1
|
Beyer-Westendorf J, Marten S. Reproductive issues in women on direct oral anticoagulants. Res Pract Thromb Haemost 2021; 5:e12512. [PMID: 33977211 PMCID: PMC8105156 DOI: 10.1002/rth2.12512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/17/2021] [Accepted: 02/26/2021] [Indexed: 12/14/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are replacing warfarin and other vitamin K antagonists for a wide range of indications. Advantages of DOAC therapy are fewer food and drug interactions and fixed dosing without routine laboratory monitoring, making DOACs the perfect choice especially for younger patients, in whom the main indication for anticoagulation is prevention and treatment of venous thromboembolism (VTE). Although DOACs are safer and much more convenient than other anticoagulant alternatives, their profile may have drawbacks, especially for younger female patients in whom reproductive issues need special considerations. These may include the issue of heavy menstrual bleeding (HMB) during anticoagulant therapy, the embryotoxicity risk from inadvertent DOAC exposure during pregnancy, and the prevention or planning of pregnancies during DOAC therapy. This review summarizes the most relevant evidence in this increasingly important field of women's health.
Collapse
Affiliation(s)
- Jan Beyer-Westendorf
- Thrombosis Research Unit Department of Medicine I Division Haematology University Hospital "Carl Gustav Carus" Dresden Dresden Germany
| | - Sandra Marten
- Thrombosis Research Unit Department of Medicine I Division Haematology University Hospital "Carl Gustav Carus" Dresden Dresden Germany
| |
Collapse
|
2
|
Takamura M, Koga K, Harada M, Hirota Y, Fujii T, Osuga Y. A case of hemorrhagic shock occurred during dienogest therapy for uterine adenomyosis. J Obstet Gynaecol Res 2020; 46:2696-2700. [PMID: 33090620 DOI: 10.1111/jog.14519] [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: 04/02/2020] [Revised: 09/06/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022]
Abstract
We present a case of hemorrhagic shock occurred during dienogest therapy for uterine adenomyosis which necessitated an emergency hysterectomy. The patient was a 45-year-old woman with adenomyosis. Magnetic resonance imaging showed type I adenomyosis measuring 10 cm. She had a history of intimal thrombectomy of pulmonary embolism and had been receiving warfarin and aspirin until the onset of the hemorrhagic shock. Following 6-month of gonadotropin-releasing hormone analogue, dienogest was commenced. Nine months after switching to dienogest, the patient experienced a persistent abnormal uterine bleeding for 2 weeks, eventually causing a massive bleeding and was transferred to our emergency room. A diagnosis of hemorrhagic shock with a severe anemia (hemoglobin 3.6 g/dL) was made. Despite blood transfusion and warfarin antagonization, continuous bleeding ≥150 g/h was not controlled. Emergent hysterectomy was opted and enabled hemostasis. Although the number of patients with adenomyosis who can avoid surgery by dienogest is increasing, care must be taken during dienogest therapy, especially in patients with anticoagulants and after gonadotropin-releasing hormone analogue treatment. To prevent such a critical event, careful management including patient education should be carried out.
Collapse
Affiliation(s)
- Masashi Takamura
- Department of Obstetrics and Gynecology, Saitama Medical University, Saitama, Japan
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Miyuki Harada
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Yasushi Hirota
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
3
|
Beyer-Westendorf J. DOACS in women: pros and cons. Thromb Res 2020; 181 Suppl 1:S19-S22. [PMID: 31477222 DOI: 10.1016/s0049-3848(19)30361-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/25/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
Abstract
The recent approval of direct-acting oral anticoagulants (DOAC) for long-term anticoagulation in atrial fibrillation and venous thromboembolism resulted in a rapid implementation of these new drugs into daily care. Although DOAC dosing is similar for women and men and, overall, results in comparable outcomes, sex specific issues need to be considered. This review will discuss DOAC topics specifically related to women's health, including the risks and benefits of DOAC treatment for women, the issue of abnormal uterine bleeding from DOAC and the risk and management of DOAC exposure in pregnancy.
Collapse
Affiliation(s)
- Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital "Carl Gustav Carus" Dresden, Fetscherstrasse 74, D-01307 Dresden, Germany; Kings Thrombosis Service, Department of Hematology, Kings College London, UK.
| |
Collapse
|
4
|
Abstract
Management of heavy menstrual bleeding (HMB) in a woman with a history of thrombosis, or who is otherwise at high risk of thrombosis, or who takes medications for anticoagulation can present a challenge to health care providers. The goal of treating HMB is to reduce menstrual blood loss. First-line therapy is typically hormonal, and hormonal therapy can be contraindicated in women with a history of thrombosis unless they are on anticoagulation. As 70% of women on anticoagulation experience HMB, successful management of HMB may involve a modification in the anticoagulation or antiplatelet regimen, hormonal therapy tailored to the patient's situation, and/or surgical therapy.
Collapse
|
5
|
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]
|
6
|
How I treat heavy menstrual bleeding associated with anticoagulants. Blood 2017; 130:2603-2609. [PMID: 29092828 DOI: 10.1182/blood-2017-07-797423] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/24/2017] [Indexed: 12/28/2022] Open
Abstract
Anticoagulant-associated heavy menstrual bleeding (HMB) is an underrecognized but not uncommon problem in clinical practice. Premenopausal women should be advised of the potential effect of anticoagulant therapy on menstrual bleeding at the time of treatment initiation. Consequences of HMB should be assessed and treated on an ongoing basis. In the acute setting, the decision to withhold anticoagulants is based on an individual patient's risk of thrombosis and the severity of the bleeding. For women who require long-term anticoagulation, a levonorgestrel intrauterine system, tranexamic acid (during menstrual flow), high-dose progestin-only therapy, or combined hormonal contraceptives are effective for controlling HMB. The risk of thrombosis during anticoagulant therapy with these treatments is not well studied but is likely to be low. Selection of type of hormonal therapy is based on patient preference, other indications for and contraindications to therapy, adverse effect profile, and ongoing thrombotic risk factors. Women who do not respond to medical treatment or who do not wish to retain their fertility should be considered for surgical management.
Collapse
|
7
|
Beyer-Westendorf J, Michalski F, Tittl L, Hauswald-Dörschel S, Marten S. Management and outcomes of vaginal bleeding and heavy menstrual bleeding in women of reproductive age on direct oral anti-factor Xa inhibitor therapy: a case series. LANCET HAEMATOLOGY 2017; 3:e480-e488. [PMID: 27692306 DOI: 10.1016/s2352-3026(16)30111-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 07/28/2016] [Accepted: 08/02/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Observational data and results from post-hoc analyses in clinical trials suggest that direct oral factor Xa inhibitors might increase menstrual bleeding intensity in women of reproductive age, but the extent of this effect is unknown. We aimed to investigate the management and outcomes of vaginal bleeding complications during therapy with direct oral factor Xa inhibitors in a case series of women of reproductive age. METHODS To identify individuals for inclusion in this case series, we searched two sources of prospectively collected data from women of reproductive age treated with direct oral factor Xa inhibitors: the non-interventional Dresden NOAC Registry (NCT01588119), which is based in the administrative district of Dresden (Saxony, Germany), and all locally archived data from phase 3 trials of direct oral factor Xa inhibitors done at University Hospital Carl Gustav Carus Dresden. Vaginal bleeding events were defined as any vaginal bleeding complications as reported by the patient. We collected data on type and dosage of anticoagulation; suspected or confirmed bleeding events, hospital admissions, and mortality; and pattern and management of vaginal bleeding events. For all cases of bleeding identified, we reviewed all available source data to identify examination results suggesting potential underlying anatomical causes of bleeding. FINDINGS We identified 178 women of reproductive age who received direct oral factor Xa inhibitor therapy, of whom 57 had vaginal bleeding events, including 50 who received rivaroxaban, six who received apixaban, and one who received edoxaban. These 57 women had 72 vaginal bleeding events, including 59 cases of heavy menstrual bleeding and 13 bleeding events unrelated to the menstrual cycle. 51 (86%) of these heavy menstrual bleeding events (two major bleeding events, 17 clinically relevant non-major bleeding events, 32 minor bleeding events) were treated conservatively (eg, change of oral hormone therapy or reduction, temporary interruption, or discontinuation of direct oral factor Xa inhibitor) and the remaining eight (14%) events (three major bleeding events and five clinically relevant non-major bleeding events) required elective surgical or interventional treatment (hysterectomy, curettage, ovary excision, or excision of ovarian cysts). Of the 57 women, 13 (23%) had a second bleeding event and two (4%) had a third event. Nine patients had underlying anatomical abnormalities; compared with patients without abnormalities, these patients had more intense bleeding, more had recurrent bleeding (five [56%] of nine patients with abnormalities vs eight [17%] of 48 patients without abnormalities), and more needed surgical treatment for bleeding (eight [89%] of nine vs zero of 48). INTERPRETATION Vaginal bleeding, particularly heavy menstrual bleeding, is a common complication in women of reproductive age on direct oral factor Xa inhibitor therapy. Most cases can be treated conservatively, but patients with severe or recurrent vaginal bleeding complications should be assessed for underlying anatomical abnormalities, which might require surgical or interventional treatment. Further data are needed to provide guidance on prevention and treatment of vaginal bleeding complications in this patient population. FUNDING None.
Collapse
Affiliation(s)
- Jan Beyer-Westendorf
- Center for Vascular Medicine and Department of Medicine III, Division of Angiology, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Dresden, Germany; Thrombosis and Haemostasis, King's College London, London, UK.
| | - Franziska Michalski
- Center for Vascular Medicine and Department of Medicine III, Division of Angiology, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Dresden, Germany
| | - Luise Tittl
- Center for Vascular Medicine and Department of Medicine III, Division of Angiology, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Dresden, Germany
| | - Susann Hauswald-Dörschel
- Center for Vascular Medicine and Department of Medicine III, Division of Angiology, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Dresden, Germany
| | - Sandra Marten
- Center for Vascular Medicine and Department of Medicine III, Division of Angiology, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Dresden, Germany
| |
Collapse
|
8
|
Klok FA, Schreiber K, Stach K, Ageno W, Middeldorp S, Eichinger S, Delluc A, Blondon M, Ay C. Oral contraception and menstrual bleeding during treatment of venous thromboembolism: Expert opinion versus current practice: Combined results of a systematic review, expert panel opinion and an international survey. Thromb Res 2017; 153:101-107. [PMID: 28376343 DOI: 10.1016/j.thromres.2017.03.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/10/2017] [Accepted: 03/11/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The optimal management of oral contraception and menstrual bleeding during treatment of venous thromboembolism (VTE) is largely unknown. We aimed to elicit expert opinion and compare that to current practice as assessed by a world-wide international web-based survey among physicians. METHODS 10 international thrombosis experts and 10 abnormal uterine bleeding experts independently completed a questionnaire containing three hypothetical patient cases each with four different scenarios, and additional queries covering different severities of VTE, patient circumstances, hormonal contraceptives and both thrombotic and bleeding complications. The consensus percentage was set a priori at ≥70%. The same questionnaire with randomized case scenarios was presented to international physicians via newsletters of the ISTH and national scientific communities. Differences between the expert groups and daily clinical care were assessed. RESULTS Expert recommendations were divergent and differed in several important points from clinical practice. In contrast to common practice in which contraceptives are discontinued at the moment of a VTE diagnosis, the thrombosis experts agreed to continue oral contraception (OC) during the anticoagulation treatment period. Also, experts reached consensus on treating patients with anticoagulation-associated abnormal uterine bleeding with tranexamic acid, although this is not supported by strong evidence from the literature. No consensus was reached on the optimal anticoagulant drug class. CONCLUSIONS International experts' opinions on handling of contraceptives and management of anticoagulant-associated abnormal uterine bleeding in female VTE patients are divergent and management in clinical practice is heterogeneous. There is a great need of further studies on these topics.
Collapse
Affiliation(s)
- F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - K Schreiber
- Thrombosis & Thrombophilia, Guy's & St Thomas' Hospital, London SE1 7EH, United Kingdom; Department of Rheumatology, Copenhagen University Hospital at Rigshospitalet, Denmark
| | - K Stach
- 1st Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - W Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - S Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - S Eichinger
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University Hospital, Vienna, Austria
| | - A Delluc
- Départment de Médicine interne et de Pneumologie, Hôpital de la Cavale Blanche, Brest, France
| | - M Blondon
- Department of Angiology and Haemostasis, Geneva University Hospital, Geneva, Switzerland
| | - C Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University Hospital, Vienna, Austria
| |
Collapse
|
9
|
James AH. Heavy menstrual bleeding: work-up and management. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:236-242. [PMID: 27913486 PMCID: PMC6142441 DOI: 10.1182/asheducation-2016.1.236] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Heavy menstrual bleeding (HMB), which is the preferred term for menorrhagia, affects ∼90% of women with an underlying bleeding disorder and ∼70% of women on anticoagulation. HMB can be predicted on the basis of clots of ≥1 inch diameter, low ferritin, and "flooding" (a change of pad or tampon more frequently than hourly). The goal of the work-up is to determine whether there is a uterine/endometrial cause, a disorder of ovulation, or a disorder of coagulation. HMB manifest by flooding and/or prolonged menses, or HMB accompanied by a personal or family history of bleeding is very suggestive of a bleeding disorder and should prompt a referral to a hematologist. The evaluation will include the patient's history, pelvic examination, and/or pelvic imaging, and a laboratory assessment for anemia, ovulatory dysfunction, underlying bleeding disorder, and in the case of the patient on anticoagulation, assessment for over anticoagulation. The goal of treatment is to reduce HMB. Not only will the treatment strategy depend on whether there is ovulatory dysfunction, uterine pathology, or an abnormality of coagulation, the treatment strategy will also depend on the age of the patient and her desire for immediate or long-term fertility. Hemostatic therapy for HMB may serve as an alternative to hormonal or surgical therapy, and may even be life-saving when used to correct an abnormality of coagulation.
Collapse
Affiliation(s)
- Andra H James
- Department of Obstetrics and Gynecology, Duke University, Durham, NC
| |
Collapse
|
10
|
Ray S, Ray A. Non-surgical interventions for treating heavy menstrual bleeding (menorrhagia) in women with bleeding disorders. Cochrane Database Syst Rev 2016; 11:CD010338. [PMID: 27841443 PMCID: PMC6734121 DOI: 10.1002/14651858.cd010338.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Heavy menstrual bleeding without an organic lesion is mainly due to an imbalance of the various hormones which have a regulatory effect on the menstrual cycle. Another cause of heavy menstrual bleeding with no pelvic pathology, is the presence of an acquired or inherited bleeding disorder. The haemostatic system has a central role in controlling the amount and the duration of menstrual bleeding, thus abnormally prolonged or profuse bleeding does occur in most women affected by bleeding disorders. Whereas irregular, pre-menarchal or post-menopausal uterine bleeding is unusual in inherited or acquired haemorrhagic disorders, severe acute bleeding and heavy menstrual bleeding at menarche and chronic heavy menstrual bleeding during the entire reproductive life are common. This is an update of a previously published Cochrane Review. OBJECTIVES To determine the efficacy and safety of non-surgical interventions versus each other, placebo or no treatment for reducing menstrual blood loss in women with bleeding disorders. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Haemoglobinopathies Trials Register (25 August 2016), Embase (May 2013), LILACS (February 2013) and the WHO International Clinical Trial registry (February 2013). SELECTION CRITERIA Randomised controlled studies of non-surgical interventions for treating heavy menstrual bleeding (menorrhagia) in women of reproductive age suffering from a congenital or acquired bleeding disorder. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion, extracted data and assessed the risk of bias. MAIN RESULTS Three cross-over studies, with 175 women were included in the review. All three studies had an unclear risk of bias with regards to trial design and overall, the quality of evidence generated was judged to be poor.Two of the studies (n = 59) compared desmopressin (1-deamino-8-D-arginine vasopressin) with placebo. Menstrual blood loss was the primary outcome for both of these studies. Neither study found clear evidence of a difference between groups. The first of these reported a mean difference in menstrual blood loss in the desmopressin versus placebo group of 21.20 mL (95% confidence interval -19.00 to 61.50)The second study reported that even though there was an improvement of pictorial bleeding assessment chart scores with desmopressin and placebo when compared to pretreatment assessment, there was no clear evidence of difference in these scores when the two were compared to each other (results presented graphically, P = 0.51). The data from these studies could not be combined.The third study (n = 116) compared desmopressin with tranexamic acid (n = 116). This study found a decrease in pictorial bleeding assessment chart scores after both treatments as compared to baseline. The decrease in these scores was greater for tranexamic acid than for desmopressin, with a mean difference of 41.6 mL (95% confidence interval 19.6 to 63) (P < 0.0002).In relation to adverse events, across two studies, there was no clear evidence of a difference when placebo was compared to desmopressin, risk ratio 1.17 (95% confidence interval 0.41 to 3.34) . The same was also true when desmopressin was compared to tranexamic acid, risk ratio 1.17 (95% confidence interval 0.41 to 3.34).Only the study that compared desmopressin to tranexamic acid assessed quality of life. However, we are unable to present any data from this study, since no differences in this outcome between the two intervention groups were reported. AUTHORS' CONCLUSIONS Evidence from randomised controlled studies on the effect of desmopressin when compared to placebo in reducing menstrual blood loss is very limited and inconclusive. Two studies, each with a very limited number of participants, have shown uncertain effects in menstrual blood loss and adverse effects. A non-randomised comparison in one of the studies points to the value of combining desmopressin and tranexamic acid, which needs to be tested in a formal randomised controlled study comparison.When tranexamic acid was compared to desmopressin, a single study showed a reduction in menstrual blood loss with tranexamic acid use compared to desmopressin.There is a need to evaluate non-surgical methods for treating of menorrhagia in women with bleeding disorders through randomised controlled studies. Such methods would be more acceptable than surgery for women wishing to retain their fertility. Given that women may need to use these treatments throughout their entire reproductive life, long-term side-effects should be evaluated.
Collapse
Affiliation(s)
- Sujoy Ray
- St. John's Medical College and HospitalDepartment of PsychiatrySarjapur RoadBangaloreKarnatakaIndia560008
| | - Amita Ray
- DM Wayanad Institute of Medical SciencesDepartment of Obstetrics and GynaecologyNaseera Nagar ,Meppadi (PO)WayanadWayanadKeralaIndia673577
| | | |
Collapse
|
11
|
Thorell SE, Winters U, Lee S, Bright J, Thachil J. Ovarian malignancy revealed by anticoagulation. Br J Hosp Med (Lond) 2015; 76:302-3. [PMID: 25959944 DOI: 10.12968/hmed.2015.76.5.302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sofia E Thorell
- Final Year Medical Student in the School of Medicine, University of Manchester, Manchester
| | | | | | | | | |
Collapse
|
12
|
Ray S, Ray A. Non-surgical interventions for treating heavy menstrual bleeding (menorrhagia) in women with bleeding disorders. Cochrane Database Syst Rev 2014:CD010338. [PMID: 25426776 DOI: 10.1002/14651858.cd010338.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Heavy menstrual bleeding without an organic lesion is mainly due to an imbalance of the various hormones which have a regulatory effect on the menstrual cycle. Another cause of heavy menstrual bleeding with no pelvic pathology, is the presence of an acquired or inherited bleeding disorder. The haemostatic system has a central role in controlling the amount and the duration of menstrual bleeding, thus abnormally prolonged or profuse bleeding does occur in most women affected by bleeding disorders. Whereas irregular, pre-menarchal or post-menopausal uterine bleeding is unusual in inherited or acquired haemorrhagic disorders, severe acute bleeding and heavy menstrual bleeding at menarche and chronic heavy menstrual bleeding during the entire reproductive life are common. OBJECTIVES To determine the efficacy and safety of non-surgical interventions versus each other, placebo or no treatment for reducing menstrual blood loss in women with bleeding disorders. SEARCH METHODS We searched the Cochrane Cystic Fibrosis Haemoglobinopathies Trials Register (13 March 2014), Embase (May 2013), LILACS (February 2013) and the WHO International Clinical Trial registry (February 2013). SELECTION CRITERIA Randomised controlled studies of non-surgical interventions for treating heavy menstrual bleeding (menorrhagia) in women of reproductive age suffering from a congenital or acquired bleeding disorder. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion, extracted data and assessed the risk of bias. MAIN RESULTS Three cross-over studies, with 175 participants were included in the review. All three studies had an unclear risk of bias with regards to trial design and overall, the quality of evidence generated was judged to be poor.Two of the studies (n = 59) compared desmopressin (1-deamino-8-D-arginine vasopressin) with placebo. Menstrual blood loss was the primary outcome for both of these studies. Neither study found clear evidence of a difference between groups. The first of these reported a mean difference in menstrual blood loss in the desmopressin versus placebo group of 21.20 mL (95% confidence interval -19.00 to 61.50)The second study reported that even though there was an improvement of pictorial bleeding assessment chart scores with desmopressin and placebo when compared to pretreatment assessment, there was no clear evidence of difference in these scores when the two were compared to each other (results presented graphically, P = 0.51). The data from these studies could not be combined.The third study (n = 116) compared desmopressin with tranexamic acid (n = 116). This study found a decrease in pictorial bleeding assessment chart scores after both treatments as compared to baseline. The decrease in these scores was greater for tranexamic acid than for desmopressin, with a mean difference of 41.6 mL (95% confidence interval 19.6 to 63) (P < 0.0002).In relation to adverse events, across two studies, there was no clear evidence of a difference when placebo was compared to desmopressin, risk ratio 1.17 (95% confidence interval 0.41 to 3.34) . The same was also true when desmopressin was compared to tranexamic acid, risk ratio 1.17 (95% confidence interval 0.41 to 3.34).Only the study that compared desmopressin to tranexamic acid assessed quality of life. However, we are unable to present any data from this study, since no differences in this outcome between the two intervention groups were reported. AUTHORS' CONCLUSIONS Evidence from randomised controlled studies on the effect of desmopressin when compared to placebo in reducing menstrual blood loss is very limited and inconclusive. Two studies, each with a very limited number of participants, have shown uncertain effects in menstrual blood loss and adverse effects. A non-randomised comparison in one of the studies points to the value of combining desmopressin and tranexamic acid, which needs to be tested in a formal randomised controlled study comparison.When tranexamic acid was compared to desmopressin, a single study showed a reduction in menstrual blood loss with tranexamic acid use compared to desmopressin.There is a need to evaluate non-surgical methods for treating of menorrhagia in women with bleeding disorders through randomised controlled studies. Such methods would be more acceptable than surgery for women wishing to retain their fertility. Given that women may need to use these treatments throughout their entire reproductive life, long-term side-effects should be evaluated.
Collapse
Affiliation(s)
- Sujoy Ray
- Kasturba Medical College, Manipal University, Manipal, Karnataka, India, 576104
| | | |
Collapse
|
13
|
Deligeoroglou E, Karountzos V, Creatsas G. Abnormal uterine bleeding and dysfunctional uterine bleeding in pediatric and adolescent gynecology. Gynecol Endocrinol 2013; 29:74-8. [PMID: 22946701 DOI: 10.3109/09513590.2012.705384] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abnormal uterine bleeding (AUB), which is defined as excessively heavy, prolonged and/or frequent bleeding of uterine origin, is a frequent cause of visits to the Emergency Department and/or health care provider. While there are many etiologies of AUB, the one most likely among otherwise healthy adolescents is dysfunctional uterine bleeding (DUB), which is characterizing any AUB when all possible underlying pathologic causes have been previously excluded. The most common cause of DUB in adolescence is anovulation, which is very frequent in the first 2-3 post-menarchal years and is associated with immaturity of the hypothalamic - pituitary - ovarian axis. Management of AUB is based on the underlying etiology and the severity of the bleeding and primary goals are prevention of complications, such as anemia and reestablishment of regular cyclical bleeding, while the management of DUB can in part be directed by the amount of flow, the degree of associated anemia, as well as patient and family comfort with different treatment modalities. Treatment options for DUB are: combined oral contraceptives (COCs), progestogens, non steroidal anti inflammatory drugs (NSAIDs), tranexamic acid (anti-fibrinolytic), GnRH analogues, Danazol and Levonorgestrel releasing intra uterine system (LNG IUS).
Collapse
Affiliation(s)
- Efthimios Deligeoroglou
- Division of Pediatric, Adolescent Gynecology and Reconstructive Surgery, 2nd Department of Obstetrics and Gynecology, University of Athens, Medical School, Aretaieion Hospital, Athens, Greece.
| | | | | |
Collapse
|
14
|
Peake LJ, Grover SR, Monagle PT, Kennedy AD. Effect of warfarin on menstruation and menstrual management of the adolescent on warfarin. J Paediatr Child Health 2011; 47:893-7. [PMID: 21658146 DOI: 10.1111/j.1440-1754.2011.02101.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM The aim of this study was to review a consecutive cohort of adolescent females on warfarin to determine the effect of warfarin on menstruation, management options and their perceived efficacy. METHODS All female patients on warfarin, over the age of 10 years, as of 31 August 2006, were identified using the Department of Haematology (Royal Children's Hospital) warfarin database. The presence of menorrhagia was defined by clinical indicators. RESULTS Of 81 adolescent females on warfarin, 24 (30%) were referred to gynaecology due to a concern about heavy periods and one for anticipatory guidance, on the basis of impending menarche. In 18 cases (22% of the cohort), menorrhagia could be substantiated on the basis of clinical indicators. Nineteen patients required treatment for menorrhagia with the options for treatment being the combined oral contraceptive pill, subdermal hormone administrations, tranexamic acid and the progesterone-only contraceptive pill. Significant adolescent psychosocial stresses were identified in those adolescents taking warfarin. CONCLUSIONS Adolescent females on warfarin commonly suffer from menorrhagia. Adolescent review of all teenage girls receiving warfarin therapy is indicated.
Collapse
Affiliation(s)
- Lyndal J Peake
- Centre for Adolescent Health, Royal Children's Hospital, Australia
| | | | | | | |
Collapse
|
15
|
Huq FY, Tvarkova K, Arafa A, Kadir RA. Menstrual problems and contraception in women of reproductive age receiving oral anticoagulation. Contraception 2011; 84:128-32. [PMID: 21757053 DOI: 10.1016/j.contraception.2010.12.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 09/15/2010] [Accepted: 12/28/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Oral anticoagulation is associated with increased bleeding complications. The aim of this study was to assess the changes in menstrual loss and pattern in women taking anticoagulant treatment. STUDY DESIGN Women on oral anticoagulant (OA) treatment at the Royal Free Hospital were interviewed and completed a questionnaire about their menstrual cycle before and after commencing oral anticoagulation treatment. They were then asked to complete a pictorial bleeding assessment chart (PBAC) during their next menstrual bleeding episode. RESULTS Fifty-three women between the ages of 20 and 50 years participated in the study. Of these, 47 women completed a PBAC. The mean duration of menstruation increased from 5 days before starting OA therapy to 7 days after the commencement of treatment. Thirty-one (66%) of the 47 women who completed the PBAC had a score that was greater than 100. The number of women who experienced flooding or clots during menstruation and intermenstrual or postcoital bleeding also increased. In total, 29 (54.7%) women changed their method of contraception during OA treatment. Seventeen women who did not want to become pregnant were not using contraception, including 10 women who were on hormonal contraception prior to starting anticoagulant therapy. CONCLUSION Women of reproductive age experience heavy and prolonged menstrual bleeding whilst on OA therapy. Women of reproductive age on OA therapy should be monitored for menstrual disorders to ensure that prompt and appropriate treatment is instituted. Advice about appropriate contraception should also be part of the medical care provided for these women. Barrier contraception, sterilization and progestin-only contraception are all suitable methods of contraception in this patient group.
Collapse
Affiliation(s)
- Farah Yasmine Huq
- Hemophilia Centre, Haemostasis Unit, Royal Free Hospital, London, UK
| | | | | | | |
Collapse
|
16
|
Health-related quality of life and patient satisfaction after global endometrial ablation for menorrhagia in women with bleeding disorders: a follow-up survey and systematic review. Am J Obstet Gynecol 2010; 202:348.e1-7. [PMID: 20060089 DOI: 10.1016/j.ajog.2009.11.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Revised: 08/19/2009] [Accepted: 11/18/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The purpose of this study was to describe health-related quality of life and satisfaction after global endometrial ablation in women with bleeding disorders and a systematic review of the literature. STUDY DESIGN A follow-up survey was mailed to 36 patients with bleeding disorders and 110 reference patients (no coagulopathies) who underwent global endometrial ablation for menorrhagia. The survey included a generic (SF-12) and menorrhagia multi-attribute utility scale questionnaires. RESULTS Ninety-six women (66%) responded. The total menorrhagia multiattribute utility scale score increased from 35-100 in bleeding disorder cohort (P = .03) and from 48-100 in the reference cohort (P < .001). Although postablation SF-12 mental domain scores were comparable in both cohorts (55 vs 55; P = .67), physical domain scores were lower in the bleeding disorder cohort (50 vs 56; P < .001). High satisfaction was reported by both cohorts (95% vs 84%; P = .60). CONCLUSION Global endometrial ablation improved health-related quality of life for women with bleeding disorders and had high satisfaction rates.
Collapse
|
17
|
Vilos GA, Tureanu V, Garcia M, Abu-Rafea B. The levonorgestrel intrauterine system is an effective treatment in women with abnormal uterine bleeding and anticoagulant therapy. J Minim Invasive Gynecol 2009; 16:480-4. [PMID: 19573825 DOI: 10.1016/j.jmig.2009.04.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 04/28/2009] [Accepted: 04/30/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the efficacy of levonorgestrel intrauterine systems (LNG-IUS) in obese women with AUB on anticoagulant therapy. DESIGN Prospective observational case series (Canadian Task Force Classification II-3). SETTING University affiliated teaching hospital. PATIENTS Premenopausal women on Warfarin therapy. INTERVENTIONS From January 2002 through January 2007, 10 women were identified from the senior author's clinical practice (G.A.V.). After clinical assessment, including Papanicolaou smear, endometrial biopsy, and pelvic sonography, the LNG-IUS was placed to treat their AUB. MEASUREMENTS AND MAIN RESULTS The median and range of age, parity, and body mass index were 45 years (34-49), 1 (0-4), and 38 kg/m(2) (26-52), respectively. All women were receiving warfarin therapy (4-12.5 mg/d) for previous venous thromboembolism. Some patients had additional comorbid conditions and were at high risk for traditional medical or surgical therapies. After placement of the LNG-IUS, all women reported menstrual reduction at 3 and 6 months. By 12 months, 1 woman with large fibroids expelled the LNG-IUS and was treated with transfemoral uterine artery embolization. Two women had amenorrhea, and 7 had hypomenorrhea. At 2 to 5 years, 1 woman expelled the LNG-IUS and hysterectomy indicated extensive adenomyosis in a 195-g uterus, and 1 woman had hysteroscopic endometrial ablation, 4 were menopausal, 2 had amenorrhea, and 1 had hypomenorrhea. In the 5 women with uterine fibroids measuring 4.2 to 147 cm(3), the fibroids were reduced in volume by approximately 75% in 2, were no longer detectable in 1, were subsequently shown to be adenomyoma in 1, and required uterine artery embolization in 1. CONCLUSION In properly assessed and selected obese, premenopausal women with AUB receiving warfarin therapy and at high risk for traditional therapies, the LNG-IUS was an effective treatment in 70% of patients.
Collapse
Affiliation(s)
- George A Vilos
- St. Joseph's Health Care, Department of Obstetrics and Gynecology, The University of Western Ontario, London, Ontario, Canada.
| | | | | | | |
Collapse
|
18
|
|
19
|
Abstract
Abnormal uterine bleeding is an extremely common indication for referral to a gynaecologist. This chapter examines the modes of presentation and the causes of such symptoms, which range from physiological variations to more sinister underlying pathology. A thorough understanding of these causes is required to direct investigation in an appropriate manner. The full range of possible investigations is discussed with emphasis on how to choose the most appropriate tests for a particular patient. This is fundamental to ensure that tests are pertinent and streamlined, and to prevent unnecessary anxiety and delay. Once the underlying causes have been clarified, a suitable management plan can be made.
Collapse
|
20
|
|
21
|
Abstract
PURPOSE OF REVIEW The aim of this article is to review the current evidence for optimal management of the adolescent who presents with heavy periods. RECENT FINDINGS A recent survey of clinicians involved in adolescent gynaecology revealed a lack of consistency in the management of acute adolescent heavy menses. Very few randomized trials have been undertaken for acute heavy menses in women of any age, although one recent trial compared the oral contraceptive pill with oral medroxy progesterone acetate in adult women and showed them to be equally effective. The applicability of this trial to adolescents is unclear. Furthermore, although guidelines have been produced for menorrhagia management in adults, there is again only limited clinical research specific to adolescents and thus room for concern that the approaches for adult women may not always be appropriate for teenagers. One small study on the successful use of the levonorgestrel intrauterine system in teenagers does mean that this management option can now be considered. SUMMARY There is a need for careful assessment of the menstrual problem for, although anovulatory bleeds are the most common cause, bleeding disorders also need to be considered. Pelvic pathology is uncommon. Adolescents can also present with acute ongoing heavy bleeding. Whilst a range of approaches is reported, there are no studies to guide optimal management.
Collapse
Affiliation(s)
- Sonia Grover
- Department of Paediatric and Adolescent Gynaecology, Royal Children's Hospital, University of Melbourne, Melbourne, Australia.
| |
Collapse
|
22
|
Kadir RA, Chi C. Levonorgestrel intrauterine system: bleeding disorders and anticoagulant therapy. Contraception 2007; 75:S123-9. [PMID: 17531603 DOI: 10.1016/j.contraception.2007.01.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2006] [Accepted: 01/19/2007] [Indexed: 11/29/2022]
Abstract
Hemostatic disorders in women are frequently associated with long-standing menorrhagia. This leads to significant morbidity and adversely affects quality of life. Management of these women poses a particular challenge; medical treatments may be contraindicated, and surgery carries additional risks. The levonorgestrel intrauterine system (LNG-IUS) has been shown to be highly efficacy in reducing menstrual blood loss in women with normal coagulation. It is also a reliable and reversible contraceptive. Data on the use of this system in women with bleeding disorders or those receiving anticoagulant therapy are limited. Analysis of data from four reported studies suggests that LNG-IUS is a viable and safe option for the management of menorrhagia in these women. Whether the underlying hemostatic disorders lead to a shorter duration of action or prolonged irregular bleeding/spotting post insertion is unknown and requires large prospective studies. Proper counselling remains crucial for patients' satisfaction.
Collapse
Affiliation(s)
- Rezan A Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia Center and Haemostasis Unit, Royal Free Hospital, NW3 2QG London, UK.
| | | |
Collapse
|
23
|
Själander A, Friberg B, Svensson P, Stigendal L, Lethagen S. Menorrhagia and minor bleeding symptoms in women on oral anticoagulation. J Thromb Thrombolysis 2007; 24:39-41. [PMID: 17260163 DOI: 10.1007/s11239-006-0003-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2006] [Accepted: 12/19/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Oral anticoagulation (OA) is a common treatment with a known risk of fatal or major bleeding, but also minor bleeding symptoms and menorrhagia can cause substantial discomfort and necessitate medical or surgical interventions. The extent of these side effects is however not previously reported. The objective of this study is to assess the frequency of minor bleeding symptoms and menorrhagia attributed to OA treatment. METHODS Ninety fertile women between 15 and 49 years-of-age on OA treatment completed an inquiry at the anticoagulation clinics of Malmö, Lund and Gothenburg, Sweden. RESULTS The frequency of minor bleeding symptoms was significantly increased during OA treatment (P < 0.05) except for hematuria. The incidence of bleeding after tooth extraction (>3 h) increased from 3.0 to 45.2%, easy bruising 17.8-75.6%, epistaxis 11.1-23.6%, gingival bleeding 22.2-48.3% and hematuria 10.0-15.6% (Table 1). Hematemesis was reported in 5.6% prior to as compared to 14.4% during OA treatment, blood in the feces in 8.9 and 18.9%, respectively. Mean duration of menses increased from 5.6 to 6.1 days (P < 0.01) and reported menorrhagia from 44.2 to 70.8% (P < 0.001). Eighteen percent were treated for menorrhagia before and 29.9% during OA treatment (P < 0.01). CONCLUSIONS OA treatment is known to confer increased risk of fatal or major bleeding. This study shows that fertile women on OA also experience significantly increased minor bleeding symptoms including menorrhagia that may considerably impair quality of life.
Collapse
Affiliation(s)
- Anders Själander
- Department of Internal Medicine, Sundsvall Hospital, Sundsvall, Sweden
| | | | | | | | | |
Collapse
|
24
|
Abstract
The management of menorrhagia has until recently been the domain of the gynaecologist. As haematologists, we are now addressing the issue of optimal management of menorrhagia in our patients with bleeding disorders. Addressing three life periods, the menarche, reproductive years, and postchildbearing years, this review will discuss the use of oral contraceptive agents, antifibrinolytics, non-steroidal anti-inflammatory drugs, intranasal DDAVP and the new levonorgestrel-impregnated IUD. Management of specific bleeding disorders will also be reviewed for von Willebrand disease, haemophilia A and B carriers, women with factor XI deficiency and PAI-1 deficiency.
Collapse
Affiliation(s)
- J E Siegel
- Cardeza Foundation Hemophilia Treatment Center at Thomas Jefferson University, Philadelphia, PA 19107, USA.
| | | |
Collapse
|
25
|
Munro MG. Abnormal uterine bleeding in the reproductive years. Part I--pathogenesis and clinical investigation. THE JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS 1999; 6:393-416. [PMID: 10548698 DOI: 10.1016/s1074-3804(99)80004-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- M G Munro
- Department of Obstetrics and Gynecology, UCLA School of Medicine, Los Angeles, CA, USA. fax 818 364 3255
| |
Collapse
|
26
|
Geller SE, Harlow SD, Bernstein SJ. Differences in menstrual bleeding characteristics, functional status, and attitudes toward menstruation in three groups of women. JOURNAL OF WOMEN'S HEALTH & GENDER-BASED MEDICINE 1999; 8:533-40. [PMID: 10839708 DOI: 10.1089/jwh.1.1999.8.533] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This report examines differences in bleeding characteristics, functional status, and attitudes toward menstruation among three groups of women: (1) women who complain of abnormal uterine bleeding (AUB), (2) women who have similar menstrual patterns as those complaining of AUB but who do not perceive themselves to have abnormal bleeding, and (3) women without evidence of prolonged or excessive bleeding. Women who complain of AUB and women with heavy bleeding but not complaining of AUB, although similar on two important menstrual symptoms (very heavy bleeding or episodes of unusually heavy bleeding) differ on a number of other menstrual characteristics, including the frequency of short cycles, the probability of having an abnormally long period, and reporting of unusually heavy bleeding lasting longer than 1 day. Whether women reported concerns with menstruation or not, the majority of women in this analysis had fairly negative attitudes toward menstruation. However, this negativity toward menstruation did not translate into women wanting a hysterectomy, even for those with heavy bleeding. The major difference among the three groups of women was the strong negative effect of AUB on functional status. A majority of women complaining of AUB reported that the bleeding interfered significantly with their daily routine, making them unable to function at work and at home. These results suggest that although the main complaint of women with AUB is very heavy bleeding, a number of other specific menstrual characteristics differentiate women with AUB from other women with very heavy bleeding who do not perceive the bleeding to be problematic. The complaint of AUB appears to be related to how significantly bleeding affects daily functioning. Therefore, an important factor to assess when considering treatment of AUB is the extent to which bleeding symptoms significantly affect functional status.
Collapse
Affiliation(s)
- S E Geller
- Department of Obstetrics and Gynecology, College of Medicine, University of Illinois, Chicago 60612-7313, USA
| | | | | |
Collapse
|
27
|
AYHAN A, BILDIRICI I, TUNCER Z, DEMIRCIN M. Complications of Gynecologic Surgery in Patients with Prosthetic Heart Valves. J Gynecol Surg 1999. [DOI: 10.1089/gyn.1999.15.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
28
|
Abstract
The monthly challenge of menstruation as well as the haemostatic challenge of childbirth postpartum renders more females than males symptomatic with von Willebrand disease. Among vWD patients, the obstetrical and gynaecological morbidity is certainly more pronounced in Type 2,3 patients compared to Type 1 patients, but even in the latter group there is a high proportion of menorrhagia with associated anaemia, loss of time from work/school and the use of hysterectomy for ultimate control of bleeding. Despite the well known adage of the "gestational palliation" of vWD, there is a high proportion of postpartum haemorrhage in Type 1 patients also especially after the first 24 h after delivery. This may occur despite normalization of the factor VIIIc level in the third trimester, particularly in Type 2,3 patients. With the increasing availability of intranasal/subcutaneous DDAVP that could be readily administered at home for menorrhagia, there recently has been ongoing efforts internationally to determine the prevalence of vWD in females presenting with menorrhagia with a prevalence of 17% combined from two studies of 180 patients total. Issues remain regarding the optimal dose/schedule of intranasal/subcutaneous DDAVP for menorrhagia and the relative efficacy of antifibrinolytic agents. The proper role of oral contraceptives and danazol also deserves further study in vWD patients with menorrhagia. In sum, a comprehensive care approach in females with vWD is warranted analogous to the successful model of care of male haemophiliacs with the intent to (a) reduce unnecessary surgical interventions for menorrhagia, (b) improve the quality of life during menses and (c) optimize peri-partum management.
Collapse
Affiliation(s)
- P A Kouides
- Mary M. Gooley Hemophilia Center, Inc., Rochester, NY, USA.
| |
Collapse
|
29
|
Clinical policy for the initial approach to patients presenting with a chief complaint of vaginal bleeding. American College of Emergency Physicians. Ann Emerg Med 1997; 29:435-58. [PMID: 9055792 DOI: 10.1016/s0196-0644(97)70364-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
30
|
Affiliation(s)
- G C Christiaens
- University Hospital, Department of Obstetrics and Gynaecology, Utrecht, Netherlands
| |
Collapse
|
31
|
Ewenstein BM. The pathophysiology of bleeding disorders presenting as abnormal uterine bleeding. Am J Obstet Gynecol 1996; 175:770-7. [PMID: 8828560 DOI: 10.1016/s0002-9378(96)80083-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Abnormal uterine bleeding is often the presenting complaint in women with underlying coagulopathies. A clear understanding of the pathophysiology of common bleeding disorders will help the practicing obstetrician/gynecologist in the diagnosis and treatment of these conditions. The normal hemostatic process can be divided into three phases. The first phase, primary hemostasis, consists of platelet adhesion and aggregation. After vascular injury, proteins in the subendothelium are exposed that promote platelet adhesion. Platelet adhesion is uniquely dependent on von Willebrand factor, a plasma protein that serves as a molecular bridge between components of the vessel wall and the platelet glycoprotein Ib/IX receptor. Activation of the adherent platelets promotes additional platelet recruitment, culminating in the formation of the platelet plug. Quantitative or qualitative defects in either the platelet or von Willebrand factor (von Willebrand disease) lead to defective primary hemostasis. Patients present with a prolonged bleeding time and mucocutaneous bleeding manifestations. In the next phase, secondary hemostasis, the plasma coagulation factors are sequentially activated, which leads to fibrin formation and cross-linking. These reactions take place primarily on the surface of activated platelets and are essential in maintaining the stability of the initial platelet plug. Defective secondary hemostasis arises from congenital or acquired deficiencies in coagulation factors. Although these defects are most often associated with bleeding into joints and soft tissues, other manifestations, including abnormal uterine bleeding, may be present. The prothrombin time and the activated partial thromboplastin time serve as initial screening tests for these coagulation disorders, although more specific tests, including factor levels, thrombin time, clot solubility, and mixing studies, are needed to fully define the defect. In the final phase of normal hemostasis, fibrinolysis, the fibrin clot undergoes an orderly process of degradation. Deficiencies in the normal inhibitors of fibrinolysis, such as alpha 2-antiplasmin or plasminogen activator inhibitor-1, may be underdiagnosed causes of delayed bleeding because they are not identified by the usual coagulation screening tests. Disorders of primary hemostasis, including thrombocytopenia and von Willebrand disease, are particularly important to consider when evaluating women with abnormal uterine bleeding. Patients with acquired or congenital deficiencies of either coagulation factors or the regulators of the fibrinolytic system may also present with menorrhagia. Accurate diagnosis of a bleeding disorder is essential to the design of an appropriate therapeutic regimen and is likely to have important clinical implications beyond that of the presenting gynecologic complaint.
Collapse
Affiliation(s)
- B M Ewenstein
- Boston Hemophilia Center, Children's Hospital/Brigham and Women's Hospital, MA 02115, USA
| |
Collapse
|