were married, 35.1% were single, and 6.1% were partnered. These factors may shape the social and health support systems accessible to them. From a health perspective, a majority (60.1%) of participants had a normal BMI, with 24.3% classified as overweight and 8.8% as obese, indicating a relatively healthy cohort, though with varied body weight. Concerning reproductive history, 42.6% had not had children, and of those who had, the distribution ranged from 1 child (25.0%) to 3 or more (11.5%). Furthermore, the mode of previous deliveries showed that 46.6% had no births, 16.2% had vaginal births, and 37.2% had cesarean births, indicating a diversity in delivery experiences. Finally, the time since the last childbirth revealed that a significant proportion of participants (34.5%) had their last child more than 3 years ago, potentially influencing their current gynecological health. The age at menarche further illustrated that most participants (71.6%) had their first menstruation between the ages of 11 and 13 years, aligning with typical developmental patterns.

Table 2 summarizes the findings of the MSAF. The majority (78.4%) of the participants experienced menstrual periods lasting between 5 and 7 days, reflecting standard menstrual health. Extended duration: notably, 13.5% had periods extending from 8 to 10 days, and 1.4% experienced more than 10 days, highlighting potential cases of prolonged menstruation that may need medical attention. Over half (52.0%) of the participants reported a menstrual cycle within the normal range of 21 to 28 days, and 35.1% experienced longer cycles between 28 to 35 days, suggesting variability in cycle regularity. Spotting appeared to be relatively common, with 72.8% reporting spotting occurrences, indicating possible menstrual irregularities or reproductive health issues that might require further investigation. A vast majority (81.1%) were aware of their ovulation periods, and similarly, 79.1% can predict when ovulation occurred, demonstrating a significant engagement with their reproductive health monitoring. Key symptoms reported during ovulation included watery vaginal discharge (60.8%) and lower abdominal pain (34.5%). Participants frequently reported watery vaginal discharge and abdominal pain, which are typical signs of ovulation. The high reporting of these symptoms indicated a thorough understanding of bodily cues related to reproductive cycles.

Table 3 provides insights into the prevalence and impact of HMB-related experiences among 148 participants, as evaluated through the SAMANTA questionnaire. This questionnaire comprised 6 questions designed to assess the severity and impact of menstrual bleeding on daily life. What follows is a detailed analysis of the responses:

Question 1, menstrual bleeding duration: 85.8% of the participants did not experience menstrual bleeding for more than 7 days per month, and 14.2% reported bleeding for more than 7 days, indicating a potential issue with prolonged menstrual bleeding.

Question 2, days of heavier menstrual bleeding: 71.6% did not experience more than 3 days of heavier bleeding, and 28.4% did experience this symptom, highlighting a significant subset of women potentially dealing with heavier menstrual flows.

Question 3, bother due to abundant menstruation: 59.5% indicated that the abundance of menstruation does not generally bother them, and 40.5% find the abundant flow bothersome, which could affect their QoL and indicate more severe menstrual issues.

Question 4, nighttime clothing staining: 61.5% reported no incidents of staining their clothes at night due to HMB, and 38.5% would experience staining if not for protective measures, which suggests that nighttime bleeding is a concern for many, impacting sleep quality and comfort.

Question 5, concerns about staining furniture: 57.4% were not worried about staining furniture during heavy menstrual days, and 42.6% were concerned about such incidents, which points to the psychological and social stress associated with HMB.

Question 6, impact on activities: 64.9% did not feel the need to alter their activities due to menstrual bleeding, and 35.1% avoided certain activities, trips, or plans because of the need for frequent changes of sanitary products, underscoring the impact of HMB on lifestyle and social engagements.

The SAMANTA questionnaire score of 3 or above is considered a supportive finding of HMB (Table 4). The responses to these questions highlight a notable proportion of participants experiencing significant issues related to HMB. This detailed analysis underlines the varied impacts of HMB on daily activities, emotional well-being, and overall QoL. A significant 41.8% of participants scored 0, indicating no symptoms of HMB. Minor scores (1 and 2) were relatively uncommon, at 3.4% and 4.1%, respectively, showing that few participants experienced mild symptoms. The scores from 3 to 10 indicate varying degrees of HMB severity. Specifically, 7.4% of participants each scored 3, 4, or 7, showing moderate levels of symptoms. Notably, scores of 5 and 6, which suggest more pronounced symptoms, were observed in 8.8% and 9.5% of participants, respectively. Scores nearing the maximum (8, 9, and 10), though less common, were reported by 3.4%, 2.0%, and 4.7% of the participants, respectively. These higher scores indicate severe symptoms that likely have a significant impact on daily activities and QoL.

This research centered on establishing the psychometric properties of the Turkish version of the SAMANTA questionnaire, a dedicated instrument for quantifying HMB in non-pregnant, reproductive-age women. It was carried out in 2 primary phases: translation and cross-cultural adaptation first, and then psychometric testing was performed to assess the instrument’s reliability and validity.

The translation and cross-cultural adaptation procedures commenced with two bilingual experts forward translating the original SAMANTA questionnaire into Turkish. Following this, a backward translation into English was performed to assure conceptual consistency with the source material and a synthesis of the translations. In a collaborative meeting with translators and researchers, inconsistencies between the translations were resolved. Subsequently, a panel of experts examined the pre-final Turkish version to ascertain that it culturally adapted to the Turkish populace and faithfully reflected the original scale’s intent.

The demographic data revealed that the average age of the participants was 30.9 years, with a vast majority (91.9%) possessing higher education, suggesting a well-informed group that is likely proactive about health issues. Many of the participants were employed (67.6%), with a smaller segment being students (18.9%), indicating a predominantly economically active demographic. In terms of marital status, 58.8% were married, and most maintained a normal BMI of 60.1%, reflecting a general awareness of health and access to healthcare resources. The data also highlighted varied reproductive histories, indicating diverse gynecological needs within the cohort. Most of the participants reported menstrual periods lasting between 5 and 7 days. However, a notable 13.5% experienced menstrual periods extending 8 to 10 days, raising concerns about prolonged menstrual durations, although 35.1% experienced longer cycles, suggesting variability in menstrual regularity. High awareness of ovulation was reported (81.1%), with common symptoms including watery vaginal discharge and lower abdominal pain, indicating a strong engagement with their reproductive health monitoring.

Responses to the Turkish SAMANTA questionnaire revealed significant insights into the prevalence and impact of HMB. About 14.2% of the women experienced menstrual bleeding for more than 7 days per month, and 28.4% had more than three days of heavier menstrual bleeding, underscoring the burden of HMB. Furthermore, 40.5% of participants found the heavy flow bothersome, impacting on their emotional and social well-being. The HMB also led 35.1% of the women to alter their normal activities, highlighting the significant lifestyle and social engagement disruptions caused by this condition. The distribution of Turkish SAMANTA questionnaire scores showed that 50.7% of participants scored $\ge$3, indicating the presence of HMB symptoms. The scores ranged from mild to severe, with 7.4% scoring a 3, and smaller percentages reaching scores as high as 10. These higher scores, while less common, indicated severe HMB symptoms that significantly impacted daily activities and QoL. This variability in scores illustrated the diverse severity of symptoms among the participants, emphasizing the need for tailored management strategies.

The second step of psychometric testing was adaptation of the newly created questionnaire to a group of 148 women who had the ability to fill out questionnaires through Google Forms platform. Psychometric properties of the questionnaire included several statistical analyses such as Cronbach’s alpha for internal consistency indices and ICCs for test-retest reliability. The responses from the participants were utilized to cross-check the efficacy of the questionnaire in terms of its capability to perceive the presence and impact of HMB. It was ensured that the translation process was as detailed as possible and provided accuracy on both linguistic and cultural aspects, and the psychometric qualities of the instrument used for the evaluation of HMB also were preserved in the Turkish context.

The Turkish SAMANTA questionnaire proved to be a valid and sensitive tool in assessing the effects HMB had on patients’ living standards and pain perceptions. The high correlation with the HMB-VAS (r = 0.762) underscores its effectiveness in assessing the severity and impact of HMB, whereas the moderate correlation with VAS-M (r = 0.527) supported its utility in evaluating pain associated with HMB. The results of the Turkish SAMANTA questionnaire proved its reliability as a tool that can be used in the clinical assessment of HMB and further recommends its broader usage in the therapeutic management of patients and in improving their health outcomes.

In a review by Perelló-Capo et al. [15], the current screening and diagnostic procedures of HMB and their limitations and potential improvements were discussed. The authors stated that quantitative and semi-quantitative methods used for the diagnosis of HMB fail to reflect the perception of patients and are often difficult to adapt to gynecological practice [15]. They noted that there is a need to update the tools used to screen and diagnose HMB considering patients’ suffering and QoL. In particular, patient-centered tools, such as the SAMANTA questionnaire, have been considered as an important advancement in assessing both the amount of bleeding and its impact on patients’ overall QoL. The findings from our study can be meaningfully contextualized within the existing literature. In alignment with Perelló-Capo et al. [15] observations regarding the importance of patient-centered tools in HMB assessment, our validation of the Turkish SAMANTA questionnaire demonstrated strong psychometric properties. Particularly, the high correlation we found with HMB-VAS (r = 0.762) supports the questionnaire’s effectiveness in reflecting patient perception, addressing the need for tools that capture both quantitative and qualitative aspects of HMB.

Rodpetch et al. [19] focused on the development of a Thai version of the Menstrual Bleeding Questionnaire (MBQ) to evaluate the QoL in Thai women experiencing HMB while on oral antithrombotic therapy. They conducted a cross-sectional study to determine the prevalence of HMB among women taking antithrombotic drugs. The translated MBQ showed excellent reliability and was effective in distinguishing between women with and without HMB. The prevalence of HMB among the participants was noted to be 26.5%, indicating a significant impact on their QoL. When comparing prevalence rates, our finding that 50.7% of participants scored $\ge$3 on the SAMANTA questionnaire differed notably from the 26.5% HMB prevalence reported in Rodpetch et al.’s [19] Thai MBQ study. This variation might be attributed to differences in study populations and measurement tools, highlighting the importance of culturally adapted instruments. Our higher prevalence rate suggests a significant burden of HMB among Turkish women, emphasizing the need for reliable screening tools.

Period-related QoL (PERIOD-QOL), developed by Lancastle et al. [4], is a short measurement tool designed to assess the impact of HMB on women’s QoL. This 10-item questionnaire asks how it affects women’s physical, psychological, and social lives. In the study, women who reported HMB had lower PERIOD-QOL scores and thus reported a worse QoL. This tool used by health care providers supports women’s decisions seeking medical help and assessing treatment effectiveness. Similar to the PERIOD-QOL developed by Lancastle et al. [4], our study demonstrated the SAMANTA questionnaire’s capability to assess HMB’s impact on women’s physical, psychological, and social well-being. The finding that 35.1% of our participants reported limiting their activities due to HMB aligns with PERIOD-QOL’s emphasis on QoL assessment, reinforcing the substantial impact of HMB on daily functioning.

The study by Pattison et al. [11] evaluated the reliability and validity characteristics of the MMAS, measuring the QoL in women with HMB. The MMAS assesses the subjective impact of menorrhagia across six domains: practical difficulties, social life, psychological well-being, physical health, work routine, and family life. The study confirmed that the MMAS possesses high validity values, as well as good Cronbach’s alpha of 0.82, indicating that the items cohesively measure the construct of impact of HMB. Additionally, MMAS demonstrated moderate correlations with general QoL scales like SF-36, supporting its specificity in reflecting the unique effects of HMB. The authors suggested that MMAS is an appropriate instrument for evaluating the outcomes of HMB management. While our Cronbach’s alpha of 0.713 is lower than the 0.82 reported by Pattison et al. [11] for the MMAS, both values indicate acceptable internal consistency. The SAMANTA questionnaire’s concise 6-item structure, compared to MMAS’s 6 domains, offers practical advantages in clinical settings while maintaining reliable assessment capabilities. This balance between brevity and effectiveness makes it particularly suitable for routine gynecological care in Turkey.

The study by Perelló et al. [3] introduced a new tool called the HMB-VAS. This tool uses two separate VASs to assess the severity of menstrual bleeding and its impact on women’s QoL. The HMB-VAS has been developed as a practical tool to quickly and effectively detect HMB. The study validated this new tool in comparison with the PBAC and SAMANTA questionnaire. The results showed that the HMB-VAS had a slightly lower accuracy rate (86.8% vs. 87.9%) compared to the SAMANTA questionnaire. Their findings indicate that the HMB-VAS performs adequately for HMB screening and is suitable for use in gynecological care. Our findings show strong alignment with Perelló et al.’s [3] HMB-VAS study. The robust correlation between SAMANTA scores and HMB-VAS (r = 0.762) in our study supports the concurrent validity of both instruments and suggests that the Turkish version effectively captures HMB severity and impact, similar to the original validation studies.

A recent study by Sinharoy et al. [10] aimed to assess the prevalence of HMB and its health implications in low- and middle-income countries. Conducted across Southern Asia and Sub-Saharan Africa, the research encompassed a sample of 6626 women, identifying a HMB prevalence of 48.6%. Women experiencing HMB reported a significantly higher likelihood of fatigue or shortness of breath during menses, with a risk ratio of 4.12. Adverse effects on physical health were quantified as 1.27 times worse, as per adjusted ratios. These findings underscore the substantial impact of HMB on women’s QoL. The HMB prevalence of 50.7% found in our study closely mirrors the 48.6% reported by Sinharoy et al. [10] in their extensive study across low- and middle-income countries. This similarity suggests consistent HMB patterns across different populations and underscores its significance as a global health concern. Furthermore, our findings of substantial impact on daily activities complement Sinharoy et al.’s [10] observations about physical health effects, emphasizing the need for comprehensive assessment tools like the Turkish SAMANTA questionnaire.

These comparisons with existing literature validate our findings while highlighting the unique contributions of our study to the field. The successful adaptation of the SAMANTA questionnaire for Turkish populations provides a valuable tool for clinical practice, addressing the need for culturally sensitive and reliable HMB assessment instruments. The results of current study suggest that Turkish SAMANTA questionnaire maintains the strong psychometric properties of the original, while being culturally appropriate for our healthcare settings.

Research indicates that the prevalence of HMB among reproductive-age women varies significantly based on geographical location, demographics, age, parity, and study methodology [20]. Estimates suggest that 10%–32% of women experience HMB during their reproductive years. However, underreporting is common, with nearly half of those affected not seeking medical consultation for their symptoms. This may be due to misconceptions about HMB, normalization of symptoms, and a general lack of menstrual health literacy. Studies show that approximately 50% of women have limited understanding of menstruation, potentially contributing to the underreporting of HMB [21, 22]. As demonstrated by DeLoughery et al. [23], the varying capacities of modern menstrual products significantly impact the assessment of menstrual blood loss. Accurate assessment of MBL is paramount for the diagnosis of HMB. However, the increasing utilization of modern menstrual products has rendered traditional quantification methods, primarily based on pad and tampon usage, less reliable. Clinicians must therefore consider the specific type of menstrual product used by patients and their individual usage patterns to mitigate the risk of underestimating HMB. Failure to account for these factors may lead to inadequate evaluations, potentially overlooking underlying health conditions and delaying necessary interventions. Cultural factors, including menstrual taboos, can also hinder open communication and accurate reporting. Additionally, the subjective nature of HMB assessment and variability in defining MBL can affect the precision of epidemiological data. While self-reported symptoms and their impact on QoL are crucial for understanding the burden of HMB, individual perception of MBL may not be entirely reliable [20, 23].

The validation of the Turkish SAMANTA questionnaire is a critical step in integrating a new tool for the HMB management by gynecologists in Turkey who encounter nonpregnant, reproductive-age women. The translation and adaptation process were laborious and involved close translation work, cultural factoring, and psychometric evaluation, which all proved the instrument’s reliability and validity. The use of the SAMANTA questionnaire has been proven and demonstrated the fact that it can be a successful instrument for gynecologists and researchers to assess patient’s QoL presentation, and to evaluate the severity of HMB condition.

Adaptation of the SAMANTA questionnaire into cultural congruence leads to its increased effectiveness during the early and accurate diagnosis of HMB. This is because the early procedure promotes the treatment that takes into account the region and the cultural determinants that are most typical in Turkish population. As a result, such initiative is expected to be helpful in the sense that patients will be doing better. The impactful nature of the SAMANTA questionnaire developed in Turkey, holds the potential of becoming an integral part of the equipment for improving the QoL of women and in turn helping health care providers to deliver customized and optimized care. It is of paramount importance that the researchers extend their efforts and widen the area of this implementation throughout Turkey. These interventions can, thus, form the fundamental components of exploring menstrual health within the individual cultural niche.

During the preparation of this work, the authors used ChatGPT and QillBot AI in order to perform efficient proofreading, grammar checks, and enhancement of overall readability of the manuscript. After using these tools, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

MPY, AC, FYG, NC, BG, IY designed the research study. MPY and AC conducted the research. MPY, IY, ST, MC analysed the data. All authors contributed to the editorial changes in the manuscript. All authors read and approved the final manuscript. All authors participated sufficiently in the study and agreed to be responsible for all aspects of the study.

The study protocol including pilot and main study processes was approved by the Human Ethics Committee of the University of Health Sciences (Ethical approval number 20/3 and dated as December 1, 2023). In this study, adherence to the ethical principles outlined in the Declaration of Helsinki was stringently upheld, ensuring the protection of participant rights and welfare at every stage of the research process. All subjects gave their informed consent for inclusion before they participated in the study.

This research received no external funding.

The authors declare no conflict of interest.