Menorrhagia associated with laboratory abnormalities of hemostasis: epidemiological, diagnostic and therapeutic aspects

Abstract

Summary. Historically, the pathogenesis of menorrhagia has focused on anatomic and hormonal etiologies. However, in the past decade, numerous epidemiological studies have confirmed an association of von Willebrand factor (VWF) deficiency and menorrhagia with an incidence of VWF deficiency of 13% (95% CI, 11%, 16%). Such patients have a reduced quality of life and incur a high rate of seemingly unnecessary gynecological interventions. In addition, it appears that platelet function abnormalities are c. 3-to 4-fold more common than VWF deficiency in association with menorrhagia. The management of menorrhagia with an underlying disorder of hemostasis involves consideration of the patientÕs age, childbearing status and preference in terms of several options: hemostatic (oral tranexamic acid, intranasal desmopressin), hormonal (oral contraceptive, levonorgestrel intrauterine system) and surgical (endometrial ablation, hysterectomy). Pending ongoing comparative trials in bleeding disorder-related menorrhagia of intranasal desmopressin (DDAVP), tranexamic acid and further study of the levonorgestrel intrauterine device, specific recommendations cannot be made at present regarding whether one intervention is superior to the other. It should also be noted that the dose and schedule and combination of intranasal DDAVP and tranexamic acid have not been well established and warrant further study. It is imperative to establish algorithms of effective menorrhagia interventions in order to justify widespread hemostasis screening of the menorrhagia patient.

Women with bleeding disorders: Clinical and psychological issues

“…12 Haematologists and clinicians caring for women with BD should remain vigilant to this problem and ensure that they ask appropriate questions. 12 Haematologists and clinicians caring for women with BD should remain vigilant to this problem and ensure that they ask appropriate questions.…”

Diagnosis and management of haemophilia

“…Oral contraceptives and antifibrinolytics (such as tranexamic acid) are effective in reducing blood loss in women with menorrhagia. 22 Haemostasis should be optimised before any invasive procedure, as it is for patients with mild haemophilia.…”

Management of menorrhagia in women with inherited bleeding disorders: general principles and use of desmopressin

“…We have to balance the pros and cons of labelling an otherwise healthy subject with an inherited haemostatic disorder with the expected benefits reasonably related to more specific treatments or prevention of future bleeding in case of haemostatic challenges like parturition, toot extraction, or surgery. So far, given the lack of definitive outcome data, there is insufficient evidence to support the suggestion for routine haemostatic investigation in women presenting with apparently isolated menorrhagia [34][35][36]. Furthermore, available diagnostic tools are not sufficiently efficient.…”