Menorrhagia from a haematologist's point of view. Part I: initial evaluation

Diagnosis and Management of Heavy Menstrual Bleeding and Bleeding Disorders in Adolescents

IMPORTANCE

Heavy menstrual bleeding is a common cause of anemia and reduced quality of life in adolescents. There is a higher prevalence of bleeding disorders in girls with heavy menstrual bleeding than in the general population. Pediatricians should be comfortable with the initial evaluation of heavy menstrual bleeding and the indications for referral to subspecialty care.

OBSERVATIONS

The most common cause of heavy menstrual bleeding in adolescents is ovulatory dysfunction, followed by coagulopathies. The most common inherited bleeding disorder is von Willebrand disease, and its incidence in adolescents with heavy menstrual bleeding is high. Distinguishing the etiology of heavy menstrual bleeding will guide treatment, which can include hemostatic medications, hormonal agents, or a combination of both. Among hormonal agents, the 52-mg levonogestrel intrauterine device has been shown to be superior in its effect on heavy menstrual bleeding and is safe and effective in adolescents with bleeding disorders.

CONCLUSIONS AND RELEVANCE

Anemia, need for transfusion of blood products, and hospitalization may be avoided with prompt recognition, diagnosis, and treatment of heavy menstrual bleeding, especially when in the setting of bleeding disorders. Safe and effective treatment methods are available and can greatly improve quality of life for affected adolescents. A multidisciplinary approach to the treatment of girls with bleeding disorders and history of heavy menstrual bleeding is optimal.

Predictors of quality of life among adolescents and young adults with a bleeding disorder

BACKGROUND

Health-related quality of life (HRQoL) in adolescents and young adults with bleeding disorders is under-researched. We aimed to describe factors related to HRQoL in adolescents and young adults with hemophilia A or B or von Willebrand disease.

METHODS

A convenience sample of volunteers aged 13 to 25 years with hemophilia or von Willebrand disease completed a cross-sectional survey that assessed Physical (PCS) and Mental (MCS) Component Summary scores on the SF-36 questionnaire. Quantile regression models were used to assess factors associated with HRQoL.

RESULTS

Of 108 respondents, 79, 7, and 14% had hemophilia A, hemophilia B, and von Willebrand disease, respectively. Most had severe disease (71%), had never developed an inhibitor (65%), and were treated prophylactically (68%). Half of patients were aged 13 to 17 years and most were white (80%) and non-Hispanic (89%). Chronic pain was reported as moderate to severe by 31% of respondents. Median PCS and MCS were 81.3 and 75.5, respectively. Quantile regression showed that the median PCS for women (61% with von Willebrand disease) was 13.1 (95% CI: 2.4, 23.8; p = 0.02) points lower than men. Ever developing an inhibitor (vs never) was associated with a 13.1-point (95% CI: 4.7, 21.5; p < 0.01) PCS reduction. MCS was 10.0 points (95% CI: 0.7, 19.3; p = 0.04) higher for prophylactic infusers versus those using on-demand treatment. Compared with patients with no to mild chronic pain, those with moderate to severe chronic pain had 25.5-point (95% CI: 17.2, 33.8; p < 0.001) and 10.0-point (95% CI: 0.8, 19.2; p = 0.03) reductions in median PCS and MCS, respectively.

CONCLUSIONS

Efforts should be made to prevent and manage chronic pain, which was strongly related to physical and mental HRQoL, in adolescents and young adults with hemophilia and von Willebrand disease. Previous research suggests that better clotting factor adherence may be associated with less chronic pain.

The prevalence of underlying bleeding disorders in patients with heavy menstrual bleeding with and without gynecologic abnormalities

OBJECTIVE

The purpose of this study was to assess the prevalence of underlying bleeding disorders in women with heavy menstrual bleeding (HMB) with and without gynecologic abnormalities.

STUDY DESIGN

We performed a single-center prospective cohort study of 112 consecutive patients who were referred for heavy menstrual bleeding. Control subjects were 28 healthy volunteers who reported no HMB. Patients and control subjects had hemostatic testing in the first week after menstruation. Patients underwent gynecologic evaluation.

RESULTS

The median age was 42.5 years (range, 17-55 years) in patients and 40.0 years (range, 25-55 years) in control subjects. Forty-six percent of patients had anemia; the median pictorial bleeding assessment chart score was 271. Seven percent of the control subjects with a subjectively normal menstruation had anemia. Twenty-six percent of patients had gynecologic abnormalities, which was considered to explain HMB. Overall, we found an underlying bleeding disorder in 29% of the patients, which was comparable for unexplained and explained HMB (31% vs 27%; P = .75). We diagnosed 6 cases of Von Willebrand's disease, 4 cases of factor XI deficiency, and 1 case of factor VII deficiency. The only abnormalities that we found in control subjects were platelet aggregation defects (11% in control subjects vs 23% in patients). Patients had a significantly longer activated partial thromboplastin time compared with control subjects (26.5 vs 25.0 seconds; P = .001) that was caused by lower median levels of factor XI (100 vs 124 IU/dL; P < .001).

CONCLUSION

Bleeding disorders play an equally important role in the cause of both unexplained and explained heavy menstrual bleeding. A novel finding is the occurrence of low, but not deficient, levels of factor XI.

Retrospective analysis of variation in heavy menstrual bleeding treatments by age and underlying cause

OBJECTIVE

To describe treatment patterns associated with heavy menstrual bleeding (HMB) in US practice.

STUDY DESIGN

A retrospective claims-based analysis of organic (ICD-9 codes 218.x, 621.0, 622.7, 219.x, and bleeding disorders) or idiopathic (no underlying condition identified) HMB treatment patterns among newly diagnosed, commercially insured women who were enrolled in a large US health plan. First HMB claim (index date; ICD-9-CM 626.2 and 627.0), second HMB claim within 180 days of index date, and continuous enrollment ≥6 months prior to (pre-index period) and 18 months following (post-index period) index date were required.

RESULTS

The database included 13,579 organic and 21,362 idiopathic HMB patients. More organic HMB patients received only one treatment type (64% vs 58%; p < 0.001) or two treatments types (14% vs 11%; p < 0.001) compared to idiopathic HMB patients. During the 18 month post-index period, fewer organic HMB patients had no observed treatment compared to idiopathic HMB patients (21% vs 31%; p < 0.001). The idiopathic cohort had significantly higher rates (p < 0.001) of medication use and endometrial ablation, whereas the organic HMB cohort had a higher rate of hysterectomy (p < 0.001). Women <35 years were more frequently prescribed medical treatments (p ≤ 0.037), while women aged >35 years utilized significantly more surgical approaches (p < 0.001).

CONCLUSIONS

Among organic and idiopathic HMB patients, considerable variation was observed in the medications and procedures used to treat HMB. Current treatment pattern awareness may improve HMB management. Future research is needed to understand factors that influence women's treatment choices (including newer medications LNG-IUS and tranexamic acid) and age in relation to child-bearing preference.

Cost-utility analysis of von Willebrand disease screening in adolescents with menorrhagia

OBJECTIVE

To construct a decision analysis model to evaluate the cost utility of von Willebrand disease (VWD) testing in adolescents with menorrhagia.

STUDY DESIGN

A 20-year Markov decision analytic model was constructed to evaluate the cost utility of two strategies: testing or not testing for VWD. The model includes probabilities of remaining well, suffering an acute menorrhagia bleeding event, surgical complications, oral contraceptive pill complications, or dying. Probabilities, costs, and utilities were estimated from published literature. The prevalence of type 1 VWD in adolescent females with menorrhagia was estimated at 13%.

RESULTS

The cost of testing adolescents with menorrhagia for VWD was $1790, versus $1251 for not testing for VWD. The effectiveness of not testing in quality-adjusted life-years (QALYs) gained (14.237 QALYs) was similar to the VWD testing strategy (14.246 QALYs). Compared with not testing for VWD, screening for VWD had an incremental cost-effectiveness ratio of $62,791 per QALY, a value typically considered economically reasonable.

CONCLUSIONS

In adolescents with menorrhagia, testing for VWD before the initiation of oral contraceptives is cost-effective.

Diagnosis and management of bleeding disorder in a child

Children with symptoms of bleeding and bruising are commonly seen in clinical practice. Primary care providers should be able to decide when and whether evaluation for bleeding disorder is warranted. This decision depends on one's index of suspicion for bleeding disorder based on history, physical examination, and screening laboratory investigations. Knowledge of the hemostatic physiology is essential to be able to order appropriate laboratory investigations and their accurate interpretation. Prothrombin time (PT), activated partial thromboplastin time (aPTT), and blood platelet concentration constitute the initial diagnostic work up of any bleeding disorder. Abnormality in any of these parameters in a child with excessive bleeding should lead to presumptive diagnosis of bleeding disorder and trigger referral to a hematologist for confirmation and definitive treatment. Awareness of basic treatment principles for management of bleeding/clotting disorders may prepare the provider to develop appropriate management plans, especially in a life threatening situation.

Evaluation and treatment of menorrhagia in an adolescent population

Bleeding in adolescence is a common but, potentially, difficult condition to manage. Adolescents present with unique issues related to their age, involvement of family members, different differential diagnosis when compared to an older populations, and challenges associated with their evaluation and treatment.

Endometriosis Is Associated With Prevalence of Comorbid Conditions in Migraine

OBJECTIVE

To examine the headache characteristics of women with migraine and endometriosis (EM), and differences in the prevalence of comorbid conditions between female migraineurs with EM, without EM and nonheadache controls.

BACKGROUND

Migraine and EM are common conditions in women of reproductive age, and both are influenced by ovarian hormones. The comorbidity of migraine and EM is newly recognized, but reasons for the association are uncertain.

METHODS

This is a cross-sectional study of female headache outpatients and healthy controls conducted at University of Toledo and Duke University in 2005 and 2006. After a headache specialist determined headache frequency and diagnosis (based on criteria of the second International Classification of Headache Disorders), patients completed a self-administered electronic survey with information on demographics, headache-related disability, menstrual disorders, premenstrual dysphoric disorder (PMDD), vascular event risk, and comorbid conditions, including irritable bowel syndrome (IBS), fibromyalgia (FM), chronic fatigue syndrome (CFS), interstitial cystitis (IC), depression, and anxiety.

RESULTS

Study enrolled 171 women with migraine and 104 controls. EM was reported more commonly in migraineurs than in controls (22% vs 9.6%, P < .01). Frequency of chronic headache was higher in migraineurs with EM compared to without EM (P= .002) and median headache-related disability scores were also higher in the EM group (P= .025). Symptoms of PMDD were more common in migraineurs, but frequency did not differ by EM status. Migraineurs with EM reported more menorrhagia, dysmenorrhea, and infertility compared to the migraine cohort without EM and to controls. Depression, anxiety, IBS, FM, CFS, and IC were more common in migraine with EM group than in controls. Anxiety (OR = 2.2, 95% CI 1.0-4.7), IC (OR = 10.6, 95% CI 1.9-56.5), and CFS (OR = 3.6, 95% CI 1.1-11.5) were more common in migraine with EM group, than in the cohort with migraine without EM.

CONCLUSION

Prevalence of EM is higher in women with migraine than in nonheadache controls. Migraineurs with EM have more frequent and disabling headaches, and are more likely to have other comorbid conditions affecting mood and pain, compared to migraineurs without EM.

Risk of excessive bleeding associated with marginally low von Willebrand factor and mild platelet dysfunction

BACKGROUND

Bleeding symptoms are so commonly reported that it is not known whether they associate causally or coincidentally with mild but measurable primary hemostatic defects. OBJECTIVES/PATIENTS/METHODS: In order to evaluate if the mild primary hemostatic defects are truly causative of increased bleeding symptoms, we surveyed a population of healthy teenagers for bleeding symptoms. Using a case-control approach, we then estimated the risk of excessive bleeding associated with low von Willebrand factor (defined as VWF below the 5th percentile of a normal reference population), and with mild platelet dysfunction [PD, defined as concurrent reduced platelet aggregation responses to two agonists (adenosine diphosphate and epinephrine)].

RESULTS

Excessive bleeding was present in 63 out of 809 teenagers (7.8%). Among the 49 cases who were tested for VWF, low values by three measures were more commonly present than in 166 controls, specifically, ristocetin cofactor (RCo) activity [20.4% vs. 5.4%, odds ratio (OR) 4.5], collagen binding (14.3% vs. 4.2%, OR 3.8), and antigen level (20.4% vs. 6.0%, OR 4.0). The low RCo values ranged from 35 to 45 U dL(-1) except for a single case with 26 U dL(-1). Of the 47 teenagers with excessive bleeding who underwent platelet aggregation studies, reduced responses were more common than in controls (12.8% vs. 4.4%, OR 3.2). Twenty-nine per cent of cases with excessive bleeding had either low RCo or PD.

CONCLUSION

Almost one in three teenagers who report excessive bleeding is likely to have a measurable hemostatic disturbance manifested either by marginally low VWF (by three measures) or by mild PD.

Migraine Is Associated With Menorrhagia and Endometriosis

OBJECTIVE

To evaluate the frequency of menorrhagia and endometriosis in female migraineurs compared to age-matched women without headache.

BACKGROUND

Migraine predominantly affects women of childbearing age and is often associated with the menstrual period, yet there is a paucity of data regarding the relationship of migraine and menstrual disorders.

METHODS

Women diagnosed with migraine, using International Headache Society criteria and an age- and sex-matched control group, were administered a semistructured questionnaire regarding migraine and migraine-related disability, menstrual history, other bleeding history, vascular event history, and vascular risk factors.

RESULTS

Fifty female migraineurs between the ages of 22 and 50 years and 52 age-matched women (mean age 37 years) were enrolled in the study. Similar proportions of women in each group reported using hormone contraceptives (30% vs. 33%, P = .77) and hormone replacement therapy (12% vs. 8%, P = .69). The proportions presently menstruating (64 % vs. 80%, P = .20) and status after hysterectomy were similar (24% vs. 14%, P = .84). Menorrhagia (defined as at least three consecutive heavy periods), both current and prior, was more commonly reported in migraineurs (63% vs. 37%, P = .009), with higher likelihood of staining clothes by menses (35% vs. 8%, P = .003), and significant impact of menses on activities of daily living (on a 10-point Likert scale) with work/school participation (P = .02), family activities (P < .0001), sleep (P = .003), life enjoyment (P = .001), mood (P = .02), and overall quality of life (P = .003). Endometriosis, which may be associated with menorrhagia, was also more commonly diagnosed in the migraineurs (30% vs. 4%, P = .001). The migraineurs more frequently described bruising (40% vs. 10%, P < .001) and rectal bleeding (18% vs. 2%, P = .017) but not more serious bleeding problems. Nonsteroidal anti-inflammatory drug (NSAID) use was more frequent in the migraine group (28% vs. 12%, P = .036), and significance for increased menorrhagia, endometriosis, menstrual interference, and bruising was maintained, even when controlling for the use of NSAIDs. With logistic regression, menorrhagia was significantly associated with migraine, adjusted odds ratio (OR) = 2.8 (95% CI 1.2 to 6.5), and with endometriosis, adjusted OR = 10.5 (95% CI 2.2 to 51.4). There were no differences in vascular events and risk factors, except for trends of increased hypertension (25% vs. 10%, P = .05), transient ischemic attack/stroke (10% vs. 2%, P = .08), and Raynaud's disease (10% vs. 2%, P = .08) in the migraineurs.

CONCLUSION

Women with migraine have a higher frequency of menorrhagia, endometriosis, and associated psychosocial consequences. These findings suggest that there should be further study of factors influencing endometriosis and menstrual blood flow, such as eicosanoids and platelet function, in migraineurs.

Testing for von Willebrand Disease in Women With Menorrhagia: A Systematic Review

OBJECTIVE

To review the evidence supporting screening of adult women with menorrhagia for von Willebrand disease.

DATA SOURCES

MEDLINE search from January 1,1990, to December 31, 2003, for articles in English, using keywords "menorrhagia," "von Willebrand disease," "diagnosis," and "screening," with a hand-search of bibliographies of identified articles, review of published abstracts, and discussion with experts.

METHODS OF STUDY SELECTION

One hundred seven articles meeting search criteria were reviewed. Articles included in the study were those that provided primary data on the prevalence of von Willebrand disease in adult women with menorrhagia, quality of life, surgical complications, and the effectiveness of medical therapy in women with menorrhagia and von Willebrand disease and test characteristics of screening tests for von Willebrand disease.

TABULATION, INTEGRATION, AND RESULTS

The reported prevalence of von Willebrand disease in women with menorrhagia ranged from 5-20% in 5 published studies. Comparison of results was limited by small sample sizes and large confidence intervals, as well as differences in the definitions of menorrhagia and von Willebrand disease used in the studies. Although menorrhagia in women with known von Willebrand disease has a substantial impact on quality of life, there are no data suggesting that this impact is substantially greater than that of menorrhagia in women without von Willebrand disease. Data on the risk of surgical bleeding in women with von Willebrand disease are limited, with only 3 studies with a total of 29 patients identified. Data on the effectiveness of specific therapies are also limited; only one controlled trial was identified. Of single tests for screening, one study of the ristocetin cofactor assay had a sensitivity of 79% and specificity of 90%. Studies of a test of platelet adhesion and aggregation resulted in pooled sensitivities of 83-94% and specificities of 80-88%; however, significant heterogeneity was present.

CONCLUSION

There are inadequate data to justify routine testing for von Willebrand disease in adult women with menorrhagia outside of the research setting.

On the correlation between local fibrinolytic activity in menstrual fluid and total blood loss during menstruation and effects of desmopressin

The primary objective of this study was to investigate the correlation between fibrinolytic activity in menstrual fluid and total menstrual blood loss during menstruation. We also wanted to evaluate the influence of desmopressin nasal inhalation on the local fibrinolytic activity in menstrual fluid. Six women with objectively verified menorrhagia and six women with normal menstrual blood loss were examined. With a slender catheter introduced through the cervical canal, menstrual fluid was collected on the day in the cycle when the most intense bleeding occurred. The fibrinolytic activity in menstrual fluid was measured both as plasmin content using an amidolytic method with chromogenic substrate and with a fibrin plate method. A significant correlation between the amount of menstrual blood loss and fibrinolytic activity was found in menstrual fluid of both groups and with both methods. We could not find an increased fibrinolytic activity in menstrual fluid when the women with menorrhagia were treated with desmopressin nasal inhalation. Knowledge of the local factors influencing monthly blood loss can be valuable when searching for more effective medical treatment of menorrhagia. Apprehension that desmopressin should increase local fibrinolytic activity in menstrual fluid could not be confirmed.

Approach to the bleeding child

Because bruising and bleeding are normal events of childhood, the pediatrician must be able to determine whether a child's symptoms are normal or perhaps indicative of a defective hemostasis. A thorough medical history and physical examination should enable the clinician to choose those patients warranting further evaluation. Rather than referral to a hematologist at that point in time, pediatricians should be quite capable of performing the initial laboratory evaluation and making the correct diagnosis in a majority of cases.