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Approximately 5% of women who seek medical assistance for menorrhagia from their primary care physicians or gynecologists never make their way to a hematologist, even though many of these women have such underlying hemostatic abnormalities as decreased von Willebrand factor (VWF), platelet dysfunction, and decreased coagulation factors. These women in turn are in danger of experiencing bleeding complications during surgery, childbirth, or other invasive procedures.
Approximately 5% of women who seek medical assistance for menorrhagia from their primary care physicians or gynecologists never make their way to a hematologist, even though many of these women have such underlying hemostatic abnormalities as decreased von Willebrand factor (VWF), platelet dysfunction, and decreased coagulation factors. These women in turn are in danger of experiencing bleeding complications during surgery, childbirth, or other invasive procedures. To help alleviate this situation and increase recognition and diagnosis of underlying bleeding disorders, Dr Claire S. Philipp, associate director of the division of hematology at UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey, and colleagues developed and tested a brief screening tool that could be used in clinical settings.
The screening tool consists of eight questions that cover four basic issues: severity of menorrhagia, family history of a diagnosed bleeding disorder, personal history of excessive bleeding after specific challenges, and history of treatment for anemia. Based on the answers to these questions, gynecologists can determine which patients might benefit from a referral for a comprehensive hemostatic evaluation.
A total of 217 women with a diagnosis of menorrhagia were included in the study; women were recruited across 6 US medical centers. The women were aged 18 to 50 years (average age = 36.83 ± 7.1). Women were asked to complete pictorial blood assessment charts; visual self-assessment and scoring of sanitary pad and tampon saturation were used to determine blood loss. In addition, the women underwent laboratory tests to check for low VWF, platelet function defects, and coagulation factor deficiencies. Blood cell counts and serum ferritin tests were also performed.
Results from the laboratory studies indicated that 71% of the women had at least one hemostatic abnormality (Figure). A greater portion of black women as compared to white women had hemostatic abnormalities (91% versus 66% of patients, respectively).
Figure. Percent of patients with hemostatic abnormality upon lab testing.
Overall, the screening tool performed well. The researchers found that the test had 89% sensitivity for hemostatic abnormalities, which resulted in the positive predictive value of 72%. Additionally, the negative predictive value was 37%; the tool had a specificity of 16%. When high pictorial blood loss assessment chart scores (> 185) and low serum ferritin levels (≤ 20 ng/ml) were combined with the screening tool, sensitivity for hemostatic defects was increased to 95% and 93%, respectively. Ultimately, if this tool was being used in a clinical setting, the authors noted that 89% of the women with a hemostatic abnormality would have been stratified correctly for further evaluation.
“In addition to preventing the bleeding complications of surgery and childbirth with appropriate hemostatic management, being able to make the diagnosis of a bleeding disorder, such as a platelet function disorder or von Willebrand disease, affords the physician the opportunity to provide effective hemostatic management of menorrhagia,” noted Philipp and colleagues. “Incorporation of a screening tool for bleeding disorders provides a useful, standardized method for the stratification of women with otherwise unexplained menorrhagia whose condition is evaluated by gynecologists.”
Bleeding and Clotting Disorders in Women
Philipp CS, Faiz A, Heit JA, et al. Evaluation of a screening tool for bleeding disorders in a US multisite cohort of women with menorrhagia