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Brun JL, Plu-Bureau G, Huchon C, Ah-Kit X, Barral M, Chauvet P, Cornelis F, Cortet M, Crochet P, Delporte V, Dubernard G, Giraudet G, Gosset A, Graesslin O, Hugon-Rodin J, Lecointre L, Legendre G, Maitrot-Mantelet L, Marcellin L, Miquel L, Le Mitouard M, Proust C, Roquette A, Rousset P, Sangnier E, Sapoval M, Thubert T, Torre A, Trémollières F, Vernhet-Kovacsik H, Vidal F, Marret H. Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2023; 288:90-107. [PMID: 37499278 DOI: 10.1016/j.ejogrb.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/25/2023] [Accepted: 07/01/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience. CONCLUSIONS The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.
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Affiliation(s)
- J L Brun
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076 Bordeaux, France.
| | - G Plu-Bureau
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - C Huchon
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2 rue Ambroise Paré, 75010 Paris, France
| | - X Ah-Kit
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, Place Amélie Raba Léon, 33076 Bordeaux, France
| | - M Barral
- Service de radiologie interventionnelle, hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
| | - P Chauvet
- Service de chirurgie gynécologique, CHU Clermont-Ferrand, 1 Place Lucie et Raymond Aubrac, 63000 Clermont-Ferrand, France
| | - F Cornelis
- Service de radiologie interventionnelle, hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
| | - M Cortet
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - P Crochet
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147 boulevard Baille, 13005 Marseille, France
| | - V Delporte
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49 rue de Valmy, 59000 Lille, France
| | - G Dubernard
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - G Giraudet
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49 rue de Valmy, 59000 Lille, France
| | - A Gosset
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - O Graesslin
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45 rue Cognac-Jay, 51092 Reims, France
| | - J Hugon-Rodin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Lecointre
- Service de chirurgie gynécologique, CHU Strasbourg, 1 avenue Molière, 67200 Strasbourg, France
| | - G Legendre
- Service de gynécologie-obstétrique, CHU Angers, 4 rue Larrey, 49933 Angers, France
| | - L Maitrot-Mantelet
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Marcellin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - L Miquel
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147 boulevard Baille, 13005 Marseille, France
| | - M Le Mitouard
- Service de gynécologie, hôpital Croix Rousse, CHU Lyon, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - C Proust
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2 boulevard Tonnellé, 37044 Tours, France
| | - A Roquette
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - P Rousset
- Service de radiologie, hôpital Sud, CHU Lyon, 165 chemin du Grand Revoyet, 69495 Pierre-Benite, France
| | - E Sangnier
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45 rue Cognac-Jay, 51092 Reims, France
| | - M Sapoval
- Service de radiologie interventionnelle, hôpital europeen Georges-Pompidou, APHP, 20 rue Leblanc, 75015 Paris, France
| | - T Thubert
- Service de gynécologie-obstétrique, Hotel Dieu, CHU Nantes, 38, boulevard Jean-Monnet, 44093 Nantes, France
| | - A Torre
- Centre de procréation médicalement assistée, centre hospitalier Sud Francilien, 40 avenue Serge Dassault, 91106 Corbeil-Essonnes, France
| | - F Trémollières
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Vernhet-Kovacsik
- Service d'imagerie thoracique et vasculaire, hôpital Arnaud-de-Villeneuve, CHU Montpellier, 371 avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France
| | - F Vidal
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330 Avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Marret
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2 boulevard Tonnellé, 37044 Tours, France
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Schmitt ML, Hagstrom C, Gruer C, Nowara A, Keeley K, Adenu-Mensah NE, Sommer M. “Girls May Bleed Through Pads Because of Demerits”: Adolescent Girls’ Experiences With Menstruation and School Bathrooms in the U.S.A. JOURNAL OF ADOLESCENT RESEARCH 2022. [DOI: 10.1177/07435584221139342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The aim of this study was to better understand the role of school bathrooms in shaping the menstrual experiences of adolescents in the U.S.A. The participants were Black and Latina, low-income adolescent girls (15–19) and adults interacting closely with youth in three U.S.A. cities (Chicago, Los Angeles, New York City). Data collection methods included: (1) Participatory Methodologies (PM) sessions with adolescent girls ( n = 73); (2) In-depth interviews (IDI) with adolescent girls ( n = 12); and (3) Key Informant Interviews (KII) with adults ( n = 23). Malterud’s “systematic text condensation,” an inductive thematic analysis method, was utilized to analyze the various data types (field notes, in-depth interviews, drawings). Key findings include, one, that menstruating girls experience embarrassment and a need for secrecy when accessing school bathrooms; two, the social and physical environments of school bathrooms, including poor design and maintenance, heighten girls’ discomfort, especially while menstruating; and three, school policies restricting students’ bathroom access are problematic for many menstruating students, especially those experiencing heavy and/or unpredictable bleeding. Schools and policymakers need to consider holistic approaches when addressing the menstrual needs of adolescents in U.S.A. schools, including better prioritizing issues related to menstrual stigma, school bathroom design and bathroom access policies.
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Affiliation(s)
| | | | | | | | - Katie Keeley
- Ann & Robert H. Lurie Children’s Hospital of Chicago, IL, USA
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EVALUATION OF HEMOSTASIS PARAMETERS IN ADOLESCENT GIRLS PRESENTING WITH MENOMETRORRHAGIA AND COMPARISON WITH HEALTHY ADOLESCENTS. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1161870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective: This study aims to investigate the presence of acquired and hereditary coagulation in adolescent girls presenting with increased menstrual bleeding.
Method: The study consisted of 63 adolescent female patients (15.4±1.5 years) who applied to the pediatric clinic of our hospital due to increased menstrual bleeding, did not have any acute or chronic disease, did not use any medication in the last 14 days, and were of the same age and gender as the study group. 74 healthy adolescents were taken as the healthy control group (15.5±1.5 years). Platelet count, all basal and advanced coagulation tests, platelet aggregation, and secretion tests were studied for each case included in the study.
Results: When basal and advanced coagulation tests, platelet aggregation, and secretion tests were examined, no significant difference was found between the study and the healthy control group. On the other hand, in our study group with heavy menstrual bleeding, 4 (6.3%) patients were found to have impaired hemostasis (2 patients with type 1 von Willebrand disease, one patient with immune thrombocytopenic purpura, and one patient with mild factor VIII deficiency).
Conclusion: Various hemostasis disorders, especially von Willebrand disease, could be detected in the group with heavy menstrual bleeding.
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Amos LE, Sherman AK, Carpenter SL. Diagnosis of Bleeding Disorders in Adolescents Hospitalized for Heavy Menstrual Bleeding. TH OPEN 2022; 6:e267-e275. [PMID: 36299809 PMCID: PMC9512591 DOI: 10.1055/a-1892-1987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022] Open
Abstract
Background
There is scarce information regarding the prevalence and clinical impact of saddle pulmonary embolism (PE) in patients with cancer.
Objectives
This study aimed to assess the prevalence, clinical findings, and short-term outcomes of patients with cancer-related saddle PE including acute symptomatic and unsuspected events.
Patients/Methods
Consecutive patients with cancer-related PE (March 1, 2006–October 31, 2014) were retrospectively reviewed by a chest radiologist to assess PE burden and signs of right ventricular (RV) overload. The clinical outcomes within 30 days were evaluated according to saddle versus nonsaddle PE.
Results
Thirty-six (12%) out of 289 patients with newly diagnosed cancer-related PE presented with saddle PE. Saddle PE was found in 21 cases (58%) with acute symptomatic PE and the remaining 15 cases (42%) were found as unsuspected findings. Patients with saddle PE had more frequently experienced a previous thrombotic event (31 vs. 13%;
p
= 0.008), and it occurred more frequently as an acute symptomatic event (58 vs. 39%;
p
= 0.025) compared with those with nonsaddle PE. Signs of RV overload including RV/left ventricle ratio ≥1 (22 vs. 4%;
p
< 0.001) and interventricular septum displacement (53 vs. 20%;
p
< 0.001) were also more common in patients with saddle PE compared with nonsaddle PE. Overall, PE-related mortality, venous thromboembolism recurrence, and major bleeding within 30 days were found to be similar according to saddle versus nonsaddle PE.
Conclusion
Saddle PE is not uncommon in patients with cancer-related PE including in those with unsuspected PE. Similar 30-day outcomes were found according to saddle versus nonsaddle PE in our cohort.
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Affiliation(s)
- Lauren E. Amos
- Division of Hematology/Oncology/Bone Marrow Transplant, Children's Mercy Hospital, Kansas City, Missouri, United States
- Department of Pediatrics, The University of Missouri-Kansas City, Kansas City, Missouri, United States
| | - Ashley K. Sherman
- Department of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Shannon L. Carpenter
- Division of Hematology/Oncology/Bone Marrow Transplant, Children's Mercy Hospital, Kansas City, Missouri, United States
- Department of Pediatrics, The University of Missouri-Kansas City, Kansas City, Missouri, United States
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Brun JL, Plu-Bureau G, Huchon C, Ah-Kit X, Barral M, Chauvet P, Cornelis F, Cortet M, Crochet P, Delporte V, Dubernard G, Giraudet G, Gosset A, Graesslin O, Hugon-Rodin J, Lecointre L, Legendre G, Maitrot-Mantelet L, Marcellin L, Miquel L, Le Mitouard M, Proust C, Roquette A, Rousset P, Sangnier E, Sapoval M, Thubert T, Torre A, Trémollières F, Vernhet-Kovacsik H, Vidal F, Marret H. [Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:345-373. [PMID: 35248756 DOI: 10.1016/j.gofs.2022.02.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To provide French guidelines for the management of women with abnormal uterine bleeding (AUB). DESIGN A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice. CONCLUSIONS The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.
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Affiliation(s)
- J-L Brun
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France.
| | - G Plu-Bureau
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - C Huchon
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - X Ah-Kit
- Service de chirurgie gynécologique, centre Aliénor d'Aquitaine, hôpital Pellegrin, CHU Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - M Barral
- Service de radiologie interventionnelle, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - P Chauvet
- Service de chirurgie gynécologique, CHU Clermont-Ferrand, 1, place Lucie-et-Raymond-Aubrac, 63000 Clermont-Ferrand, France
| | - F Cornelis
- Service de radiologie interventionnelle, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
| | - M Cortet
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - P Crochet
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - V Delporte
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49, rue de Valmy, 59000 Lille, France
| | - G Dubernard
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - G Giraudet
- Service de gynécologie, hôpital Jeanne de Flandre, CHU Lille, 49, rue de Valmy, 59000 Lille, France
| | - A Gosset
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - O Graesslin
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45, rue Cognac-Jay, 51092 Reims, France
| | - J Hugon-Rodin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Lecointre
- Service de chirurgie gynécologique, CHU Strasbourg, 1, avenue Molière, 67200 Strasbourg, France
| | - G Legendre
- Service de gynécologie-obstétrique, CHU Angers, 4, rue Larrey, 49933 Angers, France
| | - L Maitrot-Mantelet
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Marcellin
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - L Miquel
- Service de gynécologie-obstétrique, hôpital de la Conception, CHU Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - M Le Mitouard
- Service de gynécologie, hôpital Croix-Rousse, CHU Lyon, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
| | - C Proust
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2, boulevard Tonnellé, 37044 Tours, France
| | - A Roquette
- Unité de gynécologie médicale, hôpital Port-Royal Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - P Rousset
- Service de radiologie, hôpital Sud, CHU Lyon, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France
| | - E Sangnier
- Service de gynécologie-obstétrique, institut mère enfant Alix de Champagne, CHU Reims, 45, rue Cognac-Jay, 51092 Reims, France
| | - M Sapoval
- Service de radiologie interventionnelle, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - T Thubert
- Service de gynécologie-obstétrique, Hôtel-Dieu, CHU Nantes, 38, boulevard Jean-Monnet, 44093 Nantes, France
| | - A Torre
- Centre de procréation médicalement assistée, centre hospitalier Sud Francilien, 40, avenue Serge-Dassault, 91106 Corbeil-Essonnes, France
| | - F Trémollières
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Vernhet-Kovacsik
- Service d'imagerie thoracique et vasculaire, hôpital Arnaud-de-Villeneuve, CHU Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier, France
| | - F Vidal
- Centre de ménopause et maladies osseuses métaboliques, hôpital Paule de Viguier, CHU, 330, avenue de Grande-Bretagne, 31059 Toulouse, France
| | - H Marret
- Service de chirurgie pelvienne gynécologique et oncologique, hôpital Bretonneau, CHRU Tours, 2, boulevard Tonnellé, 37044 Tours, France
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Kasinathan G, Sathar J. Blood management strategies in congenital Glanzmann thrombasthenia at a hematology referral center. Blood Res 2021; 56:315-321. [PMID: 34916340 PMCID: PMC8721450 DOI: 10.5045/br.2021.2021165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/31/2021] [Accepted: 11/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background Glanzmann thrombasthenia is associated with abnormalities in the glycoprotein IIb/IIIa receptor. This study, conducted at Ampang Hospital, Malaysia, aimed to assess outcomes of blood management strategies for Glanzmann thrombasthenia. Methods Ten patients with Glanzmann thrombasthenia aged 9 years (2009‒2018) were examined. Data on clinical characteristics, transfusion practices, and patient blood management were obtained from medical records. Patient blood management methods included parenteral iron, erythropoietin, hormonal pills, intrauterine progesterone contraceptive devices, tranexamic acid, and recombinant factor VIIa. Primary outcomes were hemoglobin levels and the proportion of patients who received blood transfusion. Secondary outcomes were morbidity and mortality. Results The median age at diagnosis was 8.2 years (range, 1‒15 yr). The female-to-male ratio was 9:1. Eight patients had type 2 disease (5‒20% of normal GPIIb/IIIa), and two patients had type 1 disease (normal GPIIb/IIIa <5%). All patients had iron deficiency. All female patients presented with significant menorrhagia. Other bleeding symptoms included epistaxis, spontaneous skin bruising, hemoptysis, gingival bleeding, knee hemarthrosis, and pelvic hematoma. No patient experienced life-threatening bleeding. Our patients had a mean hemoglobin level of 5.6 g/dL at diagnosis. All patients were optimized using non-transfusion methods as described above. Our patient had a current mean hemoglobin level of 11 g/dL. Approximately 70% (7/10) of patients did not experience receiving blood transfusions in the last 5 years. No patient experienced non-transfusion-related morbidities such as sepsis, thromboembolism, or cardiorespiratory events. Conclusion High cost, transfusion-related adverse events, and immunomodulation could be effectively prevented by avoiding unnecessary blood transfusions.
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Affiliation(s)
| | - Jameela Sathar
- Department of Hematology, Ampang Hospital, Selangor, Malaysia
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Screening hemostatic defects in Saudi University students with unexplained menorrhagia: a diagnosis, which could be missed. Blood Coagul Fibrinolysis 2021; 32:278-284. [PMID: 33741756 DOI: 10.1097/mbc.0000000000001033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bleeding disorders are a common cause of unexplained menorrhagia in adolescents. However, there is lack of information provided on Arab girls. To estimate the prevalence of coagulation factor deficiencies and platelet dysfunction among Saudi university students with unexplained menorrhagia. In this cross sectional study, 463 adolescent girls surveyed for having heavy menses for further evaluation of underlying bleeding tendencies using screening standardized questionnaire. Only 109 girls out of the total 463 girls reported menorrhagia and were included in the evaluation. All girls with menorrhagia were evaluated by Pictorial blood assessment chart (PBAC) for precise evaluation of menstrual blood loss (PBAC score >100), had underwent pelvic ultrasonography and screening of hemostatic abnormalities (complete blood count, PFA-100, PT, aPTT, vWF:RCo, vWF:Ag, coagulation factors assay). On the basis of the score of PBAC more than 100, 25.6% (28/109) of adolescent women (age ranged: 17-25 years old) had confirmed menorrhagia. In 30.8% of them, an ultimate diagnosis of bleeding tendency or hemostatic abnormality was detected [five cases of probable von Willebrand disease (vWD) or low level of vWF:Ag and/or vWF:RCo, two cases of probable platelet dysfunction, and one case of factorV (FV) deficiency]. Anemia was found in 39.28% (11/28) of them; however, only 4 (36%) had received iron supplements. Our study demonstrated that hemostatic defects are not uncommon in Saudi adolescent women presenting with menorrhagia but mostly unrecognized and untreated. It is probably advisable to screen women with menorrhagia for these defects.
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Brown MC, White MH, Friedberg R, Woods K, Childress K, Kulkarni M, Sidonio RF. Elevated von Willebrand factor levels during heavy menstrual bleeding episodes limit the diagnostic utility for von Willebrand disease. Res Pract Thromb Haemost 2021; 5:e12513. [PMID: 33977212 PMCID: PMC8105159 DOI: 10.1002/rth2.12513] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/11/2021] [Accepted: 02/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is often the first bleeding symptom for female individuals with inherited bleeding disorders. Guidelines recommend performing the hemostatic evaluation at HMB presentation. Von Willebrand factor (VWF) levels increase with stress, making it unclear if VWF studies during acute bleeding are beneficial in diagnosing von Willebrand disease (VWD). OBJECTIVES To determine the utility of testing for VWD during acute HMB. PATIENTS/METHODS This retrospective cohort study evaluated VWF levels of individuals presenting to the emergency department (ED) with HMB from January 1, 2017, to December 31, 2018, after prospective implementation of a clinical practice guideline recommending hemostatic evaluation in the ED. We compared VWF and factor VIII (FVIII) levels between acute presentation and follow-up visit after bleeding resolution. We compared the diagnostic accuracy of initial and follow-up labs. RESULTS During the study period, 221 individuals were seen in the ED for acute HMB, and 39 had VWD testing at both time points. Median FVIII and VWF levels were higher during acute bleeding than at follow-up. The difference in VWF levels between visits was negligible when initial FVIII value was normal. Overall incidence of VWD was 7.5%; 69% of those with VWD had low VWF levels during acute HMB. CONCLUSION VWD testing during acute HMB detects the majority of individuals with VWD but also leads to elevated levels of VWF, potentially limiting at the accuracy of diagnostic labs during acute bleeding episodes. Delayed testing until resolution of anemia and active bleeding may provide more accurate diagnostic evaluation for VWD.
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Affiliation(s)
- Megan C. Brown
- Aflac Cancer and Blood Disorders CenterChildren's Healthcare of AtlantaEmory UniversityAtlantaGAUSA
| | - Michael H. White
- Aflac Cancer and Blood Disorders CenterChildren's Healthcare of AtlantaEmory UniversityAtlantaGAUSA
| | | | - Kalinda Woods
- Department of Gynecology and ObstetricsEmory UniversityAtlantaGAUSA
| | - Krista Childress
- Division of Pediatric SurgeryChildren's Healthcare of AtlantaAtlantaGAUSA
- Division of Gynecologic SpecialtiesDepartment of Gynecology and ObstetricsEmory UniversityAtlantaGAUSA
| | | | - Robert F. Sidonio
- Aflac Cancer and Blood Disorders CenterChildren's Healthcare of AtlantaEmory UniversityAtlantaGAUSA
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9
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Zia A, Kouides P, Khodyakov D, Dao E, Lavin M, Kadir RA, Othman M, Bauman D, Halimeh S, Winikoff R, Revel-Vilk S. Standardizing care to manage bleeding disorders in adolescents with heavy menses-A joint project from the ISTH pediatric/neonatal and women's health SSCs. J Thromb Haemost 2020; 18:2759-2774. [PMID: 32573942 DOI: 10.1111/jth.14974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/19/2020] [Accepted: 06/08/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Bleeding disorders (BD) are under-recognized in adolescents with heavy menstrual bleeding (HMB). OBJECTIVES The lack of clinical guidelines and variable symptomatic management of HMB created the imperative to standardize HMB care to identify and manage BD in adolescents. METHODS We convened an international working group (WG), utilized the results of a literature review to define knowledge gaps in HMB care, and used the collective clinical experience of the WG to develop care considerations for adolescents with BD and HMB. We then solicited input on the appropriateness of HMB care considerations from expert stakeholders representing hematology, adolescent medicine, and obstetrics-gynecology. We conducted an expert panel online, using the ExpertLens platform. During a three-round online modified-Delphi process, the expert panel rated the appropriateness of 21 care considerations using a 9-point scale to designate care as appropriate (7-9), uncertain (4-6), or inappropriate (1-3) covering screening for BD, the laboratory work-up, and management of adolescents with BD that present with HMB. We used the RAND/UCLA appropriateness method to determine the existence of consensus among the interdisciplinary panel of experts. RESULTS Thirty-nine experts participated in the panel. The experts rated fifteen HMB care considerations as appropriate, six as uncertain, and none as inappropriate. CONCLUSIONS The HMB care statements represent the first set of HMB care considerations in adolescents with BD, developed with broad expert input on appropriateness. Although likely to be of interest to a range of clinicians who routinely manage adolescents with HMB, additional research is required in many key areas.
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Affiliation(s)
- Ayesha Zia
- The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Pediatric Hematology Oncology, Children's Health, Dallas, TX, USA
| | - Peter Kouides
- The University of Rochester and the Mary M. Gooley Hemophilia Treatment Center, Rochester, NY, USA
| | | | - Emily Dao
- RAND Corporation, Santa Monica, CA, USA
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Rezan Abdul Kadir
- The Royal Free Foundation Hospital and Institute for Women's Health, University College, London, UK
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, Queen's University Kingston, School of Baccalaureate Nursing, St Lawrence College Kingston, Kingston, ON, Canada
| | - Dvora Bauman
- Department of Pediatric and Adolescent Gynecology, Hadassah University Medical Center, Jerusalem, Israel
| | - Susan Halimeh
- Medical Thrombosis and Haemophilia Treatment Center, Duisburg, Germany
| | - Rochelle Winikoff
- Division of Hematology-Oncology, Sainte-Justine University Health Center, Montréal, Canada
| | - Shoshana Revel-Vilk
- Pediatric Hematology/Oncology Unit, Shaare Zedek Medical Center, Hebrew University Medical School, Jerusalem, Israel
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10
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Gresele P, Falcinelli E, Bury L. Inherited platelet disorders in women. Thromb Res 2020; 181 Suppl 1:S54-S59. [PMID: 31477229 DOI: 10.1016/s0049-3848(19)30368-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 01/22/2023]
Abstract
Inherited platelet disorders (IPD) are a heterogeneous group of hemorrhagic diseases affecting both men and women, but usually associated with more evident bleeding symptoms in women due to the exposure to sexspecific hemostatic challenges, like menstruation and delivery. Indeed, up to 50% of women presenting with menorrhagia are diagnosed an IPD, moreover women with IPD can have ovulation-associated bleeding events and are at higher risk of endometriosis. Large retrospective studies have shown that women with IPD have a significantly increased risk of post-partum hemorrhage, predicted by a high bleeding score at previous history and by a platelet count below 50X109/L. In addition, in patients with IPD, female sex was associated with a higher frequency of excessive bleeding after surgery, even when excluding gynecological procedures. In conclusion, IPD may represent a serious problem for women's health, and their diagnosis and appropriate management is crucial to ensure female patients a good quality of life.
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Affiliation(s)
- Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy.
| | - Emanuela Falcinelli
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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11
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Borzutzky C, Jaffray J. Diagnosis and Management of Heavy Menstrual Bleeding and Bleeding Disorders in Adolescents. JAMA Pediatr 2020; 174:186-194. [PMID: 31886837 DOI: 10.1001/jamapediatrics.2019.5040] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Claudia Borzutzky
- Keck School of Medicine of University of Southern California, Los Angeles.,Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Julie Jaffray
- Keck School of Medicine of University of Southern California, Los Angeles.,Children's Center for Cancer and Blood Diseases, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
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12
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Batorova A, Galen KV, Mackensen SV, Tsimpanakos I, Grimberg E. Gynaecological issues in women with bleeding disorders: CSL Behring Symposium. ACTA ACUST UNITED AC 2019. [DOI: 10.17225/jhp00142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Abstract
The symposium focused on issues around surgery, ovulation bleeding, health-related quality of life (HRQoL) and pelvic pain in women with bleeding disorders.
Surgery
Young women with congenital bleeding disorders, especially those with severe forms, are more likely to experience gynaecological and obstetric disorders than unaffected women. Surgery may be required to manage heavy menstrual bleeding (HMB), ovulatory bleeding, endometriosis and delivery. Major surgery should be undertaken only in hospitals with a haemophilia centre and 24-hour laboratory capability. Correction of haemostasis, either by desmopressin, coagulation factor or platelet transfusion, is essential for a successful outcome of surgery. Management of pregnancy requires a multidisciplinary approach; the mode of delivery is based on the consensus of gynaecologist and haematologist, and with respect to the patient’s diagnosis.
Ovulation bleeding
Women with bleeding disorders are at risk for excessive gynaecological bleeding associated with menstruation, ovulation, pregnancy and delivery. Ovulation bleeding is associated with the rupture of ovarian cysts and causes abdominal pain; complications include haemoperitoneum, fertility problems and ovarian torsion. Management includes hormonal and haemostatic therapies, in combination if necessary, and surgery as a last resort. Current management is based on experience in a relatively small number of cases and more clinical data are needed.
Health-related quality of life
In addition to experiencing joint and tissue bleeds, women experience psychosocial and medical issues associated with menstruation, pregnancy, labour and delivery. HMB has the greatest impact, and is associated with impaired HRQoL in almost all and dissatisfaction with the burden of treatment. There is a need for focused psychosocial support and a specific tool for the assessment of HRQoL in women with bleeding disorders.
Pelvic pain
Gynaecological causes of pelvic pain in women with bleeding disorders include dysmenorrhoea, mid-cycle pain, bleeding into the corpus luteum and endometriosis. There is no correlation between bleeding tendency and endometriosis severity; however, screening for a bleeding disorder should be considered. Pharmacological management may be hormonal or non-hormonal. Gonadotrophin-releasing hormone agonists offer an alternative to surgery for women with severe bleeding disorders who have endometriosis. Paracetamol is the preferred early analgesic option. Endometrial ablation controls heavy bleeding and pelvic pain but is not recommended for women with large fibroids or a large endometrial cavity. Hysterectomy is an option of last resort. Education for health professionals should include raising awareness about the management of pain in women with bleeding disorders.
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Affiliation(s)
- Angelika Batorova
- Director of the National Haemophilia Centre, University Hospital Bratislava , Bratislava Slovakia
| | - Karin van Galen
- Utrecht University Medical Centre , Utrecht , The Netherlands
| | - Sylvia von Mackensen
- Department of Psychology , University Medical Centre , Hamburg -Eppendorf, Germany
| | | | - Evelyn Grimberg
- Women and Bleeding Disorders Committee, European Haemophilia Consortium Utrecht , The Netherlands
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13
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Zia A, Jain S, Kouides P, Zhang S, Gao A, Salas N, Lau M, Wilson E, DeSimone N, Sarode R. Bleeding disorders in adolescents with heavy menstrual bleeding in a multicenter prospective US cohort. Haematologica 2019; 105:1969-1976. [PMID: 31624107 PMCID: PMC7327636 DOI: 10.3324/haematol.2019.225656] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/14/2019] [Indexed: 12/03/2022] Open
Abstract
Heavy menstrual bleeding is common in adolescents. The frequency and predictors of bleeding disorders in adolescents, especially with anovulatory bleeding, are unknown. Adolescents referred for heavy menstrual bleeding underwent an evaluation of menstrual bleeding patterns, and bleeding disorders determined a priori. The primary outcome was the diagnosis of a bleeding disorder. Two groups were compared: anovulatory and ovulatory bleeding. Multivariable logistic regression analysis of baseline characteristics and predictors was performed. Kaplan Meier curves were constructed for the time from the first bleed to bleeding disorder diagnosis. In 200 adolescents, a bleeding disorder was diagnosed in 33% (n=67): low von Willebrand factor levels in 16%, von Willebrand disease in 11%, and qualitative platelet dysfunction in 4.5%. The prevalence of bleeding disorder was similar between ovulatory and anovulatory groups (31% vs. 36%; P=0.45). Predictors of bleeding disorder included: younger age at first bleed (OR: 0.83; 95%CI: 0.73, 0.96), Hispanic ethnicity (OR: 2.48; 95%CI: 1.13, 5.05), non-presentation to emergency department for heavy bleeding (OR: 0.14; 95%CI: 0.05, 0.38), and International Society on Thrombosis and Haemostasis (ISTH) Bleeding Assessment Tool score ≥4 (OR: 8.27; 95%CI: 2.60, 26.44). Time from onset of the first bleed to diagnosis was two years in the anovulatory, and six years in the ovulatory cohort (log-rank test, P<0.001). There is a high prevalence of bleeding disorders in adolescents with heavy periods, irrespective of the bleeding pattern. Among bleeding disorders, the prevalence of qualitative platelet dysfunction is lower than previously reported.
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Affiliation(s)
- Ayesha Zia
- The University of Texas Southwestern Medical Center, Dallas, TX .,Department of Pediatrics, Children's Medical Center, Dallas, TX.,Division of Hematology/Oncology, Children's Medical Center, Dallas, TX.,Children's Medical Center, Dallas, TX
| | - Shilpa Jain
- Hemophilia Center of Western New York, John R. Oishei Children's Hospital of Buffalo, Division of Pediatric Hematology-Oncology, Buffalo, NJ
| | - Peter Kouides
- Mary M. Gooley Hemophilia Center, University of Rochester School of Medicine, Rochester, MN
| | - Song Zhang
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Data and Population Sciences, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Ang Gao
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Data and Population Sciences, The University of Texas Southwestern Medical Center, Dallas, TX
| | | | - May Lau
- The University of Texas Southwestern Medical Center, Dallas, TX.,Division of Hematology/Oncology, Children's Medical Center, Dallas, TX.,Division of Adolescent Medicine, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Ellen Wilson
- The University of Texas Southwestern Medical Center, Dallas, TX.,Children's Medical Center, Dallas, TX.,Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Nicole DeSimone
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ravi Sarode
- The University of Texas Southwestern Medical Center, Dallas, TX.,Department of Pathology and Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
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14
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Zia A, Stanek J, Christian-Rancy M, Ahuja SP, Savelli S, O'Brien SH. Utility of a screening tool for haemostatic defects in a multicentre cohort of adolescents with heavy menstrual bleeding. Haemophilia 2018; 24:957-963. [PMID: 30207633 DOI: 10.1111/hae.13609] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/11/2018] [Accepted: 08/06/2018] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Heavy menstrual bleeding (HMB) may be expected for many adolescents after menarche. Accurate assessment of HMB, a key component in the diagnosis of a haemostatic defect (HD), is a well-recognized challenge. AIM Our objective was to determine the diagnostic accuracy of an HMB-specific screening tool for HDs in adolescents with HMB, presenting to a secondary care setting. METHODS Adolescents with HMB were evaluated for a HD at 4 US centres. A screening tool, the Philipp Tool, developed and validated in adult women with HMB, was administered. We modified the tool by assigning a score based on the number of affirmative responses. Sensitivity, specificity and likelihood ratios (LRs) of a positive tool, modified tool, with a pictorial blood assessment chart (PBAC) score >185, and with serum ferritin ≤20 ng/mL were calculated for HDs. RESULTS Among 248 adolescents with HMB, 29% were diagnosed with HDs. Sensitivity, specificity and LR of a positive screening tool for HDs were 95% (range 88-99), 14% (9-21) and 1.1 (1-1.2), respectively. A score of ≥2, addition of a PBAC score >185 and ferritin ≤20 ng/mL changed the sensitivity, specificity and LR of the tool to 72% (61-81), 94% (83-99), 76% (65-85); 60% (53-68), 24% (16-34) and 39% (31-47) and 1.8 (1.4-2.2), 1.2 (1.1-1.4) and 1.2 (1-1.4), respectively. CONCLUSION Although sensitive, the discriminative ability of the tool to identify adolescents with HDs from those without, who presented with HMB, was low. Further research is needed to optimize or develop an adolescent-specific HMB tool for secondary care settings.
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Affiliation(s)
- Ayesha Zia
- Division of Pediatric Hematology/Oncology, Dallas, Texas.,University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joseph Stanek
- Division of Pediatric Hematology/Oncology, Dallas, Texas.,Nationwide Children's Hospital, Columbus, Ohio
| | - Myra Christian-Rancy
- Division of Pediatric Hematology/Oncology, Dallas, Texas.,Nationwide Children's Hospital, Columbus, Ohio
| | - Sanjay P Ahuja
- Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Case Western Reserve University, Cleveland, Ohio
| | | | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Dallas, Texas.,Nationwide Children's Hospital, Columbus, Ohio.,The Ohio State University, Columbus, Ohio
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15
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Bahrami A, Avan A, Sadeghnia HR, Esmaeili H, Tayefi M, Ghasemi F, Nejati Salehkhani F, Arabpour-Dahoue M, Rastgar-Moghadam A, Ferns GA, Bahrami-Taghanaki H, Ghayour-Mobarhan M. High dose vitamin D supplementation can improve menstrual problems, dysmenorrhea, and premenstrual syndrome in adolescents. Gynecol Endocrinol 2018; 34:659-663. [PMID: 29447494 DOI: 10.1080/09513590.2017.1423466] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Vitamin D has a crucial role in female reproduction, possibly through its effects on calcium homeostasis, cyclic sex steroid hormone fluctuations, or neurotransmitter function. We have assessed the effects of vitamin D supplementation on dysmenorrhea and premenstrual syndrome (PMS) in adolescents. In this study, 897 adolescent girls living in Mashhad and Sabzevar, Iran, received nine high-dose vitamin D supplements (as 50,000 IU/week of cholecalciferol) and were followed up over 9 weeks. We evaluated the effect of vitamin D supplementation on individuals in four categories: those with only PMS; individuals with only dysmenorrhea; subjects with both PMS and dysmenorrhea and normal subjects. The prevalence of PMS after the intervention fell from 14.9% to 4.8% (p < .001). Similar results were also found for the prevalence of subjects with dysmenorrhea (35.9% reduced to 32.4%), and in subjects with both PMS and dysmenorrhea (32.7% reduced 25.7%). Vitamin D supplementation was associated with a reduction in the incidence of several symptoms of PMS such as backache and tendency to cry easily as well as decrement in pain severity of dysmenorrhea (p < .05). High dose vitamin D supplementation can reduce the prevalence of PMS and dysmenorrhea as well as has positive effects on the physical and psychological symptoms of PMS.
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Affiliation(s)
- Afsane Bahrami
- a Student Research Committee , Mashhad University of Medical Sciences , Mashhad , Iran
- b Department of Modern Sciences and Technologies, Faculty of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Amir Avan
- b Department of Modern Sciences and Technologies, Faculty of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
- c Metabolic Syndrome Research Center, Mashhad University of Medical Sciences , Mashhad , Iran
| | - Hamid Reza Sadeghnia
- d Pharmacological Research Center of Medicinal Plants, Mashhad University of Medical Sciences , Mashhad , Iran
| | - Habibollah Esmaeili
- e Department of Biostatistics and Epidemiology, School of Health , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Maryam Tayefi
- f Clinical Research Unit , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Faezeh Ghasemi
- g Department of Biotechnology, Faculty of Medicine , Arak University of Medical Sciences , Arak , Iran
| | - Fatemeh Nejati Salehkhani
- h Department of Nutrition, School of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Mahla Arabpour-Dahoue
- h Department of Nutrition, School of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Azam Rastgar-Moghadam
- b Department of Modern Sciences and Technologies, Faculty of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Gordon A Ferns
- i Division of Medical Education , Brighton & Sussex Medical School , Brighton , UK
| | - Hamidreza Bahrami-Taghanaki
- j Complementary and Chinese Medicine, Persian and Complementary Medicine Faculty , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Majid Ghayour-Mobarhan
- c Metabolic Syndrome Research Center, Mashhad University of Medical Sciences , Mashhad , Iran
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16
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Abstract
Abnormal uterine bleeding is common in adolescents and is thought to affect 9% to 14% of women in their reproductive years. Certain unique aspects of underlying inherited or acquired blood disorders exacerbate the "expected" hormonal imbalance at this age, thereby increasing the morbidity of the underlying problem. A multifactorial etiology demands a collaborative approach between hematologists and gynecologists or adolescent medicine physicians to effectively manage abnormal uterine bleeding in young women with blood disorders.
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Affiliation(s)
- Kathryn E Dickerson
- Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Neethu M Menon
- Pediatric Hematology Oncology, Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, The University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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17
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Abnormal Uterine Bleeding including coagulopathies and other menstrual disorders. Best Pract Res Clin Obstet Gynaecol 2018; 48:51-61. [DOI: 10.1016/j.bpobgyn.2017.08.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 08/06/2017] [Accepted: 08/07/2017] [Indexed: 12/20/2022]
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18
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Eising HP, Roest M, de Groot PG, Huskens D, Konings J, Urbanus RT, de Laat B, Remijn JA. High prevalence of reduced thrombin generation and/or decreased platelet response in women with unexplained heavy menstrual bleeding. Int J Lab Hematol 2018; 40:268-275. [PMID: 29336529 DOI: 10.1111/ijlh.12775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/14/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Heavy menstrual bleeding (HMB) is a condition that affects 20%-30% of women of reproductive age. HMB has a multifactorial pathophysiology, which is incompletely understood. HMB symptoms are very common in patients with established haemostasis defects, likewise, women with heavy menstrual bleeding have a higher prevalence of impaired Von Willebrand factor (VWF) levels and function, thrombocytopenia, impaired platelet function and impaired coagulation. The aim of this study was to quantify the prevalence of impaired platelet function, impaired coagulation and reduced VWF activity in patients with HMB. METHODS We have used thrombin generation (TG), a flow cytometry-based platelet function test and a flow cytometry-based VWF function test to study haemostasis in 58 women (median age: 48.4 years, range 40-60 years) with HMB. In addition, we determined VWF antigen levels and VWF ristocetin co-factor activity in platelet-poor plasma. Reference ranges of platelet function were measured in whole blood of 123 healthy volunteers, while reference ranges of TG were determined in platelet-poor plasma (PPP) of 126 healthy volunteers. RESULTS Fourteen (24%) patients with HMB had impaired platelet function and 17 (29.3%) patients had impaired coagulation. Five patients (8.6%) had both impaired platelet function and impaired coagulation. Only 2 (3.4%) patients had an impaired VWF function or levels; one of them was in combination with impaired coagulation. CONCLUSION Our approach in women with HMB using a high precision platelet function test in combination with thrombin generation showed impaired coagulation or impaired platelet function in more than 40% of the patients.
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Affiliation(s)
- H P Eising
- Department of Gynaecology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - M Roest
- Synapse Research Institute, Maastricht, The Netherlands
| | - P G de Groot
- Synapse Research Institute, Maastricht, The Netherlands.,Department of Clinical Chemistry and Hematology, University Medical Centre, Utrecht, The Netherlands
| | - D Huskens
- Synapse Research Institute, Maastricht, The Netherlands
| | - J Konings
- Synapse Research Institute, Maastricht, The Netherlands
| | - R T Urbanus
- Department of Clinical Chemistry and Hematology, University Medical Centre, Utrecht, The Netherlands
| | - B de Laat
- Synapse Research Institute, Maastricht, The Netherlands
| | - J A Remijn
- Synapse Research Institute, Maastricht, The Netherlands.,Department of Clinical Chemistry and Hematology, University Medical Centre, Utrecht, The Netherlands.,Department of Clinical Chemistry and Hematology, Gelre Hospitals, Apeldoorn, The Netherlands
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19
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Acquired Vitamin K Deficiency as Unusual Cause of Bleeding Tendency in Adults: A Case Report of a Nonhospitalized Student Presenting with Severe Menorrhagia. Case Rep Obstet Gynecol 2017; 2017:4239148. [PMID: 28928999 PMCID: PMC5592002 DOI: 10.1155/2017/4239148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/18/2017] [Accepted: 07/30/2017] [Indexed: 11/18/2022] Open
Abstract
We report a rare case of acquired vitamin K deficiency presenting with severe menorrhagia and without any gynecological problem. Partial thromboplastin time (59.2 seconds) and prothrombin time (33.1 seconds, INR: 5.97) were considerably prolonged in laboratory evaluations. A complete coagulation factor assay test was performed for the patient: factor IX, 24%; factor II, 41%; factor VII, 3%; and factor X, 52%. She had been taking many high-energy drinks and she had inadequate dietary intake for the past 6 months. Given that she had vitamin K deficiency (VKD), a course of vitamin K therapy was started for her in the hospital. This case showed the potential for menorrhagia due to VKD with use of high-energy drinks and the value of a complete and detailed history in early diagnosis.
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Heavy Menstrual Bleeding in Adolescents. J Pediatr Adolesc Gynecol 2017; 30:335-340. [PMID: 28108214 DOI: 10.1016/j.jpag.2017.01.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/14/2016] [Accepted: 01/04/2017] [Indexed: 11/22/2022]
Abstract
Heavy menstrual bleeding (HMB) is a very common gynecological condition in female adolescents and a frequent presenting complaint of those with bleeding disorders. Recommendations have been established to screen for bleeding disorders in this age group where appropriate. The purpose of this document is to impart clinical recommendations regarding HMB in adolescents. Specifically, in this article we provide a description of the epidemiology, clinical presentation, diagnostic approach, and treatment of HMB in adolescents.
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Maslyanskaya S, Talib HJ, Northridge JL, Jacobs AM, Coble C, Coupey SM. Polycystic Ovary Syndrome: An Under-recognized Cause of Abnormal Uterine Bleeding in Adolescents Admitted to a Children's Hospital. J Pediatr Adolesc Gynecol 2017; 30:349-355. [PMID: 27903446 DOI: 10.1016/j.jpag.2016.11.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 11/14/2016] [Accepted: 11/19/2016] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE To evaluate whether ovulatory dysfunction due to polycystic ovary syndrome (PCOS) is a common underlying etiology of abnormal uterine bleeding (AUB) in adolescents who require hospitalization and to explore etiology, treatment, and complications of AUB with severe anemia in adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We identified female patients aged 8-20 years admitted to a children's hospital for treatment of AUB from January 2000 to December 2014. Our hospital protocol advises hormonal testing for PCOS and other disorders before treatment for AUB. We reviewed medical records and recorded laboratory evaluations, treatments, and final underlying diagnoses as well as recurrences of AUB and readmissions in the subsequent year. RESULTS Of the 125 subjects, the mean age was 16.5 ± 2.9 years; mean hemoglobin level was 7.0 ± 1.8 g/dL; 54% were overweight/obese; and 41% sexually active. PCOS accounted for 33% of admissions; hypothalamic pituitary ovarian axis immaturity 31%; endometritis 13%; bleeding disorders 10%. Girls with PCOS were more likely to be overweight/obese (74% vs 46%; P < .01) and girls with hypothalamic pituitary ovarian axis immaturity had lower hemoglobin levels (6.4 g/dL vs 7.4 g/dL; P < .05), than girls with all other etiologies of AUB. Treating physicians failed to diagnose endometritis as the etiology for AUB in 4 of 8 girls with positive tests for sexually transmitted infection and no other etiology. CONCLUSION PCOS was the most common underlying etiology in adolescents hospitalized with AUB. Screening for hyperandrogenemia is important for early diagnosis of PCOS to allow ongoing management and prevention of comorbidities. Endometritis was frequently underestimated as an etiology for AUB.
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Affiliation(s)
- Sofya Maslyanskaya
- Pediatrics, Albert Einstein College of Medicine, Bronx, New York; Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, New York.
| | - Hina J Talib
- Pediatrics, Albert Einstein College of Medicine, Bronx, New York; Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Jennifer L Northridge
- Pediatrics, Albert Einstein College of Medicine, Bronx, New York; Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Amanda M Jacobs
- Pediatrics, Albert Einstein College of Medicine, Bronx, New York; Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Chanelle Coble
- Pediatrics, Albert Einstein College of Medicine, Bronx, New York; Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, New York
| | - Susan M Coupey
- Pediatrics, Albert Einstein College of Medicine, Bronx, New York; Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, New York
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Kulkarni M, Glanville J, Phillot S, Balen A. A review of paediatric and adolescent gynaecology services in a tertiary outpatient clinic. HUM FERTIL 2017; 20:168-178. [PMID: 28152641 DOI: 10.1080/14647273.2017.1283067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Adolescence is a distinctive stage in human development during which many simple and complex medical conditions can present for the first time. Paediatric and adolescent gynaecological conditions need careful multidisciplinary clinical management with a sensitive approach understanding the patients' psychological and physiological circumstances. The objective of this study is to review the tertiary paediatric and adolescent gynaecology service in Leeds, United Kingdom and to present an overview of the various conditions that present to such a clinic. A total of 985 patients were seen over a 16-year period and the increasing number of patients seen over this time establishes the need for such a service to exist. Complex developmental anomalies of the genital tract and disorders of sexual differentiation formed a major portion of the referrals. Presence of a significant number of referrals for simple gynaecological conditions including menstrual irregularities, gynaecological pain, vulvovaginitis, polycystic ovary syndrome and concerns about labial appearance indicates the reluctance of general gynaecologists and general practitioners to manage such conditions in young patients. This emphasizes the need for continued education of primary health care professionals and establishment of clear guidelines and care pathways for the management of this special patient group.
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Affiliation(s)
- Mugdha Kulkarni
- a Leeds Centre for Reproductive Medicine, Seacroft Hospital , Leeds , UK
| | - Julie Glanville
- a Leeds Centre for Reproductive Medicine, Seacroft Hospital , Leeds , UK
| | - Sally Phillot
- a Leeds Centre for Reproductive Medicine, Seacroft Hospital , Leeds , UK
| | - Adam Balen
- a Leeds Centre for Reproductive Medicine, Seacroft Hospital , Leeds , UK
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Singh S, Best C, Dunn S, Leyland N, Wolfman WL. Saignements utérins anormaux chez les femmes préménopausées. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S231-S263. [PMID: 28063539 DOI: 10.1016/j.jogc.2016.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Rathod AD, Chavan RP, Pajai SP, Bhagat V, Thool P. Gynecological Problems of Adolescent Girls Attending Outpatient Department at Tertiary Care Center with Evaluation of Cases of Puberty Menorrhagia Requiring Hospitalization. J Obstet Gynaecol India 2016; 66:400-6. [PMID: 27651637 PMCID: PMC5016410 DOI: 10.1007/s13224-015-0770-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 08/13/2015] [Indexed: 10/22/2022] Open
Abstract
ABSTRACT Adolescence is a period of enormous physical and psychological change for young girls. Many adolescents with menstrual disturbances never present to their family doctor or gynecologist. Embarrassment about discussing menstruation, fear of disease, and ignorance about services available may lead to delayed presentation or consultation with doctor. AIMS AND OBJECTIVE To evaluate the different gynecological problems in adolescent girls attending outpatient department.To evaluate the prevalence of severe anemia requiring indoor admission in adolescent girls with puberty menorrhagia.To assess the etiologies of puberty menorrhagia. RESULT There were a total of 655 adolescent girls attending the gynecology OPD during the study period. Menstrual complaints (84.88 %) were the commonest indication for OPD consultation among adolescent girls. 17 girls required hospitalization; all of them needed blood transfusion due to significant severe anemia resulting from puberty menorrhagia. 14 (82.35 %) had anovulatory DUB, while 2 (11.76 %) had coagulation disorders, and one (5.88 %) had hypothyroidism. CONCLUSION Adolescent girls with menorrhagia need to be evaluated thoroughly earlier rather than later so that effective management can be started and severe anemia with its consequences can be avoided. Adolescent health education and group discussion is needed to create awareness regarding adolscent gynecological problems; it should be conducted regularly in schools and colleges.
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Affiliation(s)
- Archana D. Rathod
- Department of Obstetrics and Gynaecology, Shri Vasantrao Naik Government Medical College & Hospital, Yavatmal, Maharashtra India
| | - Rohidas P. Chavan
- Department of Obstetrics and Gynaecology, Shri Vasantrao Naik Government Medical College & Hospital, Yavatmal, Maharashtra India
| | - Sandhya P. Pajai
- Department of Obstetrics and Gynaecology, Shri Vasantrao Naik Government Medical College & Hospital, Yavatmal, Maharashtra India
| | - Vijay Bhagat
- Department of Preventive and Social Medicine, JNMC, Sawaghi, Wardha, India
| | - Prachi Thool
- Department of Obstetrics and Gynaecology, Shri Vasantrao Naik Government Medical College & Hospital, Yavatmal, Maharashtra India
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Karaman K, Ceylan N, Karaman E, Akbayram S, Akbayram HT, Kaba S, Garipardıç M, Öner AF. Evaluation of the Hemostatic Disorders in Adolescent Girls with Menorrhagia: Experiences from a Tertiary Referral Hospital. Indian J Hematol Blood Transfus 2016; 32:356-61. [PMID: 27429530 PMCID: PMC4930760 DOI: 10.1007/s12288-015-0583-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/17/2015] [Indexed: 10/23/2022] Open
Abstract
Bleeding disorders are a common cause of menorrhagia in the adolescent age group. We aimed to evaluate the incidence of hemostatic disorders, using clinical and laboratory findings of bleeding disorders in adolescent girls with menorrhagia. A retrospective chart review used to evaluate adolescent girls with menorrhagia who were referred to Yuzuncu Yil University Pediatric Hematology clinic between January 2010 and December 2014. Out of 52 patients referred for investigation, 50 patients were included in the study. The mean age and mean menarche age were 14.8 ± 1.42 (range: 12-17) and 12.47 ± 0.55, respectively. In 42 % (n = 21) of patients, anemia was detected. In 22 % (n = 11) of patients, a bleeding disorder was detected: five cases with von Willebrand disease, two cases with acute immune thrombocytopenic purpura, one case with Bernard-Soulier syndrome, one case with Glanzmann thrombasthenia, one case with aplastic anemia and one case with factor X deficiency. The remaining 39 out of the 50 patients were finally diagnosed with dysfunctional uterine bleeding. When compared the patients with bleeding disorders and without bleeding disorders, bleeding from other sites, including gingival bleeding or epistaxis, low platelet counts and prolonged activated partial thromboplastin time were found statistically more frequent in patients with bleeding disorders (p < 0.05). Menorrhagia in adolescents is frequently associated with underlying bleeding disorders. Adolescents with heavy menstrual bleeding and a history of nose or gingival bleeding should be evaluated for congenital bleeding disorders.
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Affiliation(s)
- Kamuran Karaman
- />Department of Pediatric Hematology, Yuzuncu Yil University, 65100 Van, Turkey
| | - Nesrin Ceylan
- />Department of Pediatrics, Yuzuncu Yil University, Van, Turkey
| | - Erbil Karaman
- />Department of Obstetric and Gynecology, Yuzuncu Yil University, Van, Turkey
| | - Sinan Akbayram
- />Department of Pediatric Hematology, Yuzuncu Yil University, 65100 Van, Turkey
| | | | - Sultan Kaba
- />Department of Pediatric Endocrinology, Yuzuncu Yıl University, Van, Turkey
| | - Mesut Garipardıç
- />Department of Pediatric Hematology, Yuzuncu Yil University, 65100 Van, Turkey
| | - Ahmet Fayik Öner
- />Department of Pediatric Hematology, Yuzuncu Yil University, 65100 Van, Turkey
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Challenges of diagnosing and managing the adolescent with heavy menstrual bleeding. Thromb Res 2016; 143:91-100. [PMID: 27208978 DOI: 10.1016/j.thromres.2016.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/26/2016] [Accepted: 05/01/2016] [Indexed: 11/20/2022]
Abstract
Unpredictable, prolonged or heavy menstrual bleeding (HMB) may be expected for many adolescents soon after menarche. A decade of clinical experience and research has now established firmly that bleeding disorders (BD) are common in adolescents with HMB. Despite these advances, many questions remain, and several aspects of the diagnosis and management of BDs in adolescents are not supported by rigorous clinical trials. In this overview, four major areas will be discussed. First, we will discuss the frequency of BDs in young women with HMB. Up to 20% of older females with HMB are thought to have an underlying BD. Estimates from retrospective studies in adolescents suggest a prevalence that varies anywhere from 10 to 62%. Prospective studies with uniform hemostatic evaluation are needed to answer this question definitively. Second, we will review existing tools that help screen and diagnose adolescents with HMB with an underlying BD. Although identification of an underlying BD in older women with HMB is relatively straight forward, uncertainties remain for adolescents. Heavy menstrual bleeding in this age group may have different pathophysiological underpinnings than those in older women and may often be disregarded as anovulatory. There is an urgent need to develop novel tools, and evaluate existing diagnostic strategies in adolescents. Third, we will discuss the optimal medical management of HMB in young adolescents. As direct evidence is largely lacking, these areas are also subject to extrapolation from older women. Lastly, an important area- prediction, and management of future bleeding in those adolescents who are diagnosed with a mild BD-will be discussed. Throughout, areas of controversy and opportunities for further research are highlighted.
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Dowlut-McElroy T, Williams KB, Carpenter SL, Strickland JL. Menstrual Patterns and Treatment of Heavy Menstrual Bleeding in Adolescents with Bleeding Disorders. J Pediatr Adolesc Gynecol 2015; 28:499-501. [PMID: 26231609 DOI: 10.1016/j.jpag.2015.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 03/03/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To characterize menstrual bleeding patterns and treatment of heavy menstrual bleeding in adolescents with bleeding disorders. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective review of female patients aged nine to 21 years with known bleeding disorders who attended a pediatric gynecology, hematology, and comprehensive hematology/gynecology clinic at a children's hospital in a metropolitan area. MAIN OUTCOME MEASURES Prevalence of heavy menstrual bleeding at menarche, prolonged menses, and irregular menses among girls with bleeding disorders and patterns of initial and subsequent treatment for heavy menstrual bleeding in girls with bleeding disorders. RESULTS Of 115 participants aged nine to 21 years with known bleeding disorders, 102 were included in the final analysis. Of the 69 postmenarcheal girls, almost half (32/69, 46.4%) noted heavy menstrual bleeding at menarche. Girls with von Willebrand disease were more likely to have menses lasting longer than seven days. Only 28% of girls had discussed a treatment plan for heavy menstrual bleeding before menarche. Hormonal therapy was most commonly used as initial treatment of heavy menstrual bleeding. Half (53%) of the girls failed initial treatment. Combination (hormonal and non-hormonal therapy) was more frequently used for subsequent treatment. CONCLUSIONS Adolescents with bleeding disorders are at risk of heavy bleeding at and after menarche. Consultation with a pediatric gynecologist and/or hematologist prior to menarche may be helpful to outline abnormal patterns of menstrual bleeding and to discuss options of treatment in the event of heavy menstrual bleeding.
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Affiliation(s)
- Tazim Dowlut-McElroy
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
| | - Karen B Williams
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Shannon L Carpenter
- Section of Hematology, Division of Hematology/Oncology/Bone Marrow Transplant, Children's Mercy Hospitals, Kansas City, Missouri
| | - Julie L Strickland
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri; Section of Gynecological Surgery, Department of Surgery, Children's Mercy Hospitals, Kansas City, Missouri
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Gursel T, Biri A, Kaya Z, Sivaslıoglu S, Albayrak M. The frequency of menorrhagia and bleeding disorders in university students. Pediatr Hematol Oncol 2014; 31:467-74. [PMID: 24684279 DOI: 10.3109/08880018.2014.886316] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVE Menorrhagia is an important health problem in women of reproductive age. The aims of this study were to assess the prevalence of menorrhagia and hemostatic abnormalities associated with menorrhagia in university students. METHODS The pictorial blood assessment chart (PBAC) was used to identify students with menorrhagia. Those with a PBAC score > 100 were examined by pelvic ultrasound and laboratory tests including complete blood count, levels of clotting factors, von Willebrand factor antigen, and ristocetin cofactor activity and Platelet Function Analyser-100 (PFA-100). Platelet aggregation was studied in students with prolonged PFA-100 closure time. RESULTS Menorrhagia was identified in 82 (21.8%) of 376 students. Six of 82 students who had pelvic pathologies were excluded. Eleven (14.5%) of the remaining 76 students were found to have bleeding disorders, including von Willebrand disease in five (6.5%), platelet function disorder in four (5.2%), and clotting factor deficiencies in two (2.6%). CONCLUSIONS Menorrhagia is a common but mostly unrecognized and untreated problem among university students. Underlying bleeding disorders are not rare and require comprehensive hemostatic evaluation for identification.
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Affiliation(s)
- Turkiz Gursel
- Department of Pediatrics, Medical School of Gazi University, Ankara, Turkey
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Mills HL, Abdel-Baki MS, Teruya J, Dietrich JE, Shah MD, Mahoney D, Yee DL, Srivaths LV. Platelet function defects in adolescents with heavy menstrual bleeding. Haemophilia 2013; 20:249-54. [DOI: 10.1111/hae.12293] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 11/30/2022]
Affiliation(s)
- H. L. Mills
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
| | - M. S. Abdel-Baki
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
| | - J. Teruya
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
- Division of Transfusion Medicine; Baylor College of Medicine; Houston TX
| | - J. E. Dietrich
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Department of Obstetrics & Gynecology; Baylor College of Medicine; Houston TX USA
| | - M. D. Shah
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
| | - D. Mahoney
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
| | - D. L. Yee
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
| | - L. V. Srivaths
- Department of Pediatrics; Baylor College of Medicine; Houston TX
- Section of Hematology/Oncology; Department of Pediatrics; Baylor College of Medicine; Houston TX
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Seravalli V, Linari S, Peruzzi E, Dei M, Paladino E, Bruni V. Prevalence of hemostatic disorders in adolescents with abnormal uterine bleeding. J Pediatr Adolesc Gynecol 2013; 26:285-9. [PMID: 24012130 DOI: 10.1016/j.jpag.2013.06.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 05/30/2013] [Accepted: 06/03/2013] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVE To evaluate the incidence of hemostatic disorders in a population of adolescents with various patterns of abnormal uterine bleeding (AUB). DESIGN Retrospective observational study. SETTING University hospital. PARTICIPANTS One hundred thirteen adolescents with AUB; mean age at menarche and mean age at the onset of symptoms 12 ± 1.2 years and 13.5 ± 2.8 years, respectively. MAIN OUTCOME MEASURES Data on menstrual history, bleeding symptoms, co-existing medical conditions, and medical therapies were assessed. All patients were screened for hemostatic disorders with laboratory testing. The incidence of the disorders was calculated. Subjects were further divided in 2 groups based on whether the AUB started in the first 2 years from menarche (group 1) or later (group 2). A statistical analysis was performed using a chi-square test to compare incidence of hemostatic disorders between the groups. RESULTS One hundred thirteen adolescents with AUB were identified. Overall, 54 (47.8%) patients had some underlying hemostatic disorder, of which a platelet dysfunction was the most common (17.7%). Von Willebrand disease was detected in 13.3% of cases and a deficiency of a coagulation factor in 12.4%. In 7.1% of patients an isolated increase of bleeding time was observed. When divided in 2 groups, 44.2% of patients in group 1 and 59.2% in group 2 had a coagulation disorders, with no statistically significant difference between the 2 groups (P = .17). CONCLUSION AUB in adolescents is frequently associated with an underlying disorder of hemostasis, most commonly a platelet function disorder. The results highlight the importance of screening for coagulation disorders in adolescents with AUB, independently from the gynecologic age at onset.
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Affiliation(s)
- V Seravalli
- Pediatric and Adolescent Gynecology Unit, Department of Science for Child and Women's Health, University of Florence, Florence, Italy.
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Naik S, Teruya J, Dietrich JE, Jariwala P, Soundar E, Venkateswaran L. Utility of platelet function analyzer as a screening tool for the diagnosis of von Willebrand disease in adolescents with menorrhagia. Pediatr Blood Cancer 2013; 60:1184-7. [PMID: 23335259 DOI: 10.1002/pbc.24456] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 12/04/2012] [Indexed: 11/08/2022]
Abstract
BACKGROUND Von Willebrand disease (VWD), and in particular, VWD type 1 and low VW factor (defined as Von Willebrand Ristocetin cofactor activity (RCoF) <30 and <50 IU/dl, respectively with normal multimers) are frequently detected in adolescents with menorrhagia and both groups benefit from similar management. Platelet function analyzer (PFA-100®) is often used as a screening test to detect VWD. We analyzed the utility of PFA-100® as a screening tool in the detection of VWD type 1 and low VW factor (VWF) in an exclusive adolescent population with menorrhagia. METHODS The study population consisted of adolescents with menorrhagia who had simultaneously drawn blood samples for VWD and PFA-100®. Abnormal PFA-100® was defined as values >183 seconds for collagen/epinephrine and/or >126 seconds for collagen/ADP. RESULTS Of a total of 235 patients tested, 23 patients had RCoF <50 IU/dl and normal multimer patterns. Statistical analysis of the utility of PFA-100® in detecting RCoF <50 IU/dl with normal multimers yielded sensitivity, specificity, positive predictive, and negative predictive values of 52%, 89%, 34%, and 95%, respectively. CONCLUSIONS Based on our results, PFA-100® was not sufficiently sensitive to detect RCoF values <50 IU/dl with normal multimer patterns in teen-aged women with menorrhagia. We conclude that in the setting of adolescent menorrhagia, PFA-100® does not have utility as an initial screening test for the diagnosis of VWD and in particular, low VWF and that clinicians need to be aware of this limitation of PFA-100® while evaluating adolescents with menorrhagia.
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Affiliation(s)
- Swati Naik
- Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Abstract
The past few decades have seen major advances in multidisciplinary obstetric care and management of gynecological conditions in women with bleeding disorders. Awareness of the impact of bleeding disorders has improved among the obstetric and gynecological community. Undiagnosed bleeding disorders can be the underlying cause for a significant proportion of women with heavy menstrual bleeding. They may also be the cause or a contributory factor for other gynecological problems, such as dysmenorrhea, intermenstrual bleeding, and endometriosis. Hemostatic assessment should be considered in women referred for menstrual abnormalities if they have a positive bleeding history as quantified by bleeding assessment tools. The reproductive choices and options for prenatal diagnosis are also expanding for families with hemophilia with a drive toward achieving a non-invasive approach. Current non-invasive prenatal diagnostic techniques are limited to identification of fetal gender. Research is ongoing to overcome the specific diagnostic challenges of identifying hemophilia mutations, utilizing free fetal DNA circulating in maternal plasma. The management of obstetric hemorrhage has recently evolved to include a greater focus on the identification of and early treatment for coagulation disorders. Deficiencies in certain hemostatic variables are associated with progression to more severe bleeding; therefore, specific interventions have been proposed to target this. Evidence is still lacking to support such strategy, and future research is required to assess the efficacy and the safety of these hemostatic interventions in women with persistent PPH.
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Affiliation(s)
- R A Kadir
- The Haemophilia Centre and Thrombosis Unit, The Royal Free Hospital, London, UK.
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Chapter 5 Special Scenarios. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2013. [DOI: 10.1016/s1701-2163(15)30738-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Venkateswaran L, Dietrich JE. Gynecologic concerns in pubertal females with blood disorders. J Pediatr Adolesc Gynecol 2013; 26:80-5. [PMID: 23095526 DOI: 10.1016/j.jpag.2012.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 07/02/2012] [Accepted: 07/03/2012] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW The incidence and prevalence of blood disorders varies depending on the underlying etiology, age, ethnicity, family history, and presence of comorbid medical conditions. Gynecologic problems occurring around puberty may cause stress to families and patients, as well as management challenges to providers. RECENT FINDINGS Management strategies in the setting of bleeding disorders include hormonal and non-hormonal options to address problems occurring around puberty. Management strategies in the setting of clotting disorders allow providers to address common problems occurring in adolescence, while minimizing risk of venous thromboembolism. SUMMARY Preparedness is important at this time of life, not only to prevent unwanted gynecologic complications or hospitalizations related to specific blood conditions, but also to identify problems related to reproductive care that may be exacerbated or complicated by an underlying blood disorder.
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Affiliation(s)
- Lakshmi Venkateswaran
- Section of Pediatric Hematology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Rodriguez V, Alme C, Killian JM, Weaver AL, Khan SP, Simmons PS. Bleeding disorders in adolescents with menorrhagia: an institutional experience. Haemophilia 2013; 19:e101-2. [DOI: 10.1111/hae.12091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2012] [Indexed: 11/28/2022]
Affiliation(s)
- V. Rodriguez
- Department of Pediatric and Adolescent Medicine; Mayo Clinic; Rochester; MN; USA
| | - C. Alme
- Department of Pediatric and Adolescent Medicine; Mayo Clinic; Rochester; MN; USA
| | - J. M. Killian
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester; MN; USA
| | - A. L. Weaver
- Division of Biomedical Statistics and Informatics; Mayo Clinic; Rochester; MN; USA
| | - S. P. Khan
- Department of Pediatric and Adolescent Medicine; Mayo Clinic; Rochester; MN; USA
| | - P. S. Simmons
- Department of Pediatric and Adolescent Medicine; Mayo Clinic; Rochester; MN; USA
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Amesse LS, Pfaff-Amesse T, Gunning WT, Duffy N, French JA. Clinical and laboratory characteristics of adolescents with platelet function disorders and heavy menstrual bleeding. Exp Hematol Oncol 2013; 2:3. [PMID: 23347697 PMCID: PMC3584827 DOI: 10.1186/2162-3619-2-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 01/19/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Platelet function disorders (PFDs) have emerged as an important etiology of heavy menstrual bleeding (HMB) in adolescents. However, neither clinical nor laboratory data have been methodically analyzed in this population subset. The objective of this study was to evaluate these parameters in order to distinguish characteristics of the disorder that in turn will lead to earlier diagnosis and therapy initiation. METHODS Retrospective review of medical records from postmenarcheal adolescents with documented PFDs referred to a hemophilia treatment center and university faculty practices for bleeding diatheses with their clinical and laboratory data evaluated. RESULTS Of 63 teens with documented PFDs, HMB was the most common clinical manifestation of PFD (43; 68.3%). Of these, 37 (86%) were diagnosed with PFD either at or after menarche with the diagnosis based on HMB symptoms alone. Only 6 (14%) were diagnosed with a PFD prior to menarche, based on associated bleeding, i.e., epistaxis, ecchymosis, and all developed HMB after menstruation onset. Interestingly, 20 girls were diagnosed with a PFD prior to menarche and of these, only 6 (30%) went on to develop HMB after pubertal transition, while the majority (14; 70%) did not. The average age-at-PFD diagnosis was 14.5yrs, significantly differing from the 10.9yrs average age-at-PFD diagnosis in their counterparts that, after menarche, did not develop HMB (P<.01) Blood type O occurred significantly more frequently (76%) than national norms (P <.037). Incidence of δ-Storage Pool deficiency (δ-SPD) was significantly higher (74%) than their non-HMB cohorts (45%) (P <.007). Coagulation and von Willebrand factor studies were all normal. Abnormal closure times and aggregation studies were observed in 42% and 60%, respectively, of tested girls. In 25.6% for whom standard platelet studies were normal, electron microscopy detected reduced platelet δ-granules numbers (δ-SPD). CONCLUSIONS Adolescents with PFDs and HMB appear to be clinically distinct from their non-HMB counterparts. This group of girls is characterized by HMB the major bleeding symptom, significantly high incidences of blood group O and the δ-SPD with a PFD diagnosed well after menarche. High false negative standard platelet function study results indicate additional diagnostic strategies, particularly for δ-SPD, should be considered.
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Affiliation(s)
- Lawrence S Amesse
- Division of Reproductive Endocrinology and Infertility, Department of OB-GYN, Section of Pediatric-Adolescent Gynecology, Wright State University Boonshoft School of Medicine, Dayton, OH, USA.
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Abstract
Under normal physiological circumstances menstruation is a highly regulated, complex process that is under strict hormonal control. During normal menstruation, progesterone withdrawal initiates menstruation. The cessation of menstrual bleeding is achieved by endometrial haemostasis via platelet aggregation, fibrin deposition and thrombus formation. Local endocrine, immunological and haemostatic factors interact at a molecular level to control endometrial haemostasis. Tissue factor and thrombin play a key role locally in the cessation of menstrual bleeding through instigation of the coagulation factors. On the other hand, fibrinolysis prevents clot organisation within the uterine cavity while plasminogen activator inhibitors (PAI) and thrombin-activatable fibrinolysis inhibitors control plasminogen activators and plasmin activity. Abnormalities of uterine bleeding can result from imbalance of the haemostatic factors. The most common abnormality of uterine bleeding is heavy menstrual bleeding (HMB). Modern research has shown that an undiagnosed bleeding disorder, in particular von Willebrand disease (VWD) and platelet function disorders, can be an underlying cause of HMB. This has led to a change in the approach to the management of HMB. While full haemostatic assessment is not required for all women presenting with HMB, menstrual score and bleeding score can help to discriminate women who are more likely to have a bleeding disorder and benefit from laboratory haemostatic evaluation. Haemostatic agents (tranexamic acid and DDAVP) enhance systemic and endometrial haemostasis and are effective in reducing menstrual blood loss in women with or without bleeding disorders. Further research is required to enhance our understanding of the complex interactions of haemostatic factors in general, and specifically within the endometrium. This will lead to the development of more targeted interventions for the management of abnormal uterine bleeding in the future.
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Affiliation(s)
- Joanna Davies
- The Haemophilia Centre and Thrombosis Unit, The Royal Free Hospital, Hampstead, London, UK
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Vo KT, Grooms L, Klima J, Holland-Hall C, O'Brien SH. Menstrual bleeding patterns and prevalence of bleeding disorders in a multidisciplinary adolescent haematology clinic. Haemophilia 2012; 19:71-5. [PMID: 23005346 DOI: 10.1111/hae.12012] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2012] [Indexed: 11/29/2022]
Abstract
Heavy menstrual bleeding (HMB) is a frequent complaint in adolescence. Although HMB is often caused by immaturity of the hypothalamic-pituitary-ovarian axis, bleeding disorders are another common yet often unidentified cause. The aim of this study was to examine the bleeding patterns and prevalence of inherited bleeding disorders among females referred for HMB to a multidisciplinary adolescent haematology clinic. We retrospectively reviewed the first 105 patients (ages 8-18 years) referred to this specialty clinic from February 2009 to December 2011. Using menstrual bleeding questionnaires and medical records, data were extracted regarding demographics, bleeding patterns, frequency and types of bleeding disorders identified, and prescribed interventions. Sixty-two per cent of patients were diagnosed with a bleeding disorder, including platelet storage pool deficiency (36%), von Willebrand's disease (9%), other platelet function defect (8%), Ehlers-Danlos syndrome (7%) and combined bleeding disorders (2%). Comparison of the bleeding profiles for females with and without a bleeding disorder revealed only three factors that were significantly different, including the reported regularity of patients' periods (P = 0.02), description of period flow (P = 0.04) and number of days of each period that the bleeding was described as 'heavy' (P = 0.007). Bleeding disorders are prevalent in adolescent females presenting to a specialty clinic. Specifically, a relatively high proportion of adolescents were diagnosed with platelet storage pool deficiency. In our small population, menstrual bleeding profiles, as examined by a standardized questionnaire, could not identify females with an underlying bleeding disorder, demonstrating the important role of haemostasis testing in the evaluation of adolescents with HMB.
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Affiliation(s)
- K T Vo
- Department of Pediatrics, The Ohio State University/Nationwide Children's Hospital, Columbus, OH, USA
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Kaunitz AM, Inki P. The levonorgestrel-releasing intrauterine system in heavy menstrual bleeding: a benefit-risk review. Drugs 2012; 72:193-215. [PMID: 22268392 DOI: 10.2165/11598960-000000000-00000] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Heavy menstrual bleeding (HMB) is a common problem in women of reproductive age and can cause irritation, inconvenience, self-consciousness and fear of social embarrassment. Our objective was to review and appraise literature identified from the MEDLINE and EMBASE databases to evaluate the clinical evidence and provide an update on the risks and benefits of using the levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of HMB. The LNG-IUS consistently reduces menstrual blood loss (MBL) in women with HMB, including those with underlying uterine pathology or bleeding disorders. The available data suggest that it reduces MBL to a greater extent than other medical therapies, including combined oral contraceptives, oral progestogens (both short- or long-cycle regimens), tranexamic acid and oral mefenamic acid. In addition, the LNG-IUS and endometrial ablation appear to reduce MBL to a similar extent. The adverse effects reported with the LNG-IUS in women with HMB are similar to those typically observed in women using the system for contraception. Uterine perforations were not reported in any of the studies reviewed, but expulsion rates may be higher than in the general population of LNG-IUS users. Overall, the LNG-IUS has a positive effect on most quality-of-life domains, at least comparable to those achieved with hysterectomy or endometrial ablation, and is consistently a cost-effective option across a variety of countries and settings. In conclusion, the LNG-IUS is an effective treatment option for women with HMB, including those with underlying organic pathology or bleeding disorders.
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Affiliation(s)
- Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, FL 32209, USA.
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Successful Management of Acute Catastrophic Juvenile Vaginal Bleeding in Glanzmann's Thromboasthenia by Uterine Tamponade: A Case Report and Review of The Literature. Case Rep Hematol 2012; 2012:530908. [PMID: 22928124 PMCID: PMC3420404 DOI: 10.1155/2012/530908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Accepted: 01/16/2012] [Indexed: 11/17/2022] Open
Abstract
Glanzmann's thromboasthenia (GT) is a rare platelet disorder, due to membrane defects involving glycoprotein GP IIb/IIIa complex. Symptoms appear in infancy with episodes of bruising, gingival bleeding, epistaxis, or at the time of menarche acute episode of uterine bleeding. Hormonal therapy and antifibrinolytic agents are first-line treatment. Platelet transfusion is given to control hemorrhage when medical treatment fails. However, repeated transfusions may result in development of platelet refractioness, due to development of antibodies against membrane glycoprotein. Activated recombinant FVII is licensed for use in acute control of bleeding in GT. Here we report a case of acute juvenile uterine bleeding at menarche, which responded successfully to uterine tamponade. To our knowledge, this is the first case report on use of balloon tamponade for control of acute catastrophic juvenile bleeding at menarche.
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Revel-Vilk S, Paltiel O, Lipschuetz M, Ilan U, Hyam E, Shai E, Varon D, Revel A. Underdiagnosed menorrhagia in adolescents is associated with underdiagnosed anemia. J Pediatr 2012; 160:468-72. [PMID: 21925680 DOI: 10.1016/j.jpeds.2011.08.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 06/20/2011] [Accepted: 08/04/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To test the hypothesis that adolescent girls with menorrhagia rarely seek medical attention. STUDY DESIGN A total of 705 adolescent girls attended a lecture on menorrhagia, completed an initial anonymous questionnaire, and were asked to participate in a more comprehensive study comprising a detailed bleeding questionnaire, a pictorial blood loss assessment chart, and blood tests. RESULTS A total of 105 adolescents (15%) reported they had heavy periods on the initial questionnaire. Among the 94 girls who completed the full questionnaire, 34 reported menorrhagia (36%; 95% CI, 26.5%-46.7%). Almost one-third (11 of 34) of these girls did not perceive having menorrhagia according to their response to the initial questionnaire. Menorrhagia was not related to age, years since menarche, or family history of menorrhagia. Among the 62 girls who consented to blood testing, 6 had anemia (9.6%; 95% CI, 3.6%-19.6%), all of whom had bleeding symptoms. CONCLUSION Using standardized questionnaires, we were able to identify adolescents with menorrhagia associated with anemia. Importantly, some of these adolescents were not aware of having menorrhagia and/or anemia. Screening programs for menorrhagia in schools could result in better detection of menorrhagia among adolescents and consequent appropriate referral for medical consultation.
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Affiliation(s)
- Shoshana Revel-Vilk
- Pediatric Hematology/Oncology Department, Hadassah Hebrew University Hospital, Jerusalem, Israel.
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Halimeh S. Menorrhagia and bleeding disorders in adolescent females. Hamostaseologie 2011; 32:45-50. [PMID: 22127528 DOI: 10.5482/ha-1181] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 10/06/2011] [Indexed: 11/05/2022] Open
Abstract
In women, von Willebrand disease (VWD) is the most common inherited bleeding disorder. Since VWD and other inherited bleeding disorders are autosomal disorders, they affect women and men. Menorrhagia, or heavy menstrual bleeding (HMB), is the most common symptom of women with bleeding disorder experience. Objectively, it is defined as bleeding that lasts for more than seven days or results in the loss of more than 80 ml of blood per menstrual cycle. The prevalence of menorrhagia in a woman with a bleeding disorder ranges from 32 to 100% in patients with VWD, from 5 to 98% in patients with a platelet dysfunction and from 35 to 70% in women with a rare factor deficiency. A detailed history and a careful physical exam are the first steps towards a diagnosis in adolescents, adding a PBAC>100 increased the sensitivity of the screening tool further to 95%. Laboratory testing should be made at the time of menstrual bleeding in an effort to capture the lowest level of VWF:Ag and FVIII:C. Treatment options for menorrhagia in VWD: (1) antifibrinolytic therapy with tranexamic acid, (2) the non-transfusional agent desmopressin (DDAVP), (3) purified blood products that contain factor VIII and VWF concentrated from plasma and (4) hormonal preparations.
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Affiliation(s)
- S Halimeh
- Medical Thrombosis and Haemophilia treatment Center, Duisburg, Germany.
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James AH, Kouides PA, Abdul-Kadir R, Dietrich JE, Edlund M, Federici AB, Halimeh S, Kamphuisen PW, Lee CA, Martínez-Perez O, McLintock C, Peyvandi F, Philipp C, Wilkinson J, Winikoff R. Evaluation and management of acute menorrhagia in women with and without underlying bleeding disorders: consensus from an international expert panel. Eur J Obstet Gynecol Reprod Biol 2011; 158:124-34. [DOI: 10.1016/j.ejogrb.2011.04.025] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 02/25/2011] [Accepted: 04/30/2011] [Indexed: 01/21/2023]
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Dietrich JE, Tran XG, Giardino AP. Bleeding disorder education in obstetrics and gynecology residency training: a national survey. J Pediatr Adolesc Gynecol 2011; 24:94-7. [PMID: 21190875 DOI: 10.1016/j.jpag.2010.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 11/03/2010] [Accepted: 11/11/2010] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE The purpose of this study was to assess the educational approach to the bleeding disorder evaluation in Obstetrics and Gynecology residency training programs in the continental United States. Information was sought from chief residents regarding training experiences and fund of knowledge regarding the evaluation of menorrhagia and diagnosis of bleeding disorders during their residency. DESIGN A 24-item questionnaire was sent to the chief residents at 241 non-military Obstetrics and Gynecology residency programs. SETTING The study was conducted at Texas Children's Health Plan in Houston, Texas. PARTICIPANTS Chief residents at 241 non-military Obstetrics and Gynecology residency programs. MAIN OUTCOME MEASURES Responses to questionnaires. RESULTS The overall response rate was 30%. Residents reported training in the medical evaluation of menorrhagia during residency with a mean of 9.1 hours per year in the first year of residency and 11.1 hours/year in the 2(nd), 3(rd) and 4(th) years; 67.7% reported they viewed their training in the medical evaluation of menorrhagia and bleeding disorders as sufficient preparation for clinical practice; and over two thirds reported specific training in common bleeding disorders, such as von Willebrand disease. CONCLUSION The current state of training in the evaluation of menorrhagia and bleeding disorders appeared to be mixed regarding the evaluation of dysfunctional uterine bleeding. An area for improvement was identified to better approach best clinical practice in the evaluation of women with menorrhagia and underlying bleeding disorders, which can be guided by the thoughtful approach taken in the recent NHLBI von Willebrand disease guidelines.
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Affiliation(s)
- Jennifer E Dietrich
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Texas, USA
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Mikhail S, Kouides P. von Willebrand disease in the pediatric and adolescent population. J Pediatr Adolesc Gynecol 2010; 23:S3-10. [PMID: 20934894 DOI: 10.1016/j.jpag.2010.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/11/2010] [Indexed: 11/30/2022]
Abstract
Recent studies indicate that bleeding disorders, particularly von Willebrand disease (VWD) is more prevalent than previously thought in adolescents with menorrhagia. Menorrhagia management in undiagnosed disorders of hemostasis may be associated with unwanted risks and complications. The prevalence of symptomatic VWD in the pediatric primary care setting appears to be 0.11% (95% CI, 0.04-0.25%). Studies evaluating the prevalence of VWD in adolescents with menorrhagia have included over 500 patients with a prevalence range from 3 to 36% depending on the clinical setting studied, with the highest prevalence seen in adolescents referred to an outpatient Hemophilia Center, while the lowest prevalence is seen in the acute hospital setting. Recently, the diagnosis of VWD has been facilitated by the use of pediatric bleeding questionnaires that have proved useful in quantifying the severity of bleeding symptoms. Treatment of VWD is often complex because a combination of therapies is often required. Potential treatment options include estrogen-progesterone preparations, desmopressin, antifibrinolytic agents and von Willebrand factor concentrates. More research is needed to evaluate the effectiveness of the various treatment modalities in the adolescent population.
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Affiliation(s)
- Sameh Mikhail
- Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC, USA
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Overview of bleeding disorders in adolescent females with menorrhagia. J Pediatr Adolesc Gynecol 2010; 23:S15-21. [PMID: 20934893 DOI: 10.1016/j.jpag.2010.08.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/11/2010] [Indexed: 11/23/2022]
Abstract
Women bleed with menses, during childbirth, and after childbirth. Women are more likely to manifest a bleeding disorder as they have more opportunities to experience bleeding challenges in their lifetime. Bleeding disorders such as hemophilia and von Willebrand disease affect 2.5-3 million American women. The most common inherited bleeding disorder in the population is von Willebrand disease with an estimated prevalence of 1-2%. von Willebrand factor (vWF) is required to adhere platelets to exposed subendothelium and protects factor VIII from proteolysis in the circulation. The prevalence of vWF rises in studies involving women with menorrhagia, with estimates ranging as high as 10-20% in white women, and 1-2% among African American women. Other bleeding disorders seen in adolescents with menorrhagia are disorders of inherited platelet dysfunction, clotting factor deficiencies, thrombocytopenia, and disorders of the fibrinolytic pathway. Not only are women more likely to present early in their life with a bleeding disorder, they are also more likely to have other gynecologic manifestations as a result of these disorders. This article presents an overview of the problem and touches upon the different management strategies available.
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Wilkinson JP, Kadir RA. Management of abnormal uterine bleeding in adolescents. J Pediatr Adolesc Gynecol 2010; 23:S22-30. [PMID: 20869283 DOI: 10.1016/j.jpag.2010.08.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/11/2010] [Indexed: 11/16/2022]
Affiliation(s)
- Jeffrey P Wilkinson
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA.
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James AH. Obstetric management of adolescents with bleeding disorders. J Pediatr Adolesc Gynecol 2010; 23:S31-7. [PMID: 20934895 DOI: 10.1016/j.jpag.2010.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/10/2010] [Indexed: 12/17/2022]
Abstract
Adolescents with bleeding disorders who become pregnant must contend with the dual challenges of their bleeding disorder and their pregnancy. Adolescents are more likely to terminate a pregnancy than adult women, and when they do carry a pregnancy, they are more likely to deliver prematurely. Otherwise, they are at risk for the same complications that adult women with bleeding disorders experience, particularly bleeding complications postpartum. Since one half to two thirds of adolescent pregnancies are unplanned, issues related to reproduction should be addressed during routine visits with the pediatrician, hematologist or gynecologist. Girls who are at risk of being carriers for hemophilia A and B, severe von Willebrand disease, and other severe bleeding disorders should have their bleeding disorder status determined before they become pregnant. During pregnancy, a plan should be established to ensure that both mother and fetus deliver safely. Young women at risk for severe bleeding or at risk of having a severely affected infant should be referred for prenatal care and delivery to a center where, in addition to specialists in high-risk obstetrics, there is a hemophilia treatment center or a hematologist with expertise in hemostasis. Prior to delivery or any invasive procedures, young women at risk for severe bleeding should receive prophylaxis. Since administration of desmopressin may result in hyponatremia, whenever available, virally inactivated or recombinant clotting factor concentrates should be used for replacement as opposed to fresh frozen plasma or cryoprecipitate.
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Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA.
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Abstract
Acquired and inherited platelet disorders can present with bleeding symptoms during adolescence. Platelet disorders include disorders of platelet number and disorders of platelet function. In adolescent females with platelet disorders, menorrhagia is a common presenting bleeding symptom. Other associated bleeding symptoms are also primarily mucocutaneous, including epistaxis and bruising. Excessive bleeding may also occur after hemostatic challenges. Diagnosis of disorders of platelet function usually requires light transmission platelet aggregometry. Management of menorrhagia in the adolescent with platelet disorders requires both hematologic and gynecologic treatment.
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Affiliation(s)
- Claire S Philipp
- University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
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