Dr Rosen is Pediatric and Adolescent Gynecology Fellow, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.

Monica Rosen, MD

Oral contraceptive pills are the most commonly used method of hormonal contraception in the United States. According to the National Survey of Family Growth conducted in 2015-2017, 80.5% of reproductive-aged women who had ever been sexually active had used oral contraceptive pills (OCPs) at some point. 

A survey of reproductive-aged women who have ever been sexually active found that 12.6% currently use pills.

There are two general types of OCPs—combined oral contraceptives (COCs), which contain both ethinyl estradiol (EE) and progestin, and progestin-only pills (POPs). Current COCs offer a range of doses and progestins to choose from.

COCs are a moderately effective method of contraception. They have a perfect use failure rate of <1% and a typical use failure rate of 9%.

 Several clinical trials have quoted failure rates of POPs between 1-13% in the first year.

Little data is available directly comparing the efficacy of different types of progestins; however, a few studies suggest no difference.5,6 It is likely that typical use failure rates are higher in POP users due to the strict dosing timeframe, including recommendations to take the pill within a 3-hour window.

EE and progestin each work separately, as well as synergistically, to provide contraceptive benefit. EE mainly works by suppressing the release of follicle-stimulating hormone (FSH) from the pituitary, which hinders folliculogenesis. 

It is also suggested that EE causes endometrial edema, which affects implantation. EE has an added benefit of stabilizing the endometrium, which reduces spotting—a favorable effect. As EE potentiates the effects of progestin, smaller doses of progestin may be used in COCs.

Progestin works in three major ways: 1) it suppresses GnRH release from the hypothalamus, decreasing LH and FSH release; 2) it prevents the LH surge from the pituitary, which prevents ovulation; and 3) it thickens cervical mucus, which impedes sperm entry into the uterus. 

There may be some inhibition of peristalsis and tubal mobility as well. Progestin causes endometrial atrophy, which impairs implantation. Each progestin has a different potency and dose for which it blocks ovulation. POPs rely on these multiple mechanisms to prevent pregnancy.

Although oral contraceptives are a great choice for many women, it is important to understand the conditions that may increase risk for the user. We will outline some of the risks below and the CDC Medical Eligibility Criteria chart can be referenced for more information.

It is important to remember that the risks and benefits must be weighed for each woman individually and that in most cases, pregnancy is more dangerous than pill use. 

In patients who have conditions in which pregnancy would increase their risk of adverse health outcomes (Table 1), long-acting reversible contraception (LARC) may be the best choice to avoid unintended pregnancy.10 It is also important to review a patient’s medication history, as there may be drug interactions that reduce efficacy of COCs and POPs.

EE is pro-coagulable and is contraindicated in a number of situations. Progestin also has risks to the user. Providers should screen for personal or family history of venous thromboembolism, as this increases coagulation risk in COC users. 

Additionally, because of hypercoagulability in the postpartum state, COCs should not be used until 6 weeks after childbirth. Women who smoke and are over age 35, women with migraine with aura, or those who have uncontrollable hypertension or vascular disease are at increased risk of stroke and should not use estrogen-containing methods.

There are self-screening tools available to check for COC eligibility, such as the one used in a study by Grossman et al, which showed a sensitivity of 83.2% and specificity of 88.8% in patients using the survey to determine true contraindications to COC use.

 These tools can be helpful to both providers and patients, particularly as we increase use of telemedicine (Table 2).

As with any medical decision, it is exceptionally important to utilize shared decision-making in choosing the right contraceptive method for each patient, which should improve satisfaction, encourage compliance, and reduce unintended pregnancy. 

Shared decision-making involves the patient and provider working together to make a decision through discussion of all options while taking patient preference into account.

Because there are many contraceptive options available, it is important to discuss values (including the acceptability of an unplanned pregnancy if there is a contraceptive failure), beliefs, dosing frequency, financial considerations, and risks and benefits of each method. 

Other considerations include how often women want to have withdrawal bleeding, and desired benefits such as improvement in dysmenorrhea, acne, and mood symptoms. All women should be provided with a multiple-month prescription to improve medication adherence.

As with any method, there are side effects of COCs and POPs that are important to discuss with patients as they decide which method is best for them. Of women who have ever discontinued using COCs or POPs, 34% reported that they were dissatisfied and 64.4% stopped due to side effects.

Some common side effects to discuss with women are breast tenderness, nausea, bloating, and breakthrough bleeding—all of which often improve or completely resolve after the first several months.

 Women may not always discuss their choice to stop taking COCs or POPs, making it essential for clinicians to ask about the experience of past side effects, as well as to provide preventive guidance about the possibility of side effects before starting a new method.

Once a woman and her provider have decided on using COCs, there are multiple options. Patients desiring a withdrawal bleed may prefer a pill pack with monthly placebo pills, while patients desiring fewer menses prefer continuous use without placebo pills and may opt for extended cycle use. 

Additionally, providers may identify other co-existing conditions that may be treated with COCs such as acne, undesired facial hair growth, bloating, and/or headaches. COCs can also help reduce risk of ovarian cysts, fibroids, and benign breast disease.

As mentioned earlier, all COCs have a progestin and EE component and doses differ by pill type. COCs have a range of EE between 10-35 mcg. 

A systematic review showed higher discontinuation rates for COCs with lower doses of EE, due to side effects such as breakthrough bleeding. To reduce estrogenic risks, it is reasonable to start at 20 mcg EE and increase if necessary,15 although for adolescents, data supports using a dose of 30 mcg EE or greater as lower doses of EE have been associated with impaired bone acquisition.

Providers should consider the progestin component of the COC, or which progestin to use on its own in a POP, as this may result in undesired side effects.

Some progestins are noted to have androgen-like effects, with users reporting oily skin, facial hair growth, or acne. Of note, all COCs have been shown to help with acne, but it is reasonable to choose a pill with a less androgen-like progestin and/or higher estrogen content if this is a concern.

First-generation progestins have a lower potency and half-life, which can result in breakthrough bleeding. While second-generation progestins are more potent with a longer half-life, they may have an androgen-like effect. Third-generation progestins maintain a high potency but have lower androgen-like effects. 

Some third-generation formulations are even approved to treat mild to moderate acne. Finally, the only fourth-generation progestin, drospirenone, has both anti-mineralocorticoid and anti-androgenic properties and is newly available in a progestin-only pill.

 It has an improved bleeding profile while matching COCs in efficacy, as well as extending the missed-pill window to 12 hours for ease of use23 (Table 3).

Many of the common side effects of COCs will resolve on their own in the first few months. Thus, in the absence of severe side effects, patients should be encouraged to continue their pills for an initial 3-month interval. If these side effects continue or are particularly bothersome, Table 4 shows some options providers can use to approach them.

In addition to bleeding patterns and progestin options, COCs can be monophasic or multiphasic. We recommend that most providers start with a monophasic preparation for ease of use and ability to extend to continuous use, although some data show that triphasic preparations—specifically those with newer progestins—help reduce acne, irregular bleeding, and menorrhagia.

Non-contraceptive benefits: dysmenorrhea and menorrhagia

In addition to contraception, COCs have non-contraceptive benefits that can be advantageous to patients. One of these benefits is helping to improve menstruation, reduce pain, and improve blood loss. Dysmenorrhea is the most common menstrual symptom complaint, affecting up to 90% of women.

COCs have been shown to reduce dysmenorrhea by 60%, and in those with severe dysmenorrhea even further (90%). This reduces absences for school or work, as well as a patient’s need for pain medication. In women who suffer from dysmenorrhea, it can be especially helpful to be on extended or continuous COC preparations to further decrease pain.

 The desogestrel-only POP has also been shown to help improve dysmenorrhea.

Menorrhagia is less common, yet still problematic, for patients, as it can lead to iron-deficiency anemia. COCs are particularly helpful for normalizing bleeding patterns and decreasing both amount and duration of bleeding. 

However, other forms of contraception, such as hormonal intrauterine devices, can have similar effects—enhancing the need for shared decision-making with a patient when deciding which hormonal method is right for her.

Additional benefits to COCs include the ability to allow a woman to predict her bleeding episodes and skip them if desired. While older generations of POPs often caused abnormal bleeding patterns in patients, new drospirenone-only pills have a more favorable bleeding profile.

COCs can also improve premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). A study looking at both POPs and COCs and their effect on premenstrual mood found that use of either one of these pills did not affect mood in over 71% of women. The remaining women were split as to whether their mood was improved or worsened. 

Having a history of premenstrual mood changes prior to starting a POP or COC was a strong predictor of the ability to improve mood, as was onset of premenstrual mood disturbance at a younger age. However, those with a history of depression prior to pill use were twice as likely than those without a history to have mood deterioration.

Studies have also shown that in women being treated for depression, COCs containing drospirenone can improve mood deterioration in the premenstrual period, as well as reduce both physical and behavioral symptoms of PMDD.

 Another way to reduce PMS and PMDD symptoms is with extended or continuous cycles and reduction of withdrawal bleeding.

Non-contraceptive benefits: Endometriosis

COCs can also be very useful to women who suffer from endometriosis. COCs have been shown to reduce pain associated with endometriosis and continuous cycles are often even more beneficial for pain reduction. 

However, it is important to remember that COCs work by causing endometriotic implants to undergo atrophy and become inactive. Upon discontinuation of COCs, the implants become active again, resulting in return of pain and other symptoms. 

Initiation of COCs after surgery for endometriosis can reduce recurrence rates of endometriomas, as well as the size and growth rates of those that do recur.31 For women who cannot take COCs but suffer from endometriosis, desogestrel-containing POPs have been shown to be equally effective in reducing endometriosis pain.

Oral contraceptive pills are a widely used form of contraception and nearly all providers in all specialties will encounter patients who are taking them. 

While different variations between pills can seem complicated, thereby making it hard to choose a pill, it is important to tailor the decision to each patient’s needs and desires. Sometimes it can take several adjustments to find the best OCP for a particular patient. 

As long as the provider and patient continue to work together through shared decision-making, many women will be able to satisfactorily find a reliable form of contraception while also taking advantage of the many non-contraceptive benefits that pills offer.

is a clinical assistant professor at Michigan Medicine, University of Michigan, Ann Arbor.

is a fourth-year medical student at the University of Michigan Medical School, Ann Arbor.

1. National Center for Health Statistics. National Survey of Family Growth 2015-2017. 

https://www.cdc.gov/nchs/nsfg/nsfg_2015_2017_puf.htm

2. David PS, Boatwright EA, Tozer BS, et al. Hormonal contraception update. 

3. Trussell J. Contraceptive failure in the United States. 

4. Broome M, Fotherby K. Clinical experience with the progestogen-only pill. 

5. Sheth A, Jain U, Sharma S, et al. A randomized, double-blind study of two combined and two progestogen-only oral contraceptives. 

6. Korver T. A double-blind study comparing the contraceptive efficacy, acceptability and safety of two progestogen-only pills containing desogestrel 75 μg/day or levonorgestrel 30 μg/day. 

7. Vessey MP, Lawless M, Yeates D, McPherson K. Progestogen-only oral contraception. Findings in a large prospective study with special reference to effectiveness. 

8. Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices. 

9. Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use. 

https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf

10. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility for Contraceptive Use, 2016. 

11. Grossman D, Fernandez L, Hopkins K, Amastae J, Garcia SG, Potter JE. Accuracy of self-screening for contraindications to combined oral contraceptive use. 

12. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: A model for clinical practice. 

13. Rosenberg MJ, Waugh MS, Meehan TE. Use and misuse of oral contraceptives: Risk indicators for poor pill taking and discontinuation. 

14. Amat L, Bulach A, Leclercq M, et al. Bénéfices non contraceptifs des contraceptions. Additional Non-Contraceptive Effects of Contraception: CNGOF Contraception Guidelines. 

15. Gallo MF, Nanda K, Grimes DA, Lopez LM, Schulz KF. 20 µg versus >20 µg estrogen combined oral contraceptives for contraception. 

16. Golden NH. Bones and Birth Control in Adolescent Girls. 

17. Scholes D, Ichikawa L, LaCroix AZ, et al. Oral contraceptive use and bone density in adolescent and young adult women. 

18. Lawrie TA, Helmerhorst FM, Maitra NK, Kulier R, Bloemenkamp K, Gülmezoglu AM. Types of progestogens in combined oral contraception: effectiveness and side-effects. 

. 2011;11(5):CD004861.19. Raney EC, Scott SC, Cauthon KAB. Individualizing selection of hormonal contraception. 

20. Sitruk-Ware R. Pharmacology of different progestogens: The special case of drospirenone. In 

21. Thorneycroft IH. Update on androgenicity. 

22. Stanczyk FZ. All progestins are not created equal. 

23. Palacios S, Regidor PA, Colli E, et al. Oestrogen-free oral contraception with a 4 micrograms drospirenone-only pill: new data and a review of the literature. 

 2020;Apr 21;1-7. https://doi.org/10.1080/13625187.2020.1743828. Online ahead of print.

24. Barr NG. Managing adverse effects of hormonal contraceptives. 

25. Cedars MI. Triphasic oral contraceptives: Review and comparison of various regimens. 

26. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. 

27. Ahrendt HJ, Karckt U, Pichl T, Mueller T, Ernst U. The effects of an oestrogen-free, desogestrel-containing oral contraceptive in women with cyclical symptoms: Results from two studies on oestrogen-related symptoms and dysmenorrhoea. 

28. Lethaby A, Wise MR, Weterings MAJ, Rodriguez MB, Brown J. Combined hormonal contraceptives for heavy menstrual bleeding. In 

29. Joffe H, Cohen LS, Harlow BL. Impact of oral contraceptive pill use on premenstrual mood: Predictors of improvement and deterioration. 

30. Yonkers KA, Brown C, Pearlstein TB, Foegh M, Sampson-Landers C, Rapkin A. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. 

31. Zorbas KA, Economopoulos KP, Vlahos NF. Continuous versus cyclic oral contraceptives for the treatment of endometriosis: a systematic review. In 

Articles

Oral contraceptive pills are a popular choice for many; providers should understand the options to guide patients effectively.

Choosing the right pill

A 16-year-old girl presents to your office complaining of heavy menstrual cycles since menarche. Her cycles last 15 days on average and she changes her pads every hour on the heaviest days. She often passes large clots and misses at least 1 day of school per cycle. Should you be concerned?

	Studies have shown that 1 in 5 women who consult their doctor for heavy or prolonged bleeding during their periods actually have an underlying bleeding disorder.

 The proportion is postulated to be even higher for adolescents.

 A study that looks at all admissions to a children’s hospital over a 9-year time period for acute menorrhagia in adolescence found a primary coagulation disorder in almost 20% of 59 adolescent patients and in 50% of those who presented at menarche. In this study, 25% of the adolescents had a hemoglobin of less than 10 g/100ml on admission, and one-third required a transfusion.

	Bleeding disorders can have major downstream health consequences, including iron deficiency anemia, the need for blood transfusions, increased bleeding during and after surgeries, postpartum bleeding, poor wound healing, and an increased risk of hysterectomy. A survey from the Centers for Disease Control and Prevention (CDC) reported that women with bleeding disorders are also more likely to have 1 or more of several other gynecologic conditions, including hemorrhagic ovarian cysts, endometriosis, polyps, and fibroids.

Recommended: von Willebrand, an underdiagnosed disorder

	Early recognition of a bleeding disorder can have a major impact on a patient’s quality of life. Because ob/gyns are often the first to evaluate menstrual bleeding concerns it is extremely important that they have a comprehensive understanding of appropriate screening measures and treatment options for patients with suspected bleeding disorders.

	In a 2002 CDC survey of 376 ob/gyns across the United States, only 4% of respondents claimed that they would consider von Willebrand disease (vWD) as the cause of heavy menstrual bleeding (HMB) in a woman of reproductive age, and only 6% of respondents would consider it in a girl near menarche.

 The responses substantially improved in a similar survey conducted in 2012, when 39% reported that they would consider a bleeding disorder as causing HMB in women of reproductive age and 77% would consider this an option in adolescents.

	vWD is the most common inherited bleeding disorder, with an overall prevalence of 0.6% to 1.3%.

 It has an autosomal-dominant inheritance pattern and is caused by a missing or defective von Willebrand factor (vWF), a clotting protein. vWF binds to both factor VIII, a key clotting protein, and to platelets, to form a platelet plug during the clotting process. There are 3 types of vWD, which vary in severity. Type 1 is the most common (60% to 80% of cases) and is relatively mild. The disease is diagnosed more often in females because of the presentation of HMB - according to a systematic review of 11 studies involving 988 women, the prevalence of vWD in women presenting with HMB was reported to be as high as 13% to 24%.

 Research has suggested that as many as 9 of 10 individuals with vWD remain undiagnosed.

 (For a full discussion of vWD, see the May 2017 issue of 

	Platelet dysfunction leads to impaired clot formation and includes disorders of platelet adhesion, aggregation, secretion, or procoagulant activity. Acquired platelet dysfunction is common with use of certain medications, such as aspirin. Data on the prevalence of platelet dysfunction in women presenting with HMB are very limited, as it is very difficult to diagnose due to the need for highly complex and specialized testing. Some studies, however, have shown a prevalence upwards of 47% in women with HMB and a higher incidence among African- American women than Caucasians.

	Women with coagulation factor deficiencies have low levels of a specific blood protein, such as factors I (fibrinogen), II, V, VII, X, XI, and XIII. A deficiency in any of these factors makes it difficult for a blood clot to form. The exact prevalence of these disorders is unknown, but deficiencies of this type are relatively rare and are estimated to occur in approximately 1 out of 500,000 individuals.

 The most common factor deficiencies involve factors VIII (Hemophilia A) and IX (Hemophilia B).

	Hemophiliac disorders represent the most common severe inherited bleeding conditions. Hemophilia largely affects males, as it is an X linked genetic condition. Females are carriers, but may also exhibit mild to severe bleeding symptoms as carriers. Hemophilia A (a deficiency in clotting factor VIII) affects approximately 1 in 10,000 individuals, and Hemophilia B (a deficiency in clotting factor IX) affects approximately one in 50,000. An estimated 10% to 57% of women with HMB are hemophilia carriers.

NEXT: Screening for and diagnosing bleeding disorders

	Screening for and diagnosing bleeding disorders

	As previously noted, gynecologists are often tasked with screening for bleeding disorders due to the complaint of HMB. According to the American College of Obstetricians and Gynecologists (ACOG), an adolescent who reports even 1 of the following should be further evaluated for a bleeding disorder: menses greater than 7 days with a flooding/gushing sensation or bleeding through a pad/tampon in 2 hours; history of anemia; family history of a bleeding disorder; or history of a bleeding disorder after a monostatic challenge (tooth extraction, surgery, delivery).

	Several qualitative and quantitative methods can be used to screen for HMB to accurately diagnose an underlying bleeding disorder. Although the alkaline hematin test is considered the gold standard for measuring menstrual blood loss (MBL), it is complex and used, primarily, in research settings. The method involves pummeling used feminine hygiene products in a solution and measuring the resulting hematin absorbance against calibration curves. The Pictorial Blood Assessment Chart (PBAC) uses diagrams with light, moderate, and heavily soaked pads and tampons to evaluate how much bleeding a patient is experiencing during her cycle. (Figure 3) A total score of more than 100 per cycle correlates to HMB.

More: Menstrual manipulation for adolescents with disabilities

	A 2014 European study of 165 women demonstrated a more practical method for estimating MBL through use of a calculated questionnaire score that compares to a baseline of healthy women of childbearing age. Like the PBAC, the MBL score calculates a numerical value based on the number of pads or tampons used, which is then used to estimate blood loss.

 The menstrual cup, a device that catches menstrual flow inside the vagina and is used by women as a hygiene product, can also be used as a quick and fairly reliable method of assessing blood loss by describing how full the cup is and how many times it is changed per day. Each cup can hold 30 mL of blood, and it is a product used by many adolescents. Questionnaires may also be used as screening tools to estimate blood loss. (Figure 4)

In both adolescents and adults, once a positive bleeding screen has been confirmed, initial tests to order include a complete blood count (CBC), platelet count, prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen. If bleeding history is strong or anemia is present in the absence of fibroids, specific tests for vWD disease may be ordered, including von Willebrand-ristocetin cofactor activity, vWF antigen, and factor VIII (often ordered as a von Willebrand panel).

 It should be noted that no single test alone can reliably diagnose vWD. A hematologist usually interprets test results in conjunction with a gynecologist. Iron studies can also be considered with heavy bleeding, even in the absence of anemia.

	Some of the hematological test results may be affected by several variables, including stress, systemic inflammation, anemia, pregnancy, oral contraceptives (OC), time of the menstrual cycle, sample processing, and quality of the laboratory. Ideally, any vWD tests should be performed before starting hormonal management and, because of potential confounders repeat testing may be necessary to establish a definitive diagnosis. Because of these and other factors, the mean time to diagnose a bleeding disorder is on the order of 9 years.

	Treatment of acute bleeding can certainly overlap in patients with and without bleeding disorders. Figure 5 lists common medications used, both hormonal and non-hormonal, as well as surgeries available for management of acute bleeding.

More: Is the prevalence of endometriosis on the rise?

	In women with vWD, the recommendation for first-line treatment of acute abnormal uterine bleeding is desmopressin (DDAVP) and tranexamic acid (TA) together for 2 to 3 days, followed by TA alone for 3 to 4 days.

 DDAVP is a synthetic derivative of the antidiuretic hormone vasopressin and works by stimulating the release of vWF from endothelial cells. It can be given intravenously, subcutaneously, intranasally or orally. Antifibrinolytics such as TA inhibit conversion of plasminogen to plasmin, which then inhibits fibrinolysis and helps to stabilize clots. TA was approved for oral treatment of HMB by the US Food and Drug Administration (FDA) in 2009. Of note, there are theoretical risks of increased VTE if taking TA while on hormonal contraception.

	Exogenous coagulation factors in the form of vWF concentrate or a factor VIII–vWF concentrate (HUMATE P) can also be infused to normalize vWF and factor VIII levels in the blood.

	Treatment for acute abnormal uterine bleeding in patients with a platelet function disorder should include platelet transfusion as first-line therapy. These patients should also avoid nonsteroidal anti-inflammatory drugs and other drugs that affect platelet aggregation.

 In the setting of factor deficiencies, factors that are missing or diminished should first be infused and consideration given to use of fibrinogen as an adjunct option. For hemophilia A carriers, DDAVP can be used. Infusions of clotting factor concentrates may also be necessary for both hemophilia A and B. Lastly, TA can be useful for treatment of acute bleeding with platelet dysfunction (Figure 6)

	Maintenance therapy for women with bleeding disorders includes evaluation of several factors, such as patient compliance, preference, cost, results of prior therapy (if applicable), insurance coverage, current medication use, and existence of any preexisting medical conditions. Both hormonal and non-hormonal options are available and are often used together. A 2010 study looked at the Mirena IUD for management of heavy menstrual bleeding in women with inherited bleeding disorders and found significant benefit in its use as a long-term treatment.

 Initiating or adding TA to a hormonal treatment regimen has also been shown to reduce HMB by 34% to 65% in patients with bleeding disorders.

 If using a combined hormonal treatment, such as OCs, the patch, or the ring, continuous or extended use is recommended to reduce menstrual bleeding.

In obstetrics, women with bleeding disorders may actually benefit from the hypercoagulable state of pregnancy, which increases concentrations of several coagulation factors and fibrinogen. Nevertheless, women with bleeding disorders remain at increased risk of multiple complications as they often do not achieve the same level of clotting factors as others.

	With respect to preconception counseling women suspected of having a bleeding disorder, or of being carriers, should undergo diagnostic testing prior to pregnancy to optimize pregnancy management. If a woman is a carrier of a certain disorder, pre-implantation genetic testing can be considered and in vitro fertilization may be used to implant only those embryos without the disorder. Another aspect of preconception care includes immunization against hepatitis A and B for those likely to require a blood transfusion.

Next: Lessons of severe maternal morbidity

	Regarding early pregnancy, there are several case reports and series documenting an increased risk of miscarriage and placental abruption in women with certain bleeding disorders, such as a Factor XIII or fibrinogen deficiency,

 and during labor there is an increased risk of spinal/epidural hematomas. A fetus can also potentially be at a substantial risk of bleeding complications during birth. Invasive intrapartum monitoring techniques (eg, fetal scalp electrode) should be avoided in pregnancies with a potentially affected fetus as intracranial hemorrhage may occur.

	Most experts agree that women with bleeding disorders can have a safe vaginal delivery and that a cesarean delivery should be reserved for standard reasons. A recent study on babies with hemophilia found no difference in the rate of fetal intracranial hemorrhage based on mode of delivery.

 Vacuum and forceps deliveries, however, should be avoided due to the higher risk of intracranial hemorrhage.

	Women with bleeding disorders are at increased risk of both antepartum and postpartum hemorrhage. Risk of postpartum hemorrhage in women with vWD is 50% higher than in those without a bleeding disorder.

 Because women with bleeding disorders are known to present with delayed hemorrhage once estrogen levels decrease in the postpartum period, some physicians will offer prophylactic therapy to cover the immediate postpartum period. DDAVP, for example, can be used to raise vWF levels for this purpose.

	Bleeding disorders are both prevalent and serious enough in obstetrical and gynecologic practice that the generalist ob/gyn should be fully aware of their existence, potential downstream consequences, and treatment options. These disorders can significantly impact quality of life, but unfortunately, many women remain undiagnosed and untreated due to a lack of familiarity on the part of both patients and the health care professionals they rely on. Ob/gyns should heighten their understanding and appreciation of the importance and implications of bleeding disorders to consistently deliver the best care possible for their patients.

	1. Davies J, Rezan AK. Heavy menstrual bleeding: An update on management. 

	2. James AH. Women and bleeding disorders. 

	3. Claessens EA, Cowell CA. Acute adolescent menorrhagia. 

	4. Kirtava A, Drews C, Lally C, Dilley A, Evatt B. Medical, reproductive and psychosocial experiences of women diagnosed with von Willebrand’s Disease receiving care in haemophilia treatment centres: A case–control study. 

	5. Dilley A, Drews C, Lally C, Austin H, Barnhart E, Evatt B. A survey of gynecologists concerning menorrhagia: Perceptions of bleeding disorders as a possible cause. 

	6. Byams VR, Anderson BL, Grant AM, Atrash H, Schulkin J. Evaluation of bleeding disorders in women with menorrhagia: A survey of obstetrician-gynecologists. 

	7. Leebeek FWG, Eikenboom JCJ. Von Willebrand’s Disease. 

	8. Shankar M, Lee CA, Sabin CA, Economides DL, Kadir RA. Von Willebrand Disease in women with menorrhagia: A systematic review. 

	9. An Introduction to von Willebrand Disease. Canadian Hemophilia Society. 

http://www.hemophilia.ca/en/bleeding-disorders/vonwillebrand-disease/an-introduction-to-vonwillebrand-disease/

	10. Philipp CS, Dilley A, Miller CH, Evatt B, Baranwal A, Schwartz R, et al. Platelet functional defects in women with unexplained menorrhagia. 

	11. Kulkarni R. Improving care and treatment options for women and girls with bleeding disorders. 

	12. Committee on Adolescent Health Care, Committee on Gynecologic Practice. Von Willebrand Disease in Women. Committee Opinion No. 580. 

	13. Zakherah MS, Sayed GH, El-Nashar SA, Shaaban MM. Pictorial blood loss assessment chart in the evaluation of heavy menstrual bleeding: diagnostic accuracy compared to alkaline hematin. 

	14. Toxqui L, Pérez-Granados AM, Blanco-Rojo R, Wright I, Vaquero MP. A simple and feasible questionnaire to estimate menstrual blood loss: Relationship with hematological and gynecological parameters in young women. 

	15. Ahuja SP, Hertweck SP. Overview of bleeding disorders in adolescent females with menorrhagia. 

	16. James AH, Kouides PA, Abdul-Kadir R, Dietrich JE, Edlund M, Federici AB, et al. Evaluation and management of acute menorrhagia in women with and without underlying bleeding disorders: Consensus from an international expert panel. 

	17. American College of Obstetricians and Gynecologists. Management of acute abnormal uterine bleeding in nonpregnant reproductive- aged women. Committee Opinion No. 557. 

	18. Chi C, Huq FY, Kadir RA. Levonorgestrel-releasing intrauterine system for the management of heavy menstrual bleeding in women with inherited bleeding disorders: Long-term follow-up. 

	19. Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. 

	20. James AH, Jamison MG. Bleeding events and other complications during pregnancy and childbirth in women with von Willebrand Disease. 

	21. Kulkarni R, Presley RJ, Lusher JM, Shapiro AD, Gill JC, Manco-Johnson M, et al. Complications of haemophilia in babies (first two years of life): A report from the Centers for Disease Control and Prevention Universal Data Collection System. 

	22. James AH. Obstetric management of adolescents with bleeding disorders. 

Studies have shown that 1 in 5 women who consult their doctor for heavy or prolonged bleeding during their periods actually have an underlying bleeding disorder.

Monica Rosen, MD

Articles

Choosing the right pill

Bleeding disorders: When to worry, how to help