Abnormal Uterine Bleeding in Young Women with Blood Disorders

What have we learned about the patient's experience of von Willebrand disease? A focus on women

Von Willebrand disease (VWD), the most common inherited bleeding disorder (IBD), disproportionately affects females, given the hemostatic challenges they may encounter throughout their lifetimes. Despite this, research about VWD remains grossly underrepresented, particularly compared to hemophilia, which is historically diagnosed in males. Structural sexism, stigmatization of menstrual bleeding, delayed diagnosis, and a lack of timely access to care result in an increased frequency of bleeding events, iron deficiency, iron deficiency anemia, and a decreased quality of life. However, we are only beginning to recognize and acknowledge the magnitude of the burden of this disease. With an increasing number of studies documenting the experiences of women with IBDs and recent international guidelines suggesting changes to optimal management, a paradigm shift in recognition and treatment is taking place. Here, we present a fictional patient case to illustrate one woman's history of bleeding. We review the evidence describing the impact of VWD on quality of life, normalization of vaginal bleeding, diagnostic delays, and the importance of access to multidisciplinary care. Furthermore, we discuss considerations around reproductive decision-making and the intergenerational nature of bleeding, which often renders patients as caregivers. Through incorporating the patient perspective, we argue for an equitable and compassionate path to overcome decades of silence, misrecognition, and dismissal. This path moves toward destigmatization, open dialogue, and timely access to specialized care.

Diagnosis of Bleeding Disorders in Adolescents Hospitalized for Heavy Menstrual Bleeding

Background  There is scarce information regarding the prevalence and clinical impact of saddle pulmonary embolism (PE) in patients with cancer.

Objectives  This study aimed to assess the prevalence, clinical findings, and short-term outcomes of patients with cancer-related saddle PE including acute symptomatic and unsuspected events.

Patients/Methods  Consecutive patients with cancer-related PE (March 1, 2006–October 31, 2014) were retrospectively reviewed by a chest radiologist to assess PE burden and signs of right ventricular (RV) overload. The clinical outcomes within 30 days were evaluated according to saddle versus nonsaddle PE.

Results  Thirty-six (12%) out of 289 patients with newly diagnosed cancer-related PE presented with saddle PE. Saddle PE was found in 21 cases (58%) with acute symptomatic PE and the remaining 15 cases (42%) were found as unsuspected findings. Patients with saddle PE had more frequently experienced a previous thrombotic event (31 vs. 13%; p  = 0.008), and it occurred more frequently as an acute symptomatic event (58 vs. 39%; p  = 0.025) compared with those with nonsaddle PE. Signs of RV overload including RV/left ventricle ratio ≥1 (22 vs. 4%; p  < 0.001) and interventricular septum displacement (53 vs. 20%; p  < 0.001) were also more common in patients with saddle PE compared with nonsaddle PE. Overall, PE-related mortality, venous thromboembolism recurrence, and major bleeding within 30 days were found to be similar according to saddle versus nonsaddle PE.

Conclusion  Saddle PE is not uncommon in patients with cancer-related PE including in those with unsuspected PE. Similar 30-day outcomes were found according to saddle versus nonsaddle PE in our cohort.

Diagnostic Value of Vaginal Ultrasound under Improved Clustering Algorithm Combined with Hysteroscopy in Abnormal Uterine Bleeding

In order to explore the diagnostic value of the improved clustering algorithm of vaginal ultrasound combined with hysteroscopy in abnormal uterine bleeding (AUB), 128 patients diagnosed with AUB in the hospital were selected as the research objects. A K-means improved clustering color image segmentation algorithm was designed and applied to AUB vaginal ultrasound image processing. The running time, mean square error (MSE), and peak to signal noise ratio (PSNR) were calculated to evaluate the algorithm, and the sensitivity, specificity, negative likelihood ratio, and positive likelihood ratio were used to evaluate the diagnostic accuracy of the detection method. In addition, combined with hysteroscopy, a comprehensive evaluation of the diagnostic value of abnormal uterine bleeding diseases was implemented. The results showed that compared with the traditional K-means clustering algorithm, the running time of the improved K-means clustering color image segmentation algorithm in the training set was significantly shortened, the MSE was significantly decreased, and the PSNR was significantly increased ( $P<0.05$ ). The sensitivity, specificity, negative likelihood ratio, and positive likelihood ratio (90.5%, 93.2%, 84.3, and 96.3%) of AUB diagnosis were significantly improved in the algorithm of vaginal ultrasound combined with hysteroscopy ( $P<0.05$ ). In summary, the combination of vaginal ultrasound and hysteroscopy based on K-means improved clustering color image segmentation algorithm can significantly improve the clinical diagnostic accuracy of AUB patients.

Psychiatric referral is required in children with vaginal foreign body injury: A case-control study from China

PURPOSE

The rate of vaginal foreign body (VFB) injury has been increasing in recent years. VFB will cause vaginal inflammation, injury and negative psychological impacts in girls. Our study aimed to elucidate the need of psychological referral in children with VFB.

DESIGN AND METHODS

A case-control study was performed. A total of 67 girls who visited the clinic due to vaginal foreign bodies were recruited. A questionnaire and Family environment scale-Chinese version (FES-CV) and social anxiety scale for children-Chinese version (SASC-CV) were completed by parents and children. Demographic information, parenting pattern, girls' social anxiety status, and their daily life trajectory and outdoor activities were collected.

RESULTS

The mean age of the 67 girls with VFB was 6.6 ± 2.1 years with a range of 2 years10 months-13 years. The 72 girls of the control group were age-matched with the patients. Scorings in two subscales of FES-CV including family cohesion, emotion expression were significantly lower in the VFB group than those in the control group (7.2 ± 2.4 vs. 7.9 ± 1.7, p < 0.05; 5.2 ± 1.6 vs. 6.5 ± 1.3, p < 0.001). Social anxiety level was higher in the VFB group comparing with the control group. Shorter time of outdoor activities (t = 3.205, p = 0.002) and significantly longer screen time were in the VFB group (t = 5.74, p < 0.001).

CONCLUSIONS AND IMPLICATIONS

The occurrence of VFB was associated with parenting patterns and social anxiety level. Psychiatric referral is required in children with VFB.

Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist

Heavy menstrual bleeding (HMB) is frequently reported by adolescents. The role of the hematologist is threefold in evaluating such patients: (1) perform a clinical and laboratory evaluation for an underlying bleeding disorder on the basis of the degree of clinical suspicion, (2) identify and manage any concomitant iron deficiency, and (3) provide input to the referring provider regarding the management of HMB, particularly for patients with identified hemostatic defects. Several clues in the menstrual history should raise suspicion for an underlying bleeding disorder, such as menses lasting >7 days, menstrual flow which soaks >5 sanitary products per day or requires product change during the night, passage of large blood clots, or failure to respond to conventional therapies. A detailed personal and family history of other bleeding symptoms should also be obtained. Iron deficiency with and without anemia is commonly found in young women with HMB. Therefore, it is important to obtain measures of hemoglobin and ferritin levels when evaluating these patients. Iron supplementation is often a key component of management in the adolescent with heavy menses and is still needed in those who have received packed red cell transfusions as a result of severe anemia. Strategies for decreasing menstrual blood flow are similar for adults and adolescents with heavy menses, with combined hormonal contraceptives recommended as first-line therapy. However, there are adolescent-specific considerations for many of these agents, and they must be incorporated into shared decision-making when selecting the most appropriate treatment.

Evaluation and management of heavy menstrual bleeding in adolescents: the role of the hematologist

Heavy menstrual bleeding (HMB) is frequently reported by adolescents. The role of the hematologist is threefold in evaluating such patients: (1) perform a clinical and laboratory evaluation for an underlying bleeding disorder on the basis of the degree of clinical suspicion, (2) identify and manage any concomitant iron deficiency, and (3) provide input to the referring provider regarding the management of HMB, particularly for patients with identified hemostatic defects. Several clues in the menstrual history should raise suspicion for an underlying bleeding disorder, such as menses lasting &gt;7 days, menstrual flow which soaks &gt;5 sanitary products per day or requires product change during the night, passage of large blood clots, or failure to respond to conventional therapies. A detailed personal and family history of other bleeding symptoms should also be obtained. Iron deficiency with and without anemia is commonly found in young women with HMB. Therefore, it is important to obtain measures of hemoglobin and ferritin levels when evaluating these patients. Iron supplementation is often a key component of management in the adolescent with heavy menses and is still needed in those who have received packed red cell transfusions as a result of severe anemia. Strategies for decreasing menstrual blood flow are similar for adults and adolescents with heavy menses, with combined hormonal contraceptives recommended as first-line therapy. However, there are adolescent-specific considerations for many of these agents, and they must be incorporated into shared decision-making when selecting the most appropriate treatment.