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Inherited Bleeding Disorders May Cause Menorrhagia

Am Fam Physician. 2001 Nov 15;64(10):1754-1756.

About 5 percent of women seek medical attention because of menorrhagia. Menorrhagia leads to significant social and medical morbidity, and is commonly treated by endometrial ablation or hysterectomy. In spite of often extensive gynecologic assessment, the cause of the excessive menstrual bleeding is not identified in about one half of patients. Recent European studies indicate that inherited bleeding disorders, especially von Willebrand disease, could be responsible for a much greater proportion of cases of menorrhagia than was previously recognized. Dilley and colleagues used data from a large health maintenance organization (HMO) to assess the prevalence of von Willebrand disease in women with menorrhagia in southeastern United States.

Women 18 to 45 years of age who consulted a physician because of menorrhagia between 1995 and 1997 were recruited as subjects. Age-matched control patients who had no record of physician visits related to menstrual disorders were selected from among the female members of the same HMO. The 121 subjects and 123 control patients were interviewed to obtain complete medical, gynecologic and family medical history and an assessment of their daily activities. Blood samples were obtained to test for clotting factor deficiencies, platelet disorders and von Willebrand disease.

TABLE 1

General Prevalence of Inherited Bleeding Disorders

Diagnosis Menorrhagia patients; n = 121 (%) Control patients; n = 123 (%) P Odds ratio (95% CI)

von Willebrand disease*

8 (6.6)

1 (0.8)

0.02

8.6 (1.3, 194.6)

Factor deficiencies†

2 (1.6)

0

0.20

NA (0.3, inf)

Platelet abnormality

3 (2.5)


3 (2.4)


1.0


1.0 (0.20, 6.0)


Total

13 (10.7)

4 (3.2)

0.02

3.6 (1.2, 13.0)


*— Based on two or more tests of von Willebrand factor antigen, von Willebrand factor activity, ristocetin cofactor or ristocetin-induced platelet aggregation two standard deviations below the control range.

†—One Factor VII deficiency and one Factor XI.

Adapted with permission from Dilley A, Drews C, Miller C, Lally C, Austin H, Ramaswamy D, et al. von Willebrand disease and other inherited bleeding disorders in women with diagnosed menorrhagia. Obstet Gynecol 2001;97:632.

TABLE 1   General Prevalence of Inherited Bleeding Disorders

View Table

TABLE 1

General Prevalence of Inherited Bleeding Disorders

Diagnosis Menorrhagia patients; n = 121 (%) Control patients; n = 123 (%) P Odds ratio (95% CI)

von Willebrand disease*

8 (6.6)

1 (0.8)

0.02

8.6 (1.3, 194.6)

Factor deficiencies†

2 (1.6)

0

0.20

NA (0.3, inf)

Platelet abnormality

3 (2.5)


3 (2.4)


1.0


1.0 (0.20, 6.0)


Total

13 (10.7)

4 (3.2)

0.02

3.6 (1.2, 13.0)


*— Based on two or more tests of von Willebrand factor antigen, von Willebrand factor activity, ristocetin cofactor or ristocetin-induced platelet aggregation two standard deviations below the control range.

†—One Factor VII deficiency and one Factor XI.

Adapted with permission from Dilley A, Drews C, Miller C, Lally C, Austin H, Ramaswamy D, et al. von Willebrand disease and other inherited bleeding disorders in women with diagnosed menorrhagia. Obstet Gynecol 2001;97:632.

Study subjects and control patients were similar in demographic variables. The average age of the study participants was 35 years, almost all had completed high school and most had attended college. About one third were white, and slightly fewer than one half of participants had type O blood. Although fewer than 1 percent of participants reported a family history of confirmed bleeding disorder, about 34 percent of patients with menorrhagia and 30 percent of control patients reported a family history of excessive bleeding. Overall, 13 (10.7 percent) of the patients with menorrhagia were diagnosed with some form of bleeding disorder compared with four (3.2 percent) of the control patients (see Table 1). The most common condition, von Willebrand disease, was diagnosed in eight of the patients with menorrhagia and one of the control patients. The prevalence of von Willebrand disease differed significantly by race (see Table 2). It was 15.9 percent among white patients with menorrhagia and only 1.4 percent among black patients with menorrhagia.

TABLE 2

Prevalence of Inherited Bleeding Disorders by Race

Menorrhagia patients Control patients
Diagnosis White; n = 44 (%) Black; n = 69 (%) White; n = 46 (%) Black; n = 76 (%)

Any bleeding disorder*

8 (18.2)

5 (7.2)

2 (4.3)

2 (2.6)

von Willebrand disease

7 (15.9)

1 (1.4)

0

1 (1.3)


*— Includes von Willebrand disease, factor deficiencies and platelet defects.

Adapted with permission from Dilley A, Drews C, Miller C, Lally C, Austin H, Ramaswamy D, et al. von Willebrand disease and other inherited bleeding disorders in women with diagnosed menorrhagia. Obstet Gynecol 2001;97:632.

TABLE 2   Prevalence of Inherited Bleeding Disorders by Race

View Table

TABLE 2

Prevalence of Inherited Bleeding Disorders by Race

Menorrhagia patients Control patients
Diagnosis White; n = 44 (%) Black; n = 69 (%) White; n = 46 (%) Black; n = 76 (%)

Any bleeding disorder*

8 (18.2)

5 (7.2)

2 (4.3)

2 (2.6)

von Willebrand disease

7 (15.9)

1 (1.4)

0

1 (1.3)


*— Includes von Willebrand disease, factor deficiencies and platelet defects.

Adapted with permission from Dilley A, Drews C, Miller C, Lally C, Austin H, Ramaswamy D, et al. von Willebrand disease and other inherited bleeding disorders in women with diagnosed menorrhagia. Obstet Gynecol 2001;97:632.

The authors conclude that inherited bleeding disorders are an important cause of menorrhagia, particularly in white women, and should be considered in the differential diagnosis of this common condition.

Dilley A, et al. von Willebrand disease and other inherited bleeding disorders in women with diagnosed menorrhagia. Obstet Gynecol. April 2001;97:630–6.

editor's note: In spite of the many limitations of this study, particularly the reliance on coding to identify cases of menorrhagia, these findings are remarkable. Women with menorrhagia are subjected to many tests and treatments, up to and including hysterectomy, yet in perhaps 15 to 20 percent of cases, bleeding disorders cause or contribute to the situation. We need to have a higher level of suspicion for bleeding disorders in patients with menorrhagia. Besides the immediate management of menstrual dysfunction, early diagnosis of bleeding disorders could be lifesaving if there is subsequent pregnancy, surgery or trauma.—a.d.w.

 

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